The lacrimal gland is essential for maintaining the health of the eye. This gland is responsible for secreting tears that keep the surface of the eye moist, preventing corneal breakdown. It also plays an important role in the prevention of eye infections by secreting enzymes that fight bacteria and viruses. The lacrimal gland is located in the orbit, the cavity surrounded by bones that harbors the ocular globe.

Tumors of the lacrimal gland are not infrequent in an oculoplastics practice. In fact, they represent up to 18% of all orbital tumors. A lacrimal gland tumor may be present as a non-tender, palpable mass on the upper eyelid and, in some cases, it be cause inflammation around the eye. Other symptoms include the protrusion of the globe, pain in the area around the eye and restriction of eye movements. Lacrimal gland tumors may be benign or they may harbor malignant cells.

Benign tumors of the lacrimal gland

Most tumors that originate in the lacrimal gland are benign in nature. These may be inflammatory or they may be secondary to a systemic disease that has not yet been diagnosed, such as sarcoidosis or systemic lupus. Other benign tumors grow from the glandular tissue without being associated with other conditions. This is true of pleomorphic adenoma, the most common non-inflammatory tumor of the lacrimal gland.

Patients with benign tumors may experience inflammation, pain on eye movement or a palpable mass on the lateral part of the upper eyelid. Some patients lack these symptoms, but notice that their eye looks larger. This occurs because the eye is pushed forward by the mass. Benign lacrimal tumors seldom cause loss of vision, unless they are very large and have not been treated promptly. A CT scan of the orbits is necessary to analyze the size, position, and characteristics of the mass.

Although a tumor may behave as benign clinically, it must be biopsied to make a correct diagnosis. The surgeon will make an incision in the eyelid crease and will take a sample of the mass which will be sent to the pathologist for analysis. This is called an incisional biopsy. If the mass is in fact benign, the surgeon may decide to treat the patient with oral medications or excise what’s left of the tumor. Another option is to remove the whole mass while performing the biopsy; this is called an excisional biopsy. The advantage of this technique is that the surgeon will not have to go back and remove more tissue. However, if the mass is too large, it may be difficult to remove it without significant risks for the patient. Therefore, if the tumor can be treated with non-surgical interventions, it may be wise to be conservative and remove only a small portion.

Malignant tumors of the lacrimal gland

Cancer of the lacrimal gland is rare, but very aggressive. These tumors usually appear in older patients, although some types of cancer are more common in younger ones. Malignant tumors of the lacrimal gland cause more disruption of local tissues, so the symptoms tend to be more concerning for the patient. The patient may notice a protrusion of the affected eye and significant restriction of eye movement, manifested clinically as diplopia, or double vision; i.e., seeing two objects instead of one. The mass may grow in a matter of weeks or months. Some types of cancer produce pain while others may cause only mild discomfort.

A CT scan of the orbits will give the surgeon a good clue about the type of tumor because there are certain characteristics that are typical of cancer.  The scan also allows the surgeon to evaluate the size of the mass and to determine if any vital ocular structures are compromised. The information provided by the scan is crucial in planning his surgical approach.

Once the scan has been analyzed, the surgeon will take a biopsy of the mass and send the specimen to a pathologist who will make the diagnosis of malignancy. After the type of cancer is identified, a prognosis can be given based on the diagnosis, and the patient may need to be referred to an oncologist. In some cases, the surgeon can go back and remove the mass in its entirety. However, some tumors will require chemotherapy or radiation in addition to surgical removal of the cancer.

Early diagnosis is the best treatment

Regardless of the type of tumor present in the lagrimal gland, it is in the patient’s best interest that the mass be identified and treated. An oculoplastics surgeon has the knowledge and skill to recognize and eliminate these tumors while preserving the functionality and aesthetic appearance of the eyelid and surrounding tissues.