Bloody tears (Haemolacria):
Haemolacria, also known as bloody tears, is a rare medical condition characterised by the presence of blood in the tears. The condition can be attributed to various underlying causes, including trauma, infections, and tumors. While haemolacria is not a life-threatening condition, it can be distressing for patients and may indicate an underlying medical issue that requires prompt diagnosis and treatment.
Haemolacria is a rare condition, with an estimated prevalence of less than one in a million. The condition can occur in individuals of any age, gender, or ethnicity. However, some studies have suggested that it may be more common in females than males.
Etiology
Haemolacria or blood in the patient’s tears can find its source at any point along the anterior ocular surface.
Ocular adnexa, and lacrimal system, from tear production through tear drainage, including the lacrimal gland, the conjunctiva, the canaliculi or the lacrimal sac.
Blood in the tear film can even represent regurgitation of nasal or sinus bleeding to the ocular surface.
Diagnosis
History
Laterality of the bloody tears and of clear excessive tearing if coexistant
Both for the bloody tearing and when the tearing is not bloody: ask the patient to describe the quality, quantity and frequency of the tears, is patient carrying a tissue all the time, do friends and strangers ask if they are crying?
Duration and frequency
- Pain
- Burning, Itching
- Exacerbating factors
- History of facial trauma or eye trauma
- History of intraocular surgery, orbital surgery, eyelid surgery, facial surgery lacrimal surgery or sinus surgery
- Personal or family history of hematologic disease
- History of vascular lesions around the eye
- Medications – any blood thinners, topical medications in or near eye
- Other Bleeding- particularly Epistaxis, Hemoptysis, spitting up blood
- Headache
- If factitious disorders suspected – is anyone with the patient immediately prior to the episode?
Physical examination
Examination should include thorough slit lamp examination of the conjunctiva (including everting upper lids to fully examine palpebral conjunctiva), lacrimal gland and puncti for any lesions, changes in anatomy or other unusual findings.
A patient with a bleeding diathesis leading to the abnormal tearing may also have Subconjunctival Hemorrhage.
Digital palpation of the lacrimal sac over the lacrimal sac fossa region and upward may be revealing and should be compared to the opposite side in unilateral cases.
Mass lesions above the medial canthal tendon are of particular concern for malignancy or other atypical process.
Reflux of bloody discharge or other material on compression of the lacrimal sac may localize the source of the bloody tears to be the lacrimal sac.
Associated Symptoms
• Psychological distress (either secondary to the blood in tears, or related to the underlying etiology as in Gardner-Diamond or factitious disorders).
• Clear drainage (tearing) or mucoid drainage. Concomitant presence of these symptoms may indicate a lacrimal outflow source of the bleeding.
• Pain in lacrimal drainage apparatus if the source of blood is a traumatic, inflammatory or infectious etiology that affects these structures.
• Skin or conjunctival lesions (thorough exam important as above, since the presence of such lesions may reveal either the underlying etiology of bloody tearing or provide clues to the source of the bloody tearing).
Diagnostic procedures
• Probing and Irrigation in the office
• Culture of discharge from punctum
• Cytology (to examine for endometrial cells, malignant cells or artificial substances) of discharge from punctum
• Nasal endoscopy (in office with ENT and/or intraoperative)
• Computed tomography of the sinuses
• Dacryocystography
• Intraoperative biopsies of the lacrimal gland, such as during Dacryocystorhinostomy if clinically indicated for persistent and severe tearing
Laboratory testing
If history, examination and imaging studies are unrevealing, consider work up for an underlying hematologic disorder. This might include complete blood count, complete metabolic panel, bleeding time, prothrombin time/INR, coagulation studies and possible consultation with a Hematologist to guide laboratory work up.
Differential diagnosis
• Canaliculitis (such as Actinomyces)
• Inflammatory diseases or lesions of the conjunctiva including Giant Papillary Conjunctivitis, Erythema Multiforme and Pyogenic Granuloma
• Hematologic conditions including Gardner-Diamond Syndrome (also known as psychogenic purpura or autoerythrocyte sensitization syndrome)
• Anticoagulant use
• Topical Silver Nitrate exposure
• Epistaxis with retrograde flow – patient may induce the reflux of blood into the tears by pinching either side of the nose
• Infections of the sinuses and/or lacrimal sac- Tuberculosis or Rhinosporidiosis
• Melanoma of the Conjunctiva
• Melanoma of the Lacrimal Sac
• Other malignancies of the Lacrimal Sac, Lacrimal Gland or Conjunctiva
• Benign mass lesions of the lacrimal sac (such as Inverted Papilloma of the Lacrimal Sac)
•Nasolacrimal endometriosis/ Vicarious Menstruation
• Factitious disorders – patients have been reported to introduce food coloring or their own blood into the eye
• Idiopathic
Credit: https://eyewiki.aao.org
Causes
Haemolacria can be caused by various underlying medical conditions, including trauma, infections, and tumors. Trauma to the eye or orbit can damage blood vessels in the conjunctiva or eyelids, leading to bleeding into the tears. Infections such as conjunctivitis, herpes simplex virus, and tuberculosis can also cause haemolacria. Tumors of the lacrimal gland or conjunctiva can also lead to bloody tears.
Other less common causes of haemolacria include coagulopathy, vasculitis, and systemic diseases such as lupus erythematosus. In some cases, no underlying cause can be identified, and the condition is classified as idiopathic haemolacria.
Symptoms
The most prominent symptom of haemolacria is the presence of blood in the tears. The blood may appear as streaks or droplets in the tears, or the tears may appear entirely bloody. Depending on the underlying cause, patients may also experience additional symptoms such as eye pain, redness, and swelling.
Treatment
The treatment of haemolacria depends on the underlying cause. In cases of trauma, the bleeding usually resolves on its own within a few days. Treatment of infections may involve topical or systemic antibiotics, antiviral medication, or steroids. Tumors may require surgical removal or radiation therapy.
In cases where no underlying cause can be identified, treatment may involve symptomatic relief with artificial tears and avoiding any triggering factors that may exacerbate the condition.
Prognosis
The prognosis for haemolacria depends on the underlying cause. In cases of trauma or infection, the condition usually resolves with appropriate treatment. Tumors of the lacrimal gland or conjunctiva may require more aggressive treatment and have a poorer prognosis.
