Omar Abdul Jolil
Introduction
Haemolacria is defined as having blood in the tears. It is an extremely rare phenomenon and is both concerning for physicians and, as you can imagine, the patients and their families. It was first noted in the literature in the 6th century and then 1000 years later in the 16th century (1). Since then there have been very few cases that have been reported in the literature.
Epidemiology, Pathophysiology and Aetiology
Due to the limited literature and number of cases of haemolacria there is no known pattern or prevalence of the condition within any given demographic (1). There have, however, been a number of different causes and associations of haemolacria which will be mentioned below.
- Lacrimal apparatus tumour (2)
- Severe bacterial conjunctivitis (2)
- Retrograde blood flow through puncta lacrimalia as a result of epistaxis (1)
- Local injury or trauma to the eye (2)
- Ectopic endometrial tissue (noted in women who suffered bloody tears during (2) or instead of menstruation (1))
- Pathological enlargement of orbital venous channels (2)
- Hereditary haemorrhagic telangiectasia (HHT) and other coagulopathies (2)
It is to be noted that 30% of the cases of haemolacria are idiopathic and all investigations done on these patients came back as normal (2). It has been noted in 4 cases that symptoms of hysteria have been present in patients presenting with haemolacria and thus it has been suggested as a cause, the mechanism of which remains unknown (3).
Presentation
The presentation of haemolacria is quite simple in that the patient will present with blood either instead of or mixed with tears. The presence of blood within the tear sample can be sent to the lab for investigation and confirmation of red blood cell presence (1).
The duration, trigger and pattern of symptoms can vary between cases. In some cases, the symptoms may occur multiple times per day lasting for a few minutes (1). Whilst others may present in a cyclical pattern like that noted in women who discharged blood from their eyes during only their menstrual period (2). It has also been noted that stress could be a trigger for the onset of tears of blood (3).
Diagnosis and Investigations
Regarding investigations, the potential causes listed above must be ruled out before one can label the presentation as idiopathic. As such the following investigations have been done on patients presenting with haemolacria (1-3):
- Blood tests including full clotting screen (for investigation of von Willebrand disease and/or other clotting disorders)
- Contrast CT scans of orbit and paranasal sinuses
- Cytology of tear films
- Conjunctival swab cultures
- Dacryocyst rhinogram
- Lacrimal gland biopsy
- Capillary fragility tests
It should also be taken into consideration that trauma is a possible cause of haemolacria (2) so safeguarding concerns including that of Munchausen’s and Munchausen’s by-proxy should be taken into consideration.
Management
Haemolacria is a benign condition and it is self-limiting (1). As such, there is no specific treatment for the condition. However, as mentioned above, the appropriate investigations are required to rule out if haemolacria is a symptom of an underlying condition which would require monitoring and potential treatment.
References
- Das D, Chiranthan M, Meel R, Neupane S. Crying out blood: haemolacria in a young girl. BMJ Case Reports. 2020 Jun;13(6):e236579.
- James R, Bharadhi M, James J. Haemolacria in a 22-year-old boy. BMJ Case Reports CP [Internet]. 2018 Nov 1 [cited 2022 Feb 1];11(1):e225151. Available from: https://casereports.bmj.com/content/11/1/e225151
- Ahluwalia BK, Khurana AK, Sood S. Bloody tears (haemolacria). Indian Journal of Ophthalmology [Internet]. 1987 Jan 1 [cited 2022 Nov 11];35(1):41. Available from: https://www.ijo.in/text.asp?1987/35/1/41/26317