Hemolacria or bloody epiphora is the presence of blood in the tear.
Alternative names of the condition include bloody tears, blood-stained tears, dacryohemorrhea, hematodacryorrhea, hemolacrimia, sanguineous tears, sanguineous lacrimation, hematic epiphora, dacryohemorrhysis, lacrimae cruentae, and tears of blood.
The source of blood in tears may be:
Haemolacria is an exceedingly rare condition. Due to low incidence and limited literature, the prevalence and predilection of haemolacria for a specific gender, race, or age is not known.
The pathophysiology of haemolacria depends on the case-specific cause of this condition, as explained above in the etiology section.
Hemolacria is typically a benign and self-limited process. However due to associations with severe systemic and ocular diseases a thorough evaluation is warranted for all patients presenting with hemolacria.
All patients presenting with haemolacria should undergo a comprehensive ocular examination as well as a systemic examination to look for organic causes and sources of the hemorrhage. Specifically, the history of systemic diseases (hematological disorders, coagulopathies, hypertension) and medications like warfarin, aspirin or clopidogrel is necessary.
When no ocular or systemic causes are present, psychiatric diseases and vicarious menstruation must be ruled out before labeling the etiology as 'unknown' or 'idiopathic.'
Thorough ocular and physical examinations are warranted on presentation. In patients with suspected ocular causes, referral to an ophthalmologist is recommended for a thorough evaluation. Radiographic imaging, usually with computed tomography of the head and orbits, is also recommended.
A unique approach involving the placement of punctal plugs has been described in the literature as well. This involves the placement of punctal plugs in the superior and inferior puncta. This helps identify retrograde flow as the cause of hemolacria. If hemolacria resolves with the placement of punctal plugs with continued or initiation of epistaxis, the anatomical source can be identified.
Dacryoendoscopy promises to be an important tool to rule out bleeding lesions within the tear drainage system, which may be undetected without this modality.
The treatment of haemolacria depends on the cause. Close observation is needed when no apparent cause of haemolacria is detected to rule out malingering.
Differential diagnosis of haemolacria includes:
Severe bleeding through tears may even be fatal in some cases especially in a patient with coagulopathy. Identifying hemolacria from systemic causes is of utmost importance.
Haemolacria as such will not lead to complications. But it can be a complication of a multitude of conditions, as explained in the etiology section. Identifying the cause and targetting the treatment towards it, is the most important step in the management of hemolacria.
If the patient is on anticoagulants due to systemic illnesses, the medication will have to be stopped, at least in the short term. It may be restarted at a reduced dose after consultation with the ophthalmologist and the patient's clinical providers.
Patients with haemolacria may first encounter their primary care provider or an emergency department provider. An ophthalmology consult is recommended. Cross-consultations with other physicians may be required based on the etiology of hemolacria. The outcomes and treatment options for patients with haemolacria depend on the primary condition.
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