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A 22-year-old boy presented with two episodes of spontaneous blood in tears (figure 1). A detailed history and clinical examination was normal. Examination of the orbits was normal. An in-depth psychosocial analysis was not contributory.
Blood tests including a complete haemogram, liver function tests and bleeding profile were normal. Bleeding time, clotting time, prothrombin time (PT) index and platelet count were also within normal limits. The capillary fragility test was negative.
PT was evaluated for von Willebrand disease. von Willebrand factor (vWF) antigen assay and the functionality of vWF with a glycoprotein Ib binding assay, collagen binding assay, ristocetin cofactor activity and ristocetin-induced platelet agglutination assays were normal. Factor VIII levels are also checked and were found to be normal. Blood tests for dengue, leptospirosis were negative. Conjunctival swab culture was normal. Dacryocyst rhinogram and lacrimal gland biopsy were normal. CT scan of the skull including the orbit and face was normal.
No cause could be attributed to haemolacria in this patient despite an extensive radiological and haematological workup, along with a normal clinical examination. Hence, we presume it to be an idiopathic form of haemolacria. Approximately 30% of the cases are reported as idiopathic.
Haemolacria is a condition in which the patient has bloody tears, instead of normal watery tears. It is a symptom of a number of diseases.1 It may be indicative of a tumour in the lacrimal apparatus. Severe bacterial conjunctivitis or local injury to the eye can present with haemolacria. In women ectopic endometrial tissue deposition in the lacrimal duct can give rise to bloody tears during the menstruation.2 Pathological enlargement of the venous channels within the orbit and giant papillary conjunctivitis, vascular tumours, Osler-Weber-Rendu disease (hereditary haemorrhagic telangiectasia) haemophilia and other coagulopathies can present with haemolacria.3–5
Epistaxis with retrograde blood flow stream into conjunctiva through puncta lacrimalia, Munchausen’s syndrome are rare cause of haemolacria.6–8
Haemolacria is a rare medical condition and needs to be investigated more to understand it better.
A multispecialty approach is needed for evaluation of haemolacria.
Special thanks to the patient and his family for giving the consent and permission for pts photos to be published.
Contributors RJ: the patient was admitted in my medicine unit III, with bleeding from the eyes. I took detailed patient history and jotted down the clinical findings, and planned the laboratory work for the patient, also helped in online search for related articles and references. MB: the patient was admitted medicine unit III, with bleeding from the eyes. I planned and collected the laboratory reports and investigations and was involved in filing the reports and investigations, also helped in online search for related articles and references. The laboratory reports included bleeding profile, including PT, PTTK, BT, CT, fibrinogen levels, LFT, CBC.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Patient consent Obtained.
Provenance and peer review Not commissioned; externally peer reviewed.
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