Medical Mystery: Hemolacria – A case report

by Md. Golam Mostofa Kamal, Ripon Kumar Sarker, Md.Golam Shaheed, Maria Akhter

Abstract:

Hemolacria is undoubtedly one of the most alarming condition for Ophthalmologists now a days. Here we report a young boy with anxiety neurosis suffering from hemolacria. He was admitted in Ophthalmology Department, Rangpur Medical College on July, 2018. We could not detect any organic cause for hemolacria after complete local and systemic investigation. As it is self-limiting counseling was done to patients, parents or caregivers

Indexing words: Hemolacria, Anxiety neurosis.

Introduction:

Hemolacria is a physical condition that causes a person to produce tears that are partially composed of blood. It can manifest as tears that are anything from merely red-tinged to appearing to be entirely made of blood. Hemolacria is a symptom of a number of diseases1 and may also be indicative of a tumor in the lacrimal apparatus. It is most often provoked by local factors such as bacterial conjunctivitis, environmental damage or injuries2. Acute hemolacria can occur in fertile women and seems to be induced by hormones3 similarly to what happens in endometriosis.16th century Italian physician Antonio Brassavola wrote of treating a nun who wept bloody tears when she was menstruating. Then in 1581, a flemish doctor wrote of a 16 year old girl he treated who discharged her tear flow throughout the eyes as drops of bloody tears, instead of through the uterus. Modern science backs up this idea. According to a 1991 study of 125 healthy subjects2, menstruation contributes to occult hemolacria or traces of blood in tears. The authors found that 18% of fertile women have some blood in their tears, while only 7% of pregnant women, 8% of men and no postmenopausal women show signs of bloody tears. The scientists concluded that, occult hemolacria in fertile women thus seems to be

  1. Assistant Professor, Dept. of Ophthalmology Rangpur Medical College
  2. Associate Professor, Dept. of Ophthalmology Rangpur Medical College

 

induced by hormones, whereas hemolacria most often is provoked by local factors (bacterial conjunctivitis, environmental damage, injuries). Here we report an interesting case of bloody tears in a young patient suffering from anxiety neurosis.

Case report:

Mr. Anjon Roy, a 18 year old boy, hailing from Nageshwari, Kurigram had been admitted to Rangpur Medical College Hospital on 6th of July, 2018 with the complains of bloody tears. These were first observed one and half year back when the patient was doing his domestic work. The relatives of the patient were startled when they saw bloody tears trickling over his cheeks while he was concentrating on his work.

A boy with crying blood from his eyes
Fig 1:
  A boy with crying blood from his eyes

 

It was accompanied by headache, giddiness, severe pain, weakness and flushing but the vision was unaffected. Since then, the patient experienced episodic attacks of bloody tears at one to one and a half month interval regularly. One attack documented in the form of a photograph (Figure-1) was observed by the authors during hospital stay of this patient. History of bleeding disorders in the family was denied. The blood was confirmed microscopically in the collected samples of tears and was of the same blood group as that of the patient (O positive).

On examination, lids, conjunctiva inclusive of fornices, palpebral part of lacrimal gland and lacrimal sac area were normal. Anterior and posterior segments did not reveal any abnormality. Vision was 6/6 in both eyes. ENT and medical check-ups were within normal limits. Consulting psychiatrist confirmed anxiety neurosis in the patient.

Patient’s sac patency test was normal. Bleeding time, clotting time, prothrombin time and platelet count were within normal limit. Serum creatinine, SGPT and Alkaline Phosphatase level were normal. Anti-Phospholipid antibody was absent. However, activated partial thromboplastin time was a little raised during this attack. X-rays of orbit, optic foramina and skull showed no abnormality.

Patient was given conservative treatment in the form of oral vitamin A and Vitamin K supplement and anxiolytic drugs.

Discussion:

Isolated bleeding from the eyes without any pathology is an extremely rare condition. Only a few cases of isolated hemolacria have been reported throughout the world so far. Duke Elder4 outlined the differential diagnosis of bloody tears; severe anemia, jaundice, vascular tumors, Oscar-Weber-Rendu disease (hereditary hemorrhagic telangiectasia), hemophillia and other coagulopathies. Other causes reported are vicarious menstruation, conjunctival manipulation for follicle expression in trachoma, clinical treatment of conjunctiva with silver nitrate and retrograde blood stream into conjunctiva through puncta lacrimalia5. Recently Bona-volnta and Sammaritino6 attributed orbital varix as a cause for bloody tears. In another interesting case, Richard and Eifemam blamed secondary giant papillary conjunctivitis for bloody tears.

Idiopathic hemolacria is rarely encountered in clinical practice. It is a diagnosis of exclusion. Before labeling it as idiopathic, it needs through clinical, imaging and laboratory evaluation. The possible causes for hemolacria after reviewing the literature include trauma, vascular tumors of the ocular surface, lacrimal system disease, retrograde epistaxis, bleeding disorders, endometriosis, psychogenic causes and medications.7,8

Conclusion:

In our case, we could not detect any organic cause for hemolacria after complete local and systemic investigation. In here all investigations (clinical, radiological, laboratory and histopathological) are negative, can be deemed idiopathic. The condition is self-limiting and spontaneous resolution is seen in majority of cases. It is important for patients with unknown etiology to have regular follow up to ascertain not missing occult pathologies. Counselling services can also be provided to help patients, parents or caregivers to cope with this distressing condition.

Reference:

  1. Ahluwali BK, Khurana AK, Sood S. Bloody tears (haemolacria)”. Indian Journal of Ophthalmology 1987; 35(1):41-43.
  2. Ottovay E, Norn M. Occult haemolacria in females. Acta Ophthalmol 1991; 69(4):544-6.
  3. Richard A, Eifemam HD. Amer J Ophthalmol 1982; 93:524
  4. Duke Elder S. System of Ophthalmology 1982; Vol. VIII, Pt.1, 37. Henry Kimpton, London
  5. Horn 11 S. “Microscopically and chemically detected haemolacria”. Acta Ophthalmol 1977; 55(1):132-140.
  6. Bonavalolanta G, Sammarting A. “Bloody Tears from an Orbital Varix”. Ophthalmologica 1981; 182(1):5-6.
  7. Ozcan KM, Ozda T, Baran H, Ozdogan F. Hemolacria: Case Report. Int J Pediatr Otorhinolaryngol 2013; 77:137-8.
  8. Sobol EK, Barmettler A. A case of idiopathic bilateral haemolacria in a 11 year old girl. Ophthal Plast Reconstr Surg 2016; 10:1097