Haemolacria (Bloody Tears)

The presence of blood in tears is haemolacria or bloody epiphora. Haemolacria is also referred to as bloody stained tears, dacryohemorrhea, bloody tears, hematodacryorrhea, hemolacrimia, hematic epiphora, sanguineous tears, tears of blood, sanguineous tears, sanguineous lacrimation, dacryohemorrhysis, or lacrimal cruentae. The source of blood in tears can come from the any point along the ocular surface. For instance, conjunctival vessels lie on the ocular surface and may bleed spontaneously or after eye rubbing. Though red blood corpuscles may be seen on microscopic examination of tears, subconjunctival hemorrhage without a breach in the conjunctiva is often associated with frank blood in tears.

Causes of Haemolacria (bloody tears)

The involvement of the conjunctiva and causes of haemolacria include:

Trauma

Surgery involving an incision or excision of the conjunctiva causes haemolacria. These can include cataract, pterygium, scleral buckling, pars plana vitrectomy, trabeculectomy, and many other ocular surgeries. Non-surgical conjunctival laceration or rupture of the conjunctival vessels may also cause haemolacria. For example, damage following trachoma, a type of bacterial infection, may cause bloody tears.

Inflammation

Conjunctival ulcers or granulation for various reasons can cause haemolacria. Severe conjunctivitis including hemorrhagic conjunctivitis, membranous or pseudomembranous conjunctivitis, follicular conjunctivitis with congested semilunar fold and caruncle, severe viral or bacterial conjunctivitis cause blood-stained tears.

Vascular Lesions

Giant papillary conjunctivitis, hemangioma, lymphangioma, inflammatory papilloma of the conjunctival sac, severe vascular papillae, pathological vasodilation of the conjunctival vessels, conjunctival variations, pyogenic granuloma, telangiectasia of the conjunctival vessels may bleed leading to bloody tears. Malignant melanoma of the conjunctiva may also be associated with this condition.

Vicarious menstruation

Vicarious menstruation is usually painless, may last for a second to a minute, and may involve one or both eyes.

The conjunctiva may periodically bleed during menstruation or hormonal disturbances. This phenomenon is usually seen around menarche or rarely around menopause. The source of blood in haemolacria in vicarious menstruation has been thought to be the lacrimal gland, the lower fornical conjunctiva, the episclera, dilation of the fornical and bulbar conjunctival vessels, and hemorrhages in the upper tarsal conjunctiva. Vicarious menstruation may cause a subconjunctival hemorrhage. Primary localized conjunctival amyloidosis may cause recurrent subconjunctival bleeding due to vicarious menstruation.

Bleeding from The Lacrimal Puncta

The source of the bleeding in tears may be the puncta. On each of the medial sides of the upper and lower lid is one lacrimal punctum. The bladder connects medially to a lacrimal canaliculus on the upper and lower lid. Both of these canaliculi meet to form a common canaliculus and then connect to the lacrimal sac, or they may open into the lacrimal sac separately. The lacrimal sac connects to the lower nasal cavity below the inferior nasal concha via the nasolacrimal duct. Sometimes bleeding through the puncta may also occur in epistaxis without nasal packing. Blood can pass retrogradely through the nasolacrimal duct, lacrimal sac, and canaliculi to the puncta when pressure within the nasal cavity increases. Fracture of the nasal bone or walls of the sinuses, and Le Fort fracture type I can cause epistaxis, which can retrogradely flow to the puncta. Haemolacria has been reported after an orbital floor fracture due to a displaced implant eroding the nasolacrimal drainage system in a patient on Warfarin and Aspirin. The bleeding through the lacrimal puncta due to epistaxis or a local pathology of the lacrimal sac or nasolacrimal duct usually occurs through the lower punctum, sometimes from both puncta, and rarely through the upper punctum alone.

Bleeding from the Lid Margin

Inflamed lid margins due to blepharitis may cause erosion of the surface of the eyelid and lead to bleeding. Trauma-causing lid margin laceration can also lead to haemolacria.

Tear Glands

In some rare cases, the source of bleeding remains undetermined. In such cases, some specialists have hypothesized that the hemorrhage may come from the lacrimal gland or accessory lacrimal gland. Other hypothesized origins of haemolacria include meibomian glands or conjunctival goblet cells. Dacryoadenitis or inflammation of the lacrimal gland can also cause bloody tears.

Orbit

Orbital varix at the junction of the angular vein and superior ophthalmic has been reported to be associated with bloody tears, due to bleeding from the medial conjunctiva and overlying skin after jugular compression. Rarely, fracture of the orbital roof, orbital hemangioma, and peribulbar dermoid may cause haemolacria if the conjunctiva is open.