Blood-tinged tears in a healthy toddler – A case of hemolacria with review of literature

Hemolacria is an uncommon ocular manifestation that can present a diagnostic challenge. In the majority of cases, a specific diagnosis is reached, while only rarely does the diagnostic workup fail to determine the underlying cause.[1] Various etiologies like trauma, inflammation, vascular lesions, vicarious menstruation, blood disorders, epistaxis, tumors, and psychiatric and systemic disorders (anemia, jaundice, exanthematous fever, and severe disturbances of the autonomic nervous system) have been known to be associated with this condition.[2] Patients presenting with hemolacria, where comprehensive investigations including radiologic, laboratory, and histopathologic assessments yield negative results, can be classified as having an idiopathic condition.[3] Till date, only 17 cases of primary hemolacria without any identifiable cause have been described in literature.[4,5] We describe the case of a 3-year-old young girl with hemolacria without any identifiable cause, possibly primary hemolacria. She was brought to ocular emergency by her parents with concerns of bleeding spontaneously from the right eye without any history of trauma or strenuous cough or valsalva [Fig. 1a]. Upon examination, the patient's visual acuity was 20/20 in both eyes; external examination revealed no abnormalities. Slit-lamp examination of the anterior segment was unremarkable, with no signs of conjunctival injection or ocular surface pathology. There was presence of thick blood-admixed yellowish discharge in the lower fornix and overlying skin. Given the unusual presentation, further investigations were conducted to identify the underlying cause of hemolacria. The patient underwent a comprehensive blood workup, including complete blood count, coagulation profile, Rheumatoid arthritis (RA) factor, Antinuclear antibody (ANA) profile, liver and kidney function tests. The results revealed no significant abnormalities or systemic pathology that could explain the bleeding episodes. A computed tomography (CT) scan of the orbits was performed, which revealed no evidence of lacrimal neoplasms, nasolacrimal duct cysts, or obstructions. Given the absence of any significant findings from the clinical examination and CT orbit findings [Fig. 1b], the patient's parents were reassured that the episode was likely an isolated event. There have been no reports of recurrent episodes of hemolacria or any symptomatic concerns during the last 5 years follow-up. A recent systematic review by Carrion-Alvarez et al. described 31 cases of hemolacria, mostly from India, which were associated with trichorrhage and hematohidrosis.[9] Bai et al. published another extensive series from China, encompassing 27 cases, predominantly consisting of adults. The study revealed that 77.8% of the cases involved the lacrimal system, ocular surface, or both, while 22.2% exhibited systemic associations such as granulomatosis with polyangiitis. Furthermore, five cases were classified as idiopathic bloody tears.[10]Table 1 summarizes a brief review of literature (2013–2023) of primary hemolacria. Idiopathic hemolacria cases show self-limiting characteristics, with spontaneous resolution observed. It is crucial for patients with an unknown etiology to maintain regular follow-up appointments to ensure potential hidden pathologies are not overlooked. In addition, counseling services can be offered to aid patients, parents, or caregivers for coping with the distressing nature of this condition.Figure 1: (a) Blood in tears from the right eye of an otherwise healthy 3-year-old girl. (b) CT orbits show no nasolacrimal duct obstruction/cysts/space-occupying lesion in the orbit. CT = computed tomographyTable 1: Review of literature on primary hemolacria within the last 10 yearsFinancial support and sponsorship: Nil. Conflicts of interest: There are no conflicts of interest.