Haemolacria: A Novel Approach to Lesion Localization

Purpose: To report the use of punctal plugs as a new modality to assist in the localization of lesions providing symptomatic relief in patients with haemolacria during their workup.

Methods: Retrospective case series.

Results: One boy and one girl, ages 16 and 20, respectively, reported spontaneous bloody tearing. Workup included probing and irrigation of the nasolacrimal system, blood and coagulation profiles, blood typing, serum hormone levels, conjunctival biopsy, and imaging. All findings were normal and failed to suggest a cause in any of the cases. Punctal plugs were inserted into each patient’s inferior punctum OS without complication. On initial follow-up visits, each patient reported cessation of bloody tears OS with continued bloody tears OD. Over time, both patients experienced complete cessation of haemolacria in both eyes.

Conclusions: Haemolacria is a condition caused by a group of disorders that result in the production of tears that are partially composed of blood. The large majority of cases result in a specific diagnosis. Only rarely does workup result in undetermined etiology. The novel approach of utilizing punctal plugs in the management of haemolacria may not only provide symptomatic relief for lesions distal to and including the punctum, but also assists in anatomic localization in idiopathic cases.     

Microscopically and chemically detected haemolacria

Two methods have been developed for the detection of occult haemolacria (occult blood in tears): 1) Microscopy of conjunctival fluid aspirated by means of the quantitative pipette method. 2) Chemical stix method employed on a sample of conjunctival fluid transferred to cotton-wool plug. Double samples from 306 eyes were subjected to microscopy, and chemical tests were performed on samples from303 other eyes. Microscopy has been found to disclose occult blood in 13 per cent of normals (greater than or equal to 100 erythrocytes/3.1 mm2 in 3 per cent of normals), while blood is detected chemically in 3 percent. Occult blood is most frequently found in cases of acute infectious conjunctivitis (65 per cent microscopically and 21 per cent chemically), less frequently in subacute and chronic infectious conjunctivitis (26 and 20 per cent respectively). Haemolacria is most feequently seen in relation to neutrophilia (45 per cent), less frequently with lymphocytosis (35 per cent), and even more rarely in the absence of both neutrophilia and lymphocytosis (11 per cent). Ciliary congestion is an unlikely cause of haemolacria. Postoperatively blood is present for two or three days, wheras blood instilled into the conjunctival sac of a normal eye disappears in less than one hour. The protein concentration in tears is raised in association with haemolacria.     

Bloody tears of unknown cause: case series and review of the literature

PURPOSE: To report 4 cases of recurrent unilateral bloody tears. METHODS: Retrospective case series. RESULTS: One boy and 3 girls, ranging in age from 6 to 14 years, reported spontaneous bloody tearing. Workup included probing and irrigation of the nasolacrimal system, blood and coagulation profiles, blood typing, serum hormone levels, conjunctival biopsy, and imaging. All findings were normal and failed to suggest a cause in any of the cases. In all patients, bloody tearing eventually resolved without further sequela. No recurrence has been reported over a follow-up period of 9 months to 11 years. CONCLUSIONS: Bloody tearing is an unusual clinical entity that concerns patients and can perplex physicians. A thorough examination and proper workup are necessary to rule out serious conditions but may fail to determine a cause. These idiopathic cases typically resolve without treatment.     

自发性血泪27例临床特征分析

目的总结以自发性血泪为首发症状患者的临床特征、病因及治疗。方法回顾性系列病例研究。选取2015年6月至2018年12月就诊解放军总医院第三医学中心眼科泪器病中心以自发性血泪为首发症状的27例患者的临床资料及随访资料进行分析,主要包括临床特征、具体病因、诊断、治疗方法及预后情况。结果27例患者中男性10例(37.0%),女性17例(63.0%),成年人(≥18岁)21例(77.8%),未成年人(<18岁)6例(22.2%)。单眼血泪者22例(81.5%),双眼血泪者5例(18.5%)。伴有其他部位出血者5例(18.5%)。血泪性状中,血性分泌物及反流液者19例(70.4%),泪中带血3例(11.1%),鲜血样泪7例(25.9%)。病因中包括全身病变引起者6例(22.2%),其中1例为肉芽肿性多血管炎,5例为特发性血泪(经过检查排除明确器质性病变的不明原因的血泪)(均<18岁);局部病变引起者21例(77.8%),其中按照病变涉及的部位分析,单纯涉及泪道系统病变者18例,单纯涉及眼表的病变及损伤者2例,同时涉及泪道系统及眼表病变者1例。局部病变按性质分析,异物源性(异物引起)5例;单纯炎性病变6例;肿物源性10例,其中1例为结膜良性肿物,另外9例涉及泪道系统(5例恶性肿物,4例良性肿物)。特发性血泪患者经心理和内科治疗后发作间隔时间延长。1例肉芽肿性多血管炎患者给予经鼻腔内窥镜下泪囊鼻腔吻合术后血泪有反复。1例结膜血管瘤患者不接受治疗,随访13个月有不定期少量出血。涉及泪道系统者给予病灶清除联合泪囊鼻腔吻合术,1例小细胞神经内分泌癌及1例腺样囊腺癌患者肿瘤复发后死亡,其他患者预后良好。结论血泪患者中以成年人及局部病变者多见,病变多涉及泪道系统,且以肿物源性多见,治疗主要为去除病灶,必要时扩大切除并联合泪道重建手术。特发性血泪多为未成年人,治疗以心理治疗配合必要的内科治疗。     

Ophthalmologic diagnosis of hereditary hemorrhagic telangiectasia or Rendu-Osler-Weber disease

CASE REPORT: Our patient was a 45-year-old woman who had recurrent episodes of hematic epiphora, repeated epistaxes for which no cause was found and a family history of gastric hemorrhage. One of her daughters also suffered from spontaneous hemorrhages. DISCUSSION: Hereditary hemorrhagic telangiectasia is rarely diagnosed by an ophthalmologist; however the occurrence of bloody tears occurring spontaneously in a patient with epistaxis or gastric hemorrhage should lead to suspicion of hereditary hemorrhagic telangiectasia or Rendu-Osler-Weber disease. It should never be forgotten that clinical examination and appropriate investigations are basic components of disease diagnosis.     

Occult haemolacria in females.

A series of 125 healthy subjects were examined by the stix method (chemical response) for occult occurrence of blood in tears. Blood was found in 18% of fertile women, definitely most often in the menstrual phase (in 39% of 51 samples within the first week, reckoned from the first day of menstruation). The incidence was independent of use of the contraceptive pill. On the other hand, occult haemolacria was observed in no more than 7% (= 30) of pregnant women and in none at the menopause (N = 7). Among males the phenomenon was noticed in 8% (N = 24). Occult haemolacria in fertile women thus seems to be induced by hormones, whereas haemolacria most often is provoked by local factors (bacterial conjunctivitis, environmental damage, injuries).     

A Very Rare Case of Bloody Tears with Enigmatic Epistaxis and Haematuria

Background: Bloody tears are a rare symptom that can be caused by local or systemic pathology.

Methods: We describe a very rare case of bloody tears that resulted from hyperthyroidism.

Results: A 15-year-old female patient presented with a 6-month history of bloody tears and epistaxis. Examination excluded local ocular and nasal pathology, including neoplasm and coagulopathy. Systemic investigations identified elevated thyroid function and following treatment her symptoms resolved. We discuss the mechanism by which hyperthyroidism may induce haemostatic dysfunction.

Conclusion: We present the first case of bloody tears secondary to thyroid dysfunction.     

An unusual presentation of spontaneous sub‐conjunctival haematoma in a patient receiving warfarin

A 65‐year‐old man on warfarin therapy with a sudden spontaneous onset of sub‐conjunctival haematoma associated with bloody tears was assessed in the clinic following a referral from an optometrist. Due to discomfort, diplopia and lagophthalmos, the haematoma necessitated suspension of warfarin therapy and a surgical evacuation. The sub‐conjunctival haematoma in a patient receiving warfarin can pose a significant management challenge.     

急性视网膜裂孔伴玻璃体积血早期误诊临床分析

目的分析急性视网膜裂孔伴玻璃体积血的早期误诊原因,探讨对急性视网膜裂孔伴玻璃体积血的早期诊断和治疗方法。方法早期给予急性玻璃体积血的患者药物治疗,一旦发现视网膜裂孔或视网膜脱离,及时根据病情给予激光封闭视网膜裂孔治疗、视网膜脱离外路手术治疗、玻璃体视网膜手术治疗。结果急性玻璃体积血患者早期给予药物治疗,612天发现其中12例视网膜裂孔或视网膜脱离。术后1年随访,12例患者视力均较手术前有所提高,其中3例患者在取出硅油后再次出现视网膜脱离,二次行硅油填充术,至今尚未取出硅油。结论对于Ⅱ级以上的急性玻璃体积血,尤其是老年患者,在早期给予药物治疗的同时,密切观察玻璃体积血吸收情况和视网膜情况,一旦发现视网膜裂孔或视网膜脱离,应尽快给予手术治疗。     

Hereditary hemorrhagic telangiectasia

A patient with hereditary hemorrhagic telangiectasia and bloody tears is described. This case report serves to familiarize the ophthalmic plastic and reconstructive surgeon with the differential diagnosis of bloody tears. Conjunctival, oral mucosal and cutaneous findings are documented, and the systemic and ocular manifestations of hereditary hemorrhagic telangiectasia are discussed.     

Pyogenic granuloma of the lacrimal sac

In this report, we describe three adult patients diagnosed with lacrimal sac pyogenic granuloma. The presenting symptoms were acute dacryocystitis, lacrimal mass, and bloody tears. The nasolacrimal drainage pathway was obstructed in all cases. Radiologic evaluation performed in one patient revealed the presence of a well-defined mass in the sac with homogenous contrast uptake. Histopathologic examination revealed capillary proliferation and inflammatory cells in a fibromyxoid stroma. The patients were followed up for 11–23 months after external dacryocystorhinostomy without recurrence of the tumor or nasolacrimal obstruction. Pyogenic granuloma may develop from the lacrimal sac mucosa and may cause bloody epiphora. Such a tumor is visualized as a hemorrhagic mass lesion, and it may not have a negative effect on the outcome of DCR.     

The severe acute respiratory syndrome coronavirus in tears

BACKGROUND: Severe acute respiratory syndrome (SARS) is a new infectious disease that caused a global outbreak in 2003. Research has shown that it is caused by a novel coronavirus. A series of cases is reported where polymerase chain reaction (PCR) testing on tears had demonstrated the presence of the virus. Detection of ocular infection from tears using the PCR technique has been widely used by ophthalmologists to diagnose infections for other viruses. METHODS: This is a case series report from cases classified as probable or suspect SARS cases. Tear samples were collected from 36 consecutive patients who were suspected of having SARS in Singapore over a period of 12 days (7-18 April 2003), and analysed by PCR using protocols developed by the WHO network of laboratories. RESULTS: Three patients with probable SARS (one female and two male patients) had positive results from their tear samples. Tear samples were used to confirm SARS in the female patient, who was positive only from her tears. The positive specimens were found in cases sampled early in their course of infection. CONCLUSIONS: This is the first case series reported with the detection of the SARS coronavirus from tears, and has important implications for the practice of ophthalmology and medicine. The ability to detect and isolate the virus in the early phase of the disease may be an important diagnostic tool for future patients and tear sampling is both simple and easily repeatable. Many healthcare workers are in close proximity to the eyes of patients and this may be a source of spread among healthcare workers and inoculating patients. Ophthalmic practices may need to change as more stringent barrier methods, appropriate quarantine, and isolation measures are vital when managing patients with SARS.     

Self-limiting corneal edema with multiple parallel lines on the endothelium (SCEMPLE)

The purpose of this study was to report the natural course and in vivo confocal microscopy (IVCM) findings of five cases with unilateral self-limiting corneal edema and multiple parallel lines on the endothelium (SCEMPLE). This study is an observational case series. Five patients, who experienced a blurred vision due to SCEMPLE, were studied using slit-lamp examination and white-light IVCM (Confoscan 4; Nidek Technologies, Padova, Italy). IVCM of the linear deposits revealed characteristic hyperreflective material protruding between the endothelial cells. The lines also displayed spot-like holes and polygonal precipitates, which resembled dislodged endothelial cells. Because other signs of corneal inflammation, such as stromal infiltration and ciliary injection, were lacking, the condition was left untreated. After 1 day, slit-lamp examination and IVCM revealed only a small residual of the lines. Spontaneous, complete resolution occurred in all five cases within 1 week, leaving a lower endothelial cell density of the affected eyes as only sequela. SCEMPLE requires no treatment but may result in endothelial cell loss. The self-limiting character and IVCM appearance dispute SCEMPLE being a form of endotheliitis and suggest a different etiology.     

Spontaneous resolution of vitreomacular traction: a case series

Three patients had unilateral vitreomacular traction (VMT) syndrome and the diagnosis was confirmed by spectral domain‐type optical coherence tomography (OCT). All patients were female aged 51, 55 and 62 years. All denied surgical intervention. In one patient, rapid spontaneous resolution of the vitreomacular traction with a complete posterior vitreous detachment (PVD) and a normal foveal contour was achieved within 15 days. In the remaining two cases a complete PVD could be detected as late as seven months after the initial presentation. In one, though the vitreomacular adhesion released spontaneously, there was a minimal residual epiretinal membrane. In all three eyes, visual acuity was considerably improved. Spontaneous, uneventful resolution has been rarely reported in the natural course of VMT but several recent studies with the aid of OCT have shown that spontaneous resolution might be more common than previously known. In light of our cases, we believe that there is still room to search for OCT clues in eyes with VMT to predict eyes with higher likelihood of spontaneous resolution, thereby avoiding unnecessary pharmacologic and/or surgical intervention.     

Early vitrectomy for fundus-obscuring dense vitreous haemorrhage from presumptive retinal tears

Background Published literature on the management of patients with fundus-obscuring dense vitreous haemorrhage due to presumptive retinal tears is sparse and advocates waiting for spontaneous resolution. Surgery is indicated only when a definite retinal tear or retinal detachment is identified. Methods A retrospective review of all patients who underwent early vitrectomy for vitreous haemorrhage associated with posterior vitreous detachment was carried out. A comparison of initial visual acuity versus final visual acuity after vitrectomy was performed. The number of eyes that were found to have retinal tears and retinal detachment were documented. Initial and final Snellen acuities were used for statistical analysis. Categorical data were analysed using Fisher’s exact test and statistical significance was considered to be p<0.05. Results Sixteen eyes were identified and all these patients presented or were referred soon after the onset of vitreous haemorrhage. Associated ocular pathology (choroidal neovascular membrane, retinal branch vein occlusion, macroaneurysm) was suspected to be the source of the haemorrhage in 4 eyes. Vitrectomy was carried out in 12 eyes soon after presentation (mean time 6.3 days, range 1–28 days). Nineteen retinal breaks were seen in these eyes and 5 eyes had more than two breaks. None of the eyes were found to have proliferative vitreo-retinopathy at the time of surgery. Two eyes needed repeat surgery for new retinal breaks. Excluding the eyes found to have an ocular pathology as the cause of vitreous haemorrhage, the mean visual acuity improved from hand movements to 6/12 (p<0.001). Conclusions Early vitrectomy for spontaneous dense fundus-obscuring vitreous haemorrhage and posterior vitreous detachment is safe. Since the number of patients in this study was small, a prospective randomised controlled study comparing early versus late vitrectomy is needed to see whether early surgery also prevents proliferative vitreoretinopathy formation.     

Recurrence after spontaneous resolution of an idiopathic epiretinal membrane

We report a case of recurrent epiretinal membrane (ERM) after spontaneous resolution of an idiopathic ERM. A 65-year-old female demonstrated a spontaneous improvement in visual acuity from 0.1 to 1.2 in her left eye attributable to spontaneous resolution of idiopathic ERM due to posterior vitreous detachment. Thereafter, however, her visual acuity again decreased to 0.2 because of the recurrence of ERM. Her visual acuity improved to 0.8 after surgical removal. A microscopic examination of the excised specimen showed a characteristic undulating internal limiting membrane (ILM) and a continuous sheet of cells overlying the inner surface of the ILM. This case report illustrates that although spontaneous ERM resolution is rare, there is a possibility of recurrence even after spontaneous ERM resolution.     

Spontaneous resolution of congenital bilateral Brown's syndrome

We report a case of bilateral Brown's syndrome in a 4-year-old girl. Forced duction testing confirmed the clinical diagnosis. After 7 months we observed a spontaneous resolution in the right eye. The problem in her left eye did not show any significant change over 36 months of follow-up. Various spontaneous resolutions in bilateral cases are reviewed.     

Spontaneous or secondary to intravitreal injections of anti-angiogenic agents retinal pigment epithelial tears in age-related macular degeneration

AIM:To evaluate the visual function evolution of retinal pigment epithelial (RPE) tears in patients with age-related macular degeneration (AMD) according to type of occurrence [spontaneous or secondary to anti-vascular endothelial growth factor (anti-VEGF) injection] and the topographic location of the tear after a two-year follow-up period.METHODS:A total of 15 eyes of 14 patients with RPE tears in exudative AMD were analyzed retrospectively at the University Eye Clinic of Trieste. Inclusion criteria were:patient age of 50 or older with AMD and RPE tears both spontaneous occurring or post anti-VEGF treatment. Screening included:careful medical history, complete ophthalmological examination, fluorescein angiography (FA), indocyanine green angiography (ICG), autofluorescence and infrared imaging and optical coherence tomography (OCT). Patients were evaluated every month for visual acuity (VA), fundus examination and OCT. Other data reported were:presence of PED, number of injections before the tear, location of the lesion.RESULTS: Mean follow-up was 24wk (SD±4wk). A total of 15 eyes were studied for RPE tear. In 6 cases (40%), the RPE tears occurred within two years of anti-VEGF injections the others occurred spontaneously. In 13 cases (86.6%), the RPE tear was associated with pigment epithelial detachment (PED). In 7 cases (46.6%), the RPE tear occurred in the central area of the retina and involved the fovea. Two lesions were found in the parafoveal region, six in the extra-macular area. In all cases visual acuity decreased at the end of the follow-up period (P<0.01) independently of the type or the topographical location of the lesion.CONCLUSION:RPE tear occurs in exudative AMD as a spontaneous complication or in relation to anti-VEGF injections. Visual acuity decreased significantly and gradually in the follow-up period in all cases. No correlation was found between visual loss and the type of onset or the topographic location of the tears.     

Use of mitomycin C in the treatment of corneal conjunctival intraepithelial neoplasia

Purpose: To evaluate the efficacy of topical mitomycin C as a treatment of corneal conjunctival intraepithelial neoplasia.
Methods: An open prospective analysis of 20 cases of corneal conjunctival intraepithelial neoplasia with recurrent disease (17 patients) or refusing surgery (three patients) were treated with topical mitomycin C. Treatment was with mitomycin C eye drops, either 0.02% or 0.04%, four times daily for 1 week followed by a week off the cycle then repeated for a second week. Patients were examined weekly until the lesions were eradicated.
Results: Clinical resolution of disease occurred in 18/20 cases. The mean time to resolution was 4.5 weeks, the mean number of cycles of treatment was two. Average follow up was 13 months with four cases of recurrent disease. These four cases were retreated with complete resolution in two cases. Epithelial toxicity occurred in 10/20 eyes and lid toxicity in two cases. There were no long-term complications on discontinuing mitomycin C.
Conclusions: Mitomycin C is effective in inducing regression of corneal conjunctival intraepithelial neoplasia. Complications are common but self-limiting. An optimal regimen is still to be established.     

Retinal pigment epithelial tears. Patterns and prognosis

Increasing experience with the diagnosis of retinal pigment epithelial (RPE) tears has led to expanded recognition and understanding of this clinical entity. The authors report 18 RPE tears followed for an average of 28 months; 16 were associated with age-related macular degeneration and 2 with presumed ocular histoplasmosis syndrome. Retinal pigment epithelial dehiscences fell into four categories: nine spontaneous tears associated with choroidal neovascularization, one tear associated with an RPE detachment without choroidal neovascularization, four iatrogenic tears occurring at krypton treatment of choroidal neovascularization, and four iatrogenic tears developing weeks to months after laser treatment of choroidal neovascularization. Eight patients had a final visual acuity of 20/100 or better, four were 20/200, and six were 20/400 or worse. Photocoagulation, particularly with the use of krypton red laser, may be modified on the basis of possible RPE tear formation. Heightened awareness of the possibility of inducing pigment epithelial rips should improve diagnosis and management of these cases.