Some authors do a trial of punctal plug to localize the bloody tearing. Treatment of the underlying systemic condition is appropriate when such conditions are present. While some authors use topical medication in cases without a clear diagnosis, observation without topical therapy may be most appropriate. Factitious disorders - patients have been reported to introduce food coloring or their own blood into the eye.Nasolacrimal endometriosis/ Vicarious Menstruation.Benign mass lesions of the lacrimal sac (such as Inverted Papilloma of the Lacrimal Sac -, Squamous Papilloma of the Lacrimal Sac due to HPV).Other malignancies of the Lacrimal Sac, Lacrimal Gland or Conjunctiva.Infections of the sinuses and/or lacrimal sac- Tuberculosis or Rhinosporidiosis.Epistaxis with retrograde flow - patient may induce the reflux of blood into the tears by pinching either side of the nose.Hematologic conditions including Gardner-Diamond Syndrome (also known as psychogenic purpura or autoerythrocyte sensitization syndrome).Inflammatory diseases or lesions of the conjunctiva including Giant Papillary Conjunctivitis, Erythema Multiforme and Pyogenic Granuloma.Canaliculitis (such as Actinomyces Israelii - ).This might include complete blood count, complete metabolic panel, bleeding time, prothrombin time/INR, coagulation studies and possible consultation with a Hematologist to guide laboratory work up. If history, examination and imaging studies are unrevealing, consider work up for an underlying hematologic disorder. Intraoperative biopsies of the lacrimal gland, such as during Dacryocystorhinostomy if clinically indicated for persistent and severe tearing.Nasal endoscopy (in office with ENT and/or intraoperative).Cytology (to examine for endometrial cells, malignant cells or artificial substances) of discharge from punctum.Skin or conjunctival lesions (thorough exam important as above, since the presence of such lesions may reveal either the underlying etiology of bloody tearing or provide clues to the source of the bloody tearing). Pain in lacrimal drainage apparatus if the source of blood is a traumatic, inflammatory or infectious etiology that affects these structures Concomitant presence of these symptoms may indicate a lacrimal outflow source of the bleeding. Psychological distress (either secondary to the blood in tears, or related to the underlying etiology as in Gardner-Diamond or factitious disorders)Ĭlear drainage (tearing) or mucoid drainage. Reflux of bloody discharge or other material on compression of the lacrimal sac may localize the source of the bloody tears to be the lacrimal sac. Mass lesions above the medial canthal tendon are of particular concern for malignancy or other atypical process. Digital palpation of the lacrimal sac over the lacrimal sac fossa region and upward may be revealing and should be compared to the opposite side in unilateral cases. A patient with a bleeding diathesis leading to the abnormal tearing may also have Subconjunctival Hemorrhage. If factitious disorders suspected - is anyone with the patient immediately prior to the episode?Įxamination should include thorough slit lamp examination of the conjunctiva (including everting upper lids to fully examine palpebral conjunctiva), lacrimal gland and puncti for any lesions, changes in anatomy or other unusual findings.
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