Blood-stained tears—a red flag for malignancy?

• Published in: Eye (London) 2023-06, Vol.37 (8), p.1711-1716
• Main Authors: Kaushik, Megha, Juniat, Valerie, Ezra, Daniel G., Verity, David H., Uddin, Jimmy, Timlin, Hannah
• Format: Article
• Language: English
• Subjects: 692/699/3161/3162; 692/699/3161/3167; Biopsy; Blood; Blood tests; Chronic lymphocytic leukemia; Conjunctiva; Contact lenses; Eyelid; Eyelids - pathology; Female; Hematological diseases; Hematology; Humans; Laboratory Medicine; Lacrimal Apparatus - pathology; Lacrimal Apparatus Diseases - diagnosis; Lacrimal Apparatus Diseases - pathology; Lacrimal Duct Obstruction - pathology; Lacrimal gland and Nasolacrimal duct; Leukemia; Liver cirrhosis; Magnetic resonance imaging; Malignancy; Medicine; Medicine & Public Health; Metastases; Middle Aged; Multiple myeloma; Nasolacrimal Duct - pathology; Ophthalmology; Papilloma; Patients; Pharmaceutical Sciences/Technology; Plasmacytoma; Retrospective Studies; Surgery; Surgical Oncology; Tears; Tomography; Transitional cell carcinoma; Trauma; Tumors; Wound drainage
• ISSN: 0950-222X; 1476-5454
• DOI: 10.1038/s41433-022-02224-x

Background Blood-stained tears can indicate occult malignancy of the lacrimal drainage apparatus. This study reviews data on patients presenting with blood in their tears and the underlying cause for this rare symptom. Methods Patients presenting with blood in their tears, identified over a 20-year period, were retrospectively collected from a single tertiary ophthalmic hospital’s database and analysed. Results 51 patients were identified, the majority female (58%) with a mean age of 55 years. Most cases were unilateral (96%) with blood originating from the nasolacrimal drainage system in 53%. The most common diagnosis for blood-stained tears was a lacrimal sac mucocele ( n  = 16) followed by a conjunctival vascular lesion ( n  = 4). Three patients had systemic haematological disorders. The rate of malignancy was 8% ( n  = 4), with 2 patients having lacrimal sac transitional cell carcinomas, one with a lacrimal sac plasmacytoma and the other with chronic lymphocytic leukaemia and bilateral orbital infiltration (with bilateral bloody tears). One patient had a lacrimal sac inverted papilloma, a premalignant lesion. Four patients had benign papillomas (of the lacrimal sac, conjunctiva and caruncle). Conclusion Haemolacria was a red flag for malignancy in 8% of patients (and tumours in 18% of patients). A thorough clinical examination including lid eversion identified a conjunctival, caruncle, eyelid or canalicular cause in 27% of cases.