Malignancy may be indicated by bloody tears and, if caught early, can increase a patient’s life expectancy. Photo: K. Ozcan/Int J Ped Otorhinolaryngol. Click image to enlarge.

Hemolacria, or bloody tears, is rarely seen, but its presence may signal malignancy. Researchers recently reviewed the patient data of a cohort with hemolacria and reported that the lacrimal sac was the most common origin of malignancy.

A total of 51 patients were identified over a 20-year period at a single center (58% female, mean age 55). The researchers reported that 96% of cases were unilateral, with blood originating from the nasolacrimal drainage system in 53%. Lacrimal sac mucocele was the most common diagnosis (found in 16 patients), followed by conjunctival vascular lesion in four patients and systemic hematological disorders in three patients.

Overall, the rate of malignancy was 8% (four patients). The researchers reported that two of these patients had lacrimal sac transitional cell carcinomas—the first had a lacrimal sac plasmacytoma, and the second had chronic lymphocytic leukemia and bilateral orbital infiltration with bilateral bloody tears. The third patient had a lacrimal sac inverted papilloma, a premalignant lesion. The fourth patient had benign papillomas of the lacrimal sac, conjunctiva and caruncle.

The researchers concluded that although malignancy rates are low, early identification can boost life expectancy and increase patients’ treatment options. They recommended performing a thorough clinical assessment with lid eversion to exclude a conjunctival, eyelid, caruncle or canalicular cause. Lid eversion identified 27% of these causes.

“If no cause is identified on examination, then lacrimal syringing should be performed,” they advised in their paper. “If the examination is clear, blood-stained tears are identified on nasolacrimal duct irrigation, or a lacrimal sac mass is palpated, then further radiological imaging ± biopsy is required for a diagnosis. Blood tests are useful [for identifying] systemic hematological anomalies that predispose [a patient] to bleeding, especially in bilateral cases.”

Kaushik M, Juniat V, Ezra DG, et al. Blood-stained tears—a red flag for malignancy? Eye Nature. September 10, 2022. [Epub ahead of print].