First author:Hemolacria or “ocular bleeding” is an extremely rare entity characterized by bloody tears.[1] The etiologies of this enigmatic presentation range from common causes like local inflammation, trauma, and infections to complex tumors of the lacrimal system, paranasal sinuses, vascular malformations, and systemic coagulopathies.[1,2,3,4] Despite exhaustive investigations, a subset of cases remain idiopathic.[5] Since the existing literature on idiopathic hemolacria is largely limited to single case reports or small case series, we present a retrospective series of 15 cases—the largest reported to date—to explore the underlying pathology, management, and clinical course of this enigmatic disorder.
Methods
A retrospective review of all cases presenting with hemolacria between January 2016 and April 2025 was conducted using electronic medical records. Patients with an identifiable local or systemic cause of ocular bleeding upon detailed ophthalmic examination, laboratory workup, or neuroimaging were excluded. Patients lost to follow-up were contacted over their mobile phones.
Results
An electronic database search yielded 26 patients with bloody tears during the study period, of whom 15 met the criteria for idiopathic hemolacria (24 eyes total). A distinct female preponderance was observed [12 females (80%), 3 males (20%)], with a mean age at presentation of 20.67 ± 5.35 years (range: 13–30 years). Bilateral involvement was most common (n = 9, 60%), while right and left eyes were equally affected in unilateral cases (n = 3 each, 20%). The mean symptom duration was 9.54 ± 16.58 months (range: 1 day to 5 years) [Table 1].
Table 1.
Demographic characteristics and management details of patients
| Parameters | Frequency | |||
|---|---|---|---|---|
| No. of patients | 15 | |||
| Gender | Male | 3 (20%) 12 (80%) |
||
| Female | ||||
| Mean age (yrs) with range | 20.67±5.35 years (Range 13-30 years) | |||
| Laterality | Right | 3 (20%) 3 (20%) 9 (60%) |
||
| Left | ||||
| Bilateral | ||||
| Mean duration of complaint (months) with range | 9.54±16.18 months (Range: 1 day to 5 years) | |||
| Positive history | Pshychiatric illness | 3 (20%) 2 (13.33%) 1 (6.67%) 1 (6.67%) |
||
| Stress | ||||
| Menstruation | ||||
| Malingering | ||||
| Imaging | CT-DCG | 2 2 3 |
||
| CT Orbit | ||||
| MRI Orbit | ||||
| Management (Spontaneous resolution) | 15 (100%) | |||
| Average F/U period (months) | 28.18±39.02 months (Range: 1 week to 7 years) | |||
A relevant underlying or triggering history was present in seven patients: Three (20%) had documented psychiatric illness or factitious disorder, two (13.33%) reported extreme emotional stress, one (6.67%) exhibited potential vicarious menstruation, and one 13-year-old female (6.67%) was found to be malingering by deliberately putting vermilion into her eyes.
Complete blood counts and comprehensive coagulation profile (bleeding time, clotting time, PT-INR, aPTT) were normal in all 15 patients. Advanced imaging performed in seven patients (CT dacryocystography, CT orbit, or MRI orbit) revealed no structural anomalies. Patients were reassured and managed conservatively. All patients were also referred for a psychiatric consultation and counselling. Spontaneous complete resolution of symptoms was seen in all patients after variable periods (weeks to months). The mean follow-up duration was 28.18 ± 39.02 months (range: 1 week to 7 years). A few patients reported significant improvement in duration after which bleeding occurred, even after years of initial presentation, mostly during periods of emotional stress.
Discussion
Idiopathic hemolacria is a diagnosis of exclusion made only after complete hematological and structural workups rule out secondary causes. The condition features a strong temporal association with emotional stress, mimicking the psychosomatic pathology of Gardner–Diamond syndrome (psychogenic purpura).[3,4]
Management of idiopathic hemolacria requires a meticulous history focusing on trauma, menstruation, and psychiatric comorbidities. Ocular examinations must rule out occult conjunctival vascular abnormalities. While distressing to patients, idiopathic hemolacria is typically a benign, self-limiting condition that resolves spontaneously. However, regular follow-up is necessary to ensure delayed presentation of occult pathologies is not missed, alongside psychiatric counselling, since most of these cases are linked to either stress and emotional disturbances or factitious disorders [Fig. 1a-c].[1,4]
Figure 1.
(a) - External photograph of a 23-year-old female showing bilateral idiopathic hemolacria. (b) - External photograph of a 24-year-old male showing unilateral idiopathic hemolacria. (c) - External photograph of a 13-year-old female suspected to be malingering who had put vermilion in her eyes
References
- 1.Bakhurji S, Yassin SA, Abdulhameed RM. A healthy infant with bloody tears: Case report and mini-review of the literature. Saudi J Ophthalmol. 2018;32:246–9. doi: 10.1016/j.sjopt.2017.10.006. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Das D, Chiranthan M, Meel R, Neupane S. Crying out blood: Haemolacria in a young girl. BMJ Case Rep. 2020;13:e236579. doi: 10.1136/bcr-2020-236579. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Carrion-Alvarez D, Trejo-Castro AI, Salas-Garza M, Fajardo-Ramirez OR, Salas-Alanis JC. Hematohidrosis, hemolacria, and “trichorrhage”: A systematic review. Skin Appendage Disord. 2022;8:179–85. doi: 10.1159/000520648. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.Ho VH, Wilson MW, Linder JS, Fleming JC, Haik BG. Bloody tears of unknown cause: Case series and review of the literature. Ophthalmic Plast Reconstr Surg. 2004;20:442–7. doi: 10.1097/01.iop.0000143713.01616.cf. [DOI] [PubMed] [Google Scholar]
- 5.Fowler BT, Kosko MG, Pegram TA, Haik BG, Fleming JC, Oester AE. Haemolacria: A novel approach to lesion localization. Orbit. 2015;34:309–13. doi: 10.3109/01676830.2015.1078371. [DOI] [PubMed] [Google Scholar]