Bloody Tears or Haemolacria has a broad differential diagnosis. Malignancy of the lacrimal gland, lacrimal sac or conjunctiva is a rare consideration, but only after consideration and exclusion of recent trauma, periocular or intraocular surgery, infectious disease, and systemic disease as an underlying etiology.
Haemolacria or blood in the patient's tears can find its source at any point along the anterior ocular surface. ocular adnexa, and lacrimal system (tear pathway), from tear production through tear drainage, including the lacrimal gland, the conjunctiva, the canaliculi or the lacrimal sac. Blood in the tear film can even represent regurgitation of nasal or sinus bleeding to the ocular surface.
The decision tree on whether to pursue infectious, inflammatory, traumatic or malignancy work up is driven first by the patient's symptomatology and history as well as the examination findings.
Pertinent history for this symptom include:
- Laterality of the bloody tears and of clear excessive tearing if coexistant
- Both for the bloody tearing and when the tearing is not bloody: ask the patient to describe the quality, quantity and frequency of the tears, is patient carrying a tissue all the time, do friends and strangers ask if they are crying?
- Duration and frequency
- Burning, Itching
- Exacerbating factors
- History of facial trauma or eye trauma
- History of intraocular surgery, orbital surgery, eyelid surgery, facial surgery lacrimal surgery or sinus surgery
- Personal or family history of hematologic disease
- History of vascular lesions around the eye
- Medications - any blood thinners, topical medications in or near eye
- Other Bleeding- particularly Epistaxis, Hemoptysis, spitting up blood
- If factitious disorders suspected - is anyone with the patient immediately prior to the episode?
Examination 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. A patient with a bleeding diathesis leading to the abnormal tearing may also have Subconjunctival Hemorrhage. 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. Mass lesions above the medial canthal tendon are of particular concern for malignancy or other atypical process. 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.
Psychological distress (either secondary to the blood in tears, or related to the underlying etiology as in Gardner-Diamond or factitious disorders)
Clear drainage (tearing) or mucoid drainage. Concomitant presence of these symptoms may indicate a lacrimal outflow source of the bleeding.
Pain in lacrimal drainage apparatus if the source of blood is a traumatic, inflammatory or infectious etiology that affects these structures
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).
- Probing and Irrigation in the office
- Culture of discharge from punctum
- Cytology (to examine for endometrial cells, malignant cells or artificial substances) of discharge from punctum
- Nasal endoscopy (in office with ENT and/or intraoperative)
- Computed tomography of the sinuses
- Intraoperative biopsies of the lacrimal gland, such as during Dacryocystorhinostomy if clinically indicated for persistent and severe tearing
If history, examination and imaging studies are unrevealing, consider work up for an underlying hematologic disorder. 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.
- Canaliculitis (such as Actinomyces Israelii - https://eyewiki.org/Canaliculitis)
- Inflammatory diseases or lesions of the conjunctiva including Giant Papillary Conjunctivitis, Erythema Multiforme and Pyogenic Granuloma
- Hematologic conditions including Gardner-Diamond Syndrome (also known as psychogenic purpura or autoerythrocyte sensitization syndrome) 
- Anticoagulant use
- Topical Silver Nitrate exposure
- Epistaxis with retrograde flow - patient may induce the reflux of blood into the tears by pinching either side of the nose
- Infections of the sinuses and/or lacrimal sac- Tuberculosis or Rhinosporidiosis
- Melanoma of the Conjunctiva
- Melanoma of the Lacrimal Sac
- Other malignancies of the Lacrimal Sac, Lacrimal Gland or Conjunctiva
- Benign mass lesions of the lacrimal sac (such as Inverted Papilloma of the Lacrimal Sac - https://eyewiki.org/Inverted_Papilloma_Lacrimal_Sac, Squamous Papilloma of the Lacrimal Sac due to HPV)
- Nasolacrimal endometriosis/ Vicarious Menstruation 
- Factitious disorders - patients have been reported to introduce food coloring or their own blood into the eye
While some authors use topical medication in cases without a clear diagnosis, observation without topical therapy may be most appropriate. Treatment of the underlying systemic condition is appropriate when such conditions are present. Some authors do a trial of punctal plug to localize the bloody tearing.
Medical follow up
On thorough evaluation , if the condition is felt to be benign and potentially idiopathic in nature, clinical follow up is indicated to ensure complete resolution of the symptoms. If the symptom recurs or does not resolve, further work up may be indicated. A review of 15 reportedly idiopathic cases in children and young adults noted that time to resolution ranged from 3 days to 9 months in the 13 of the 15 who experienced resolution. Once symptoms resolved, recurrence was uncommon. Ho et al. also found that all four of the patients in their series experienced eventual resolution of their symptoms. 
If there are any red flags for a malignancy, biopsy of the suspicious area should be considered.
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