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Dacryoendoscopy in a Case of Unexplained Hemolacria

Ali, Mohammad Javed, F.R.C.S.; Naik, Milind N., M.D.

Ophthalmic Plastic & Reconstructive Surgery: November/December 2018 - Volume 34 - Issue 6 - p e213
doi: 10.1097/IOP.0000000000001154
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Govindram Seksaria Institute of Dacryology, L.V. Prasad Eye Institute, Hyderabad, India

Accepted for publication April 18, 2018.

M.J.A. received support from the Alexander von Humboldt Foundation for his research, and he also receives royalties from Springer for the textbook “Principles and Practice of Lacrimal Surgery” and “Atlas of Lacrimal Drainage Disorders.”

The authors have no conflicts of interest to disclose.

Address correspondence and reprint requests to Mohammad Javed Ali, F.R.C.S., L. V. Prasad Eye Institute, Govindram Seksaria Institute of Dacryology, Hyderabad-34, India. E-mail:

Hemolacria or bloody epiphora is an uncommon presentation with multiple etiopathogenetic factors, and establishing the causative factor can be challenging. A female, aged 35 years, presented with repeated episodes of right-sided bloody tears of 3-month duration. She also had a right-sided intermittent epiphora of 1-year duration. There was no past history of any trauma or other systemic disorders. Lacrimal drainage irrigation was suggestive of a right partial nasolacrimal duct obstruction, and the left side was patent. Ocular examination was normal. A dacryoendoscopy evaluation showed 2 large submucosal varices at the junction of the lacrimal sac and nasolacrimal duct (Fig. A, black arrows). During the examination, one of the dilated vessels demonstrated spontaneous leakage of blood (Fig. B, black arrow). In the vicinity of these vessels, was a large dacryolith (Fig. C, black arrow), which was filling two thirds of the lumen and intermittently touching the varices with irrigation fluid movements. Because the dacryolith was very large and the location of varices at the narrow sac/duct junction, an option of a dacryocystorhinostomy with removal of the dacryolith and cauterization of the vessels was considered but the patient decided to observe for now.

The submucosal areas of the sac-duct junction and the nasolacrimal duct have large dilated cavernous sinuses and hence is more prone for the development of varices. The cause of hemolacria in the present case was the friable varices with the dacryolith in the vicinity, being an exacerbating factor. The differential diagnosis of hemolacria includes trauma, lacrimal tumors, endometriosis, and bleeding disorders. Although rare, lacrimal varices should also be kept in the differential diagnosis of an unexplained hemolacria.

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