An unusual case of bloody tears.

Conjunctival bleeding although occurs in many pathological conditions enlisting diseases like purulent conjunctivitis, infection with epstian bar virus, and accidental damage to conjunctiva. We report here a rare case of bloody tears which was accompanied with severe headache in a12-years school-going girl.

Introduction

Hemolacria (blood tears) is a rare and sever clinical condition which may occur due to accidental and non-accidental trauma to conjunctiva lacrimal glad or sac.[1234] As conjunctiva is exposed surface of the eye, it suffers from many diseases, inflammation, and infection.[5] But clinical condition known as bloody tears without trauma and infection is a rare condition. Carotid artery and vertebral artery dissection is the cause of chronic migraine. Moreover, it has been found out that vertebral artery dissection is more common in younger patient's especially female gender with chronic migraine.[6] We report a case of a 12-year-old girl who presented with bloody tears following anattack of severe headache.

Case Report

This 12-year-old girl visited outpatient department (OPD) of neurology in Shaheed Zulfiqar Ali Butto Medical University, Islamabad on 28 May 2014 with investigations of bloody tears with severe headache. These were first observed when the patient was playing in her house. The parents of the patient were startled when they saw bloody tears trickling over her cheeks while she was playing with her friends. It was accompanied by headache and giddiness and the vision was unaffected. A day before her visit, bloody tears were seen for the 4th time. The 5th attack documented in the form of a photograph [Figure 1] was observed by the authors during the hospital stay of the patient and was conspicuous by the attention seeking behavior of the patient. So far, she has had 11 such episodes and no relationship with menstruation could be established in any of these. History of bleeding, disorders in the family was also denied. The blood count of the collected tears was done on Cell Dyne Rubby (Abbott USA) and the slides for microscopy and morphology were prepared. Moreover, the collected samples of tears and peripheral blood were of the same group AB Positive).

Figure 1

Bloody tears in the both eyes and orbital region

On examination, lids, conjunctiva inclusive of fornices, palpebral part of lacrimal gland, and lacrimal sac area were normal. Anterior and posterior segments did not reveal any abnormality. Vision was 6/6 both eyes. Gynecological; ear nose, and throat (ENT); and medical check-ups were within normal limits.

Complete hemogram was normal. Bleeding time, clotting time, prothrombin time index, and platelet count were also within normal limits. The capillary fragility test was negative. Skiagrams of orbits, optic foramina, and skull were without any abnormality. The patient was diagnosed with vertebral artery dissection accompanied migraine and bloody tears.

Discussion

Conjuctival, subconjunctival, and lacrimal hemorrhage and hematomaare known to occur in many clinical conditions. Like bacterial and viral infection, it has been reported in purulent conjunctivitis and acute infection with epstienbarr virus,[7] in non-accidental trauma,[8] genetic polymorphism of factor XIII Val34Leu,[9] and idiopathic thrombocytopenic purpura.[10] A rare cause of conjunctival bleeding causing bloody discharge is malignant melanoma of the conjunctiva. It has typical presentation of pigmented lesion on conjunctival surface with newly born blood vessels.[10] Bloody tears with headache have been reported in different literatures. Bloody tears of unknown cause have been reported in literature without ascertaining the cause.[11] According to Bona-volanta and Sammaritino,[11] orbital varixis the cause of bloody tears. Secondary giant papillary conjunctivitis for bloody tears was reported by Richard and Eifermam.[12] In the present case of bloody tears, we could not detect any organic cause for hemolacria after complete local and systemic examination and through investigations. Vertebral artery dissection with migraine and bloody tears were confirmed by consultant neurologist in this case.

Conclusion

We report here a case of bloody tears which was accompanied by severe headache. In our knowledge, no such case has been reported before. This is an unusual clinical entity and can be very perplexing for the clinician.