Eyes, menstruation and endometriosis

Vicarious menstruation refers to cyclical bleeding outside the uterine cavity during the menstrual cycle. Haemolacria, or blood in tears, is a rare medical phenomenon that can occur with menstruation or in association with endometriosis. Endometriosis, defined by the presence of endometrial-like tissue in extra-uterine sites, affects around 10% of fertile women; the ocular system is one of the rarest sites it can be present in. Endometriosis usually requires a biopsy for diagnosis, and the anatomic difficulty of obtaining a biopsy of the ocular system makes ocular endometriosis diagnosis more obscure. However, few cases have been described in the literature and due to the psychological, physical, and social implications of haemolacria on the patient, treatment is of utmost importance. We reviewed the literature on ocular endometriosis and ocular vicarious menstruation with the aim to discuss the clinical presentation, necessary workup and various treatment modalities, while also shedding light on the connection between the eyes and endometriosis in general. It is hypothesised that uterine endometrial cells can travel lymphatically or haematogenously and deposit extra-uterine endometriotic lesions that bleed in response to hormonal changes in the menstrual cycle. Additionally, the conjunctival vasculature has been found to be responsive to hormonal changes due to the presence of oestrogen and progesterone receptors, causing bleeding at the corresponding sites, even without endometriotic lesions. Clinical correlation of the haemolacria with the menstrual cycle can suffice for a diagnosis of vicarious menstruation, and thus opens the possibility of treatment to provide symptomatic treatment for the patient.

[Diagnostic value of occult haemolacria]

PURPOSE

To study tears for occult (latent) haemolacria in women and compare the representativeness of the main methods of tear examination.

MATERIAL AND METHODS

Tear samples from 72 women aged between 18 and 46 years were evaluated using two methods: microscopic and chemical with reagent test strips.

RESULTS

In the follicular phase of the menstrual cycle, erythrocytes in tears were detected in 59.1% (13) subjects, which was significantly higher (χ²=4.2, p=0.041) compared to the luteal phase - erythrocytes were detected in 40.9% (9) women. The proportion of women in the luteal phase of the cycle who had single epithelial cells in the tear (76.9%) was significantly lower (χ²=5.2, p=0.022) than in women in the follicular phase (83.9%). The predictive value of the chemical method was 0.53 of that of the microscopic one. Microscopically, blood was detected in 30.6% of tear samples, while chemically - in 16.7%. An associative relationship was found between occult haemolacria in women and a diagnosis of endometriosis (K=0.75, p≤0.05). The proportion of women with erythrocytes in tears determined with the chemical method was 41.7% in patients with endometriosis, which was significantly higher (χ²=6.5, p=0.011) than 11.7% in women without endometriosis.

CONCLUSION

Fluctuations of hormones during the menstrual cycle are reflected in tear composition, manifested as an increase in the number of epithelial cells in the luteal phase, and erythrocytes in the follicular phase. Erythrocytes found in a tear amid accumulations of epithelial cells, their glandular atypia and neutrophilic infiltration in patients with endometriosis may indicate the manifestation of extragenital endometriosis. The microscopic method turned out to be more sensitive in detecting occult haemolacria, and additionally it provided information about other cells. At the same time, the chemical method, which was relatively diagnostically informative, faster and technically simpler, can be used for screening.

Factitious disorder, presenting haemolacria in a Pakistani tribal illiterate female: A rare case report

INTRODUCTION

It could be challenging for healthcare workers to diagnose patients with factitious disorder who present with rare ophthalmologic manifestations such as haemolacria, because of the unavailability of adequate literature and associated guidelines. The present case report aims to fulfill this knowledge gap.

CASE PRESENTATION

A 20-year-old tribal illiterate married female patient with symptoms of bleeding episodes from her left eye was admitted to the hospital. An extensive workup was done for diagnosing possible bleeding disorders but all the parameters were normal. Later on, she was diagnosed with factitious disorder presenting haemolacria after sufficient evidence at the psychiatric unit observations. The patient was treated accordingly, counseled and discharged, but lost-out to follow-ups.

PRACTICAL IMPLICATIONS

The present case is reported from a developing country, Pakistan, for the first-time may help in diagnosing patients suffering from factitious disorder with unusual ophthalmologic problems.

[Haemolacria: etiopathogenesis, diagnosis, treatment]

This article is devoted to the problem of haemolacria, which is a condition that causes a person to produce tears containing blood. The article generalizes and analyzes the data on this rare pathology from scientific literature, systematizes the information about etiopathogenesis of haemolacria and its clinical manifestations, describes possible diagnostic and treatment options, and presents the points of view of authors on this disease. The main purpose of this review is to inform about this rare pathology, which a doctor of any specialty has a chance to encounter.

Haemolacria: A Novel Approach to Lesion Localization

PURPOSE

To report the use of punctal plugs as a new modality to assist in the localization of lesions providing symptomatic relief in patients with haemolacria during their workup.

METHODS

Retrospective case series.

RESULTS

One boy and one girl, ages 16 and 20, respectively, reported spontaneous bloody tearing. Workup included probing and irrigation of the nasolacrimal system, blood and coagulation profiles, blood typing, serum hormone levels, conjunctival biopsy, and imaging. All findings were normal and failed to suggest a cause in any of the cases. Punctal plugs were inserted into each patient's inferior punctum OS without complication. On initial follow-up visits, each patient reported cessation of bloody tears OS with continued bloody tears OD. Over time, both patients experienced complete cessation of haemolacria in both eyes.

CONCLUSIONS

Haemolacria is a condition caused by a group of disorders that result in the production of tears that are partially composed of blood. The large majority of cases result in a specific diagnosis. Only rarely does workup result in undetermined etiology. The novel approach of utilizing punctal plugs in the management of haemolacria may not only provide symptomatic relief for lesions distal to and including the punctum, but also assists in anatomic localization in idiopathic cases.