Epistaxis Complicated by Hemolacria: A Case Report

Discussion

Etiologies of hemolacria can include retrograde epistaxis, surgical or other trauma to the lacrimal system, conjunctival hemorrhage, lacrimal sac tumors or infections, hereditary hemorrhagic telangiectasias, and aberrant microvascular endometrial tissue causing bleeding into the lacrimal basin (vicarious menstuation).1,2 Conjunctival hemorrhages can be caused by trauma, conjunctivitis, conjunctival ulcers, telangiectasias, hemangiomas, conjunctival varices, and tumors; the lid rim has also been reported as a site of hemolacria in a case of blepharoconjunctivitis.2 Hemolacria secondary to retrograde epistaxis (as suspected in our case) has been reported in patients with epistaxis and increased pressure within the nasal cavity, which can be caused by nasal packing as well as by pinching or blowing the nose.3,4 Blood emerging through the lacrimal punctum is most frequently a result of retrograde epistaxis, but can also be caused by tumors, foreign bodies, or contusive trauma. In the absence of nasal packing or other forms of nasal obstruction, it is generally assumed that the bleeding is the result of extravasation in the lacrimal pathways rather than epistaxis with retrograde flow.2 No case reports were identified in the literature in which hemolacria preceded epistaxis, which suggests that hemolacria in the setting of retrograde epistaxis is a secondary outcome rather than a primary presenting symptom.

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Figure 1

Anatomy of the nasolacrimal system. Note the position of the lacrimal puncta, valve of Rosenmuller, nasolacrimal duct, and the valve of Hasner.21 Reproduced with permission. Meyer, et al. AJNR Am J Neuroradiol. 1993;14(4):1008–1010. Copyright © 1993 American Society of Neuroradiology. All rights reserved.

In the case of retrograde epistaxis, the underlying cause is thought to be the anatomic connection between the inferior nasal turbinates and the lacrimal system. In the setting of epistaxis with tamponade, blood pools in the inferior turbinate of the nasal fossae. From this area it can ascend through the Valve of Hasner into the nasolacrimal duct and lacrimal sac, pass through the valve of Rosenmüller, and then extrude through the lacrimal canaliculi and enter the eye as bloody tears via the lacrimal puncta5 (see Figure 1). If the source of the epistaxis is distal to the Valve of Hasner, a significant arterial hemorrhage is likely, and nasal tamponade may theoretically cause the valve to become incompetent and result in a retrograde nasolacrimal hemorrhage.5 Hemolacria, however, is rare; it does not occur in most patients with epistaxis, even those with severe arterial hemorrhage treated with nasal tamponade. This raises the question of whether there is a rare anatomic anomaly that might increase the risk for hemolacria. Incompetency of the valve of Hasner is usually congenital, but may also occur in cases of surgical or accidental trauma to the orifice of the nasolacrimal duct, or from nasal infection.18 According to Duke-Elder, about 5% of persons can “whistle through their eyes, as it were, when air is forcibly exhaled with the nose closed.”18 Tanenbaum and McCord note that for patients with congenital absence of both the valve of Hasner and the valve of Rosenmüller, “it is possible to blow air from the nose into the eye, and nosebleeds may produce bloody tears.”19 We postulate that only patients with congenital absence or incompetence of the valves of Hasner and Rosenmüller are predisposed to develop hemolacria in the setting of epistaxis treated with nasal tamponade. This could explain the rarity of hemolacria as a complication of epistaxis in the general population. In the case of our patient who had no prior history of hemolacria or (presumably) whistling through the eyes, incompetence of the lacrimal valves could have played a significant role in the development of hemolacria. While the nasolacrimal valvular system has never been studied in isolation in terms of age, venous valvular incompetence is known to increase with increasing age and findings can likely be extrapolated to include valves of other systems (Figure 1).20