自发性血泪27例临床特征分析

Retrospective investigation of spontaneous bloody tears:a report of 27 cases

目的总结以自发性血泪为首发症状患者的临床特征、病因及治疗。方法回顾性系列病例研究。选取2015年6月至2018年12月就诊解放军总医院第三医学中心眼科泪器病中心以自发性血泪为首发症状的27例患者的临床资料及随访资料进行分析,主要包括临床特征、具体病因、诊断、治疗方法及预后情况。结果27例患者中男性10例(37.0%),女性17例(63.0%),成年人(≥18岁)21例(77.8%),未成年人(<18岁)6例(22.2%)。单眼血泪者22例(81.5%),双眼血泪者5例(18.5%)。伴有其他部位出血者5例(18.5%)。血泪性状中,血性分泌物及反流液者19例(70.4%),泪中带血3例(11.1%),鲜血样泪7例(25.9%)。病因中包括全身病变引起者6例(22.2%),其中1例为肉芽肿性多血管炎,5例为特发性血泪(经过检查排除明确器质性病变的不明原因的血泪)(均<18岁);局部病变引起者21例(77.8%),其中按照病变涉及的部位分析,单纯涉及泪道系统病变者18例,单纯涉及眼表的病变及损伤者2例,同时涉及泪道系统及眼表病变者1例。局部病变按性质分析,异物源性(异物引起)5例;单纯炎性病变6例;肿物源性10例,其中1例为结膜良性肿物,另外9例涉及泪道系统(5例恶性肿物,4例良性肿物)。特发性血泪患者经心理和内科治疗后发作间隔时间延长。1例肉芽肿性多血管炎患者给予经鼻腔内窥镜下泪囊鼻腔吻合术后血泪有反复。1例结膜血管瘤患者不接受治疗,随访13个月有不定期少量出血。涉及泪道系统者给予病灶清除联合泪囊鼻腔吻合术,1例小细胞神经内分泌癌及1例腺样囊腺癌患者肿瘤复发后死亡,其他患者预后良好。结论血泪患者中以成年人及局部病变者多见,病变多涉及泪道系统,且以肿物源性多见,治疗主要为去除病灶,必要时扩大切除并联合泪道重建手术。特发性血泪多为未成年人,治疗以心理治疗配合必要的内科治疗。

Objective To summarize clinical experience on the clinical feature,etiology and treatment of patients with spontaneous bloody tears as the initial symptom.Methods Retrospective series of case studies.The clinical data and follow-up data of 27 cases of bloody tears as the first symptom in Lacrimal Center of Ophthalmology,the Third Medical Center of Chinese PLA General Hospital from June 2015 to December 2018 were reviewed.The clinical feature,specific cause,diagnosis,treatment and prognosis of these cases were evaluated.Results A total of 27 cases were collected in this study.The patients were 10 males(37.0%)and 17 females(63.0%),including 21 adults(≥18 years old,77.8%)and 6 minors(<18 years old,22.2%).There were 22 monocular cases(81.5%)and 5 binocular cases(18.5%).Five cases(18.5%)were bleeding from the eye and other parts of the body,and 22 cases(81.5%)were bleeding only from the eye.There were 19 cases(70.4%)with hematic epiphora and secretions from the punctum,3 cases(11.1%)with blood-stained tears,and 7 cases(25.9%)with blood-like tears.With regard to etiology,6 cases(22.2%)were combined with systemic lesions,one of which was granulomatosis with polyangiitis and five of which(<18 years old)were idiopathic bloody tears.Twenty-one cases(77.8%)were local lesions,including 18 cases only involving the lacrimal system,2 cases only involving the ocular surface,and 1 case involving both the lacrimal system and the ocular surface.Among the 21 cases with local lesions,5 cases were induced by foreign body,6 cases were induced by simple inflammation,and 10 cases were induced by tumor including 1 case with conjunctival benign tumor and 9 cases with tumor of the lacrimal system(5 with malignant tumor and 4 with benign tumor).Patients with idiopathic bloody tears received psychological and medical treatment,and interictal discharge was lengthened.One case of granulomatosis with polyangiitis was treated by trans-nasal endoscopic dacryocystorhinostomy.With the recurrence of granulomatosis and polyangiitis,bloody tears recurred after surgery.One patient with conjunctival hemangioma was untreated.Lesions in the lacrimal duct system were removed and dacryocystorhinostomy was performed.In this study,2 patients(1 with small cell neuroendocrine carcinoma and 1 with adenoid cystic adenocarcinoma)died and the other had a good prognosis.Conclusions Among the cases of bloody tears,adults and local lesions are more common.Most of the lesions are located in the lacrimal system and are tumors.The main treatment is to remove the lesions,and if necessary,to expand the resection and reconstruct the lacrimal duct.Idiopathic bloody tears occur in minors,who are gave psychotherapy and necessary medical treatment.