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CASE REPORT
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Frank conjunctival bleeding in a male patient – A very rare presentation


 Department of Ophthalmology, Andaman and Nicobar Islands Institution of Medical Science, Port Blair, Andaman and Nicobar Islands, India

Date of Submission23-May-2020
Date of Decision19-Jul-2020
Date of Acceptance07-Aug-2020

Correspondence Address:
Sujit Das,
Assistant Professor, Department of Ophthalmology, Adesh Medical College and Hospital, Near Ambala Cantt, Vill-Mohri, Dist-Shahbad, Kurukshetra, Haryana-136135
India
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/mjdrdypu.mjdrdypu_275_20

  Abstract 


Frank conjunctival bleeding in an adult male is a very rare presentation. There are so many causes of conjunctival bleedings; hence, a detailed medical history along with investigations apart from ocular, ENT, and a systemic evaluation is very important to find the exact etiology. Here, we present a case of frank conjunctival bleeding in an 18-year-old boy with a history of acne disorder and hematemesis. Detailed ocular, dermatological, and systemic examination has shown a correlation between acne disorder, meibomian gland dysfunction, dry eye syndrome, and Helicobacter pylori (HP) gastritis in this case. HP infection along with androgen hormone overactivity has been thought to be responsible for the pathophysiology of this frank conjunctival bleeding in this case.

Keywords: Acne rosacea/acne vulgaris with conjunctival bleeding, conjunctival telangiectasis and fresh conjunctival bleeding, frank conjunctival bleeding, hematemesis and frank conjunctival bleeding, meibomian gland dysfunction and conjunctival bleeding



How to cite this URL:
Das S. Frank conjunctival bleeding in a male patient – A very rare presentation. Med J DY Patil Vidyapeeth [Epub ahead of print] [cited 2021 Nov 30]. Available from: https://www.mjdrdypv.org/preprintarticle.asp?id=319172




  Introduction Top


Hemolacria (bleeding from the eye) apart from injury, local infection, and systemic disorder is a very rare presentation in a young male.[1] There are so many causes of conjunctival bleeding such as viral conjunctivitis,[2] conjunctival amyloidosis,[2] vicarious menstruation,[3] hemophilia,[4] vascular tumors,[5] Vitamin-K deficiency,[6] conjunctival telangiectasia,[7] bleeding from the lacrimal gland tumors,[8] bleeding from nasal pathology and regurgitation of blood through the lacrimal passages,[9] and hysteria.[10] Chronic conjunctival inflammation may lead to telangiectatic vessels formation, and subsequent microtrauma to these delicate vessels can lead to fresh bleeding.[2]  Meibomian gland More Details dysfunction (MGD), dry eye syndrome, and acne vulgaris are well known for conjunctival inflammation.[11] Androgens (testosterone) are known for their control over meibomian gland function.[11] They regulate the quality and/or quantity of lipids produced by this tissue and promote the formation of the tear film's lipid layer.[11] Very little information exists between the correlation of serum levels of sex hormones and MGD between 20 and 30 years of age.[11] Increased serum levels of dehydroepiandrosterone sulfate (DHEA-S) have been reported in patients with seborrheic MGD, seborrheic dermatitis, acne vulgaris, acne rosacea (AR), and hirsutism.[11],[12] Conjunctival vessels are delicate and telangiectatic vessels are very pretty fragile in nature. Inflamed conditions of the eye thus can cause microtrauma to these delicate vessels.[13] The nasolacrimal duct connects the eye to the area behind the nose, and sometimes, a growth or an infected duct can cause blood-tinged tears.[14] Nasal bleeding can also shed bloody tear. This is the reason why our nose starts running when we cry.[14] Hence, a detailed nasal examination is mandatory in a case of hemolacria. Systemic disorders such as diabetes mellitus, hypertension, arteriosclerosis, sickle cell disease, multiple myeloma, and polycythemia vera are all known for their microangiopathy and microtrauma to the conjunctival vessels.[15] These causes should be considered in a case of frank conjunctival bleeding.[15] Vitamin-K and Vitamin-C are known for the strengthening of capillary walls, and any gastrointestinal problems or dietary less intake of such vitamins can cause weakening of the blood vessels.[16],[17] Helicobacter pylori (HP) infection is a major cause of gastritis and known for hematemesis and nasal regurgitation.[18] HP also plays an important role in AR,[19] and its eradication treatment has been proven effective in AR.[20] HP infection hence gains interest to the ophthalmologists.[21]


  Case Report Top


An 18-year-old boy came to the emergency (January 25, 2018) department with complaining of fresh bleeding from the eyes [Figure 1]a. It was sudden in onset, and there was no history of any associated pain, redness, and discharge. He had no history of any ocular trauma. There is a history of on–off blurring of vision and eye rubbing for the past 3 months of duration. He had no recent history of any eye infection. The patient had a recent episode of hematemesis 7 days back and was diagnosed as a case of distal esophagitis [Figure 1]b and congestive gastropathy [Figure 1]c along with gastroesophageal reflux disease. He was started on proton-pump inhibitors. A similar episode occurred in January 2016. He was prescribed proton-pump inhibitors but was on irregular medication. There was no past history of hepatitis, tuberculosis, hypertension, diabetes, bleeding per rectum, gums bleeding, bleeding disorders, and psychiatric problems. He was on irregular use of topical azelaic acid for acne disorder [Figure 1]d for the past 1 year. Family history was insignificant. He was nonalcoholic and nonsmoker. The patient was admitted and proper evaluation was carried out. On examination, blood pressure was found 110/80 mmHg. Pulse was 88/min and regular. Detailed gastrointestinal endoscopic examination revealed evidence of gastropathy. ENT evaluation was unremarkable. Best-corrected visual acuity was − 6/6 in both the eyes. Intraocular pressure was 14 mmHg. Cycloplegic refraction was insignificant. Punctate corneal lesions were noted in both the cornea [Figure 2]a after fluorescein staining along with meibomian gland capping [Figure 2]b. Telangiectatic vessels [Figure 2]c were there in the conjunctiva and had a lacy appearance on fluorescein staining [Figure 2]d. Mild papillary changes were also present in the upper palpebral conjunctiva [Figure 3]a. Lacrimal punctum was found normal [Figure 3]b. Syringing was done and found patent. Schirmer's test signifies dry eyes [Figure 3]c. Tear film breakup time was <10 s. Rest anterior and posterior segment examination was appeared normal. On investigations, there was no evidence of leukemia, hemophilia, and thrombocytopenia. The liver function test was normal. Serological test for HIV, hepatitis, syphilis, C-ANCA, P-ANCA, RA factor, and ANA was found negative. Computed tomography (CT) scan dacrocystography [Figure 3]d, noncontrast CT of the head, neck, and para nasal sinus (PNS) [Figure 4]a, ultrasonography of the abdomen, chest X-ray posteroanterior view [Figure 4]b, and CECT chest [Figure 4]c all were found normal. Dental examination was unremarkable [Figure 4]d The patient was started on anti-H-pylori eradication kit (HP-kit = amoxicillin [1 g] plus tablet metronidazole [400 mg] twice daily plus omeprazole [20 mg] twice daily)-1 tablet twice daily for 15 days. Tablet doxycycline (100 mg) 1 tablet twice daily × 15 days was added for MFD. The topical application of azelaic was continued after taking advice from a dermatologist. Carboxymethylcellulose drop was started, 1 drop 6 times a day along with lid application of mild steroid (Neosporin-H eye ointment) twice a day. The patient was advised for dark glass, hot fomentation twice a day, and to avoid eye rubbing. He responded well with all medications and was discharged with proton-pump inhibitors. Carboxymethylcellulose drop was continued. There was no further episode of such bleeding in the next 1-year follow-up.
Figure 1: (a) Fresh bleeding from eyes. (b) Endoscopy showed distal esophagitis. (c) Congestive gastropathy. (d) Acne vulgaris

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Figure 2: (a) Punctate corneal lesion. (b) Meibomian gland orifice capping. (c) Conjunctival telangiectatic vessels. (d) Lacy conjunctival vessels

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Figure 3: (a) Conjunctival papillary changes. (b) Normal lacrimal punctum. (c) Schirmer's test shows dry eyes. (d) Computed tomography dacrocystography showed normal lacrimal passage

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Figure 4: (a) Noncontrast computed tomography of the neck, PNS, and nasopharynx does not reveal any abnormality. (b) Normal chest X-ray. (c) Normal noncontrast computed tomography chest. (d) Normal gum appearance

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  Discussion Top


Frank conjunctival bleeding in a male is a rare phenomenon. There are various causes of such bleeding such as ocular trauma, viral conjunctivitis, conjunctival amyloidosis, vicarious menstruation, hemophilia, vascular tumors, Vitamin-K deficiency, hereditary hemorrhagic telangiectasia, bleeding from the lacrimal gland tumor, regurgitation of blood from the nose through the lacrimal passages, and hysteria.[2],[3],[4],[5],[6],[7],[8],[9],[10] Bleeding from conjunctiva in a young girl is not unknown, as it is seen in vicarious menstruation and hysteria.[10] Scientists concluded that occult hemolacria in fertile women thus seems to be induced by hormones,[3],[10] but hemolacria in young male is very rare. MGD and associated dry eye syndrome is a well-known association.[11] Patients with MGD commonly present with blurring of vision, dry eye, and eye rubbing.[11] Very little information exists between the correlation of serum sex hormone levels and MGD between 20 and 30 years of age.[11],[12] Meibomian gland is considered as an androgen target organ.[11],[12] Androgens (testosterone) are reported to control meibomian gland function, regulate the quality and/or quantity of lipids produced by this tissue, and promote the formation of the tear film's lipid layer.[12] The lipid layer produced by meibomian glands stabilizes the tear film and prevents evaporation. Abnormality of this function is the primary cause of blepharitis and evaporative type of dry eye.[11],[12] It has been seen that there is an increased serum level of testosterone and DHEA-S in both genders with seborrheic MGD and considered as a diagnostic marker for seborrheic MGD.[12],[18] Acne vulgaris/AR is a chronic cutaneous inflammatory disease of the midface and mainly involves young adults.[11],[12] In the adolescent age group, sex hormone plays an important role in the pathology of acne vulgaris.[11],[12] Ocular involvement occurs in 30%–70% of patients with acne vulgaris and AR.[11],[12] Conjunctival capillary telangiectasias are common in patients with AR and acne vulgaris.[11],[12],[22] Microtrauma to these vessels may lead to fresh conjunctival bleeding.[7],[11],[12],[15] Although AR affects women more than men, ocular involvement is seen equally in both the sexes.[22] Testosterone excess is considered to aggravate seborrhea on the human skin and reported to increase sebaceous gland growth. It is also well known that testosterone excess plays an important role in the formation of acne vulgaris/AR and seborrhea.[11],[12],[22],[23] Environmental influences also have been considered in the pathogenesis of both obstructive and seborrheic variety of MGD.[24] Triggering factors such as excessive sunlight exposure, temperature extremes, hot and spicy foods consumption, menopause, and emotional factors such as stress, anger, and embarrassment can also play an important role in the pathogenesis of MGD.[22],[23],[24] Acne vulgaris/AR has been found to be associated with the increased tear fluid levels of several inflammatory mediators such as interleukin-1, matrix metalloproteinases, interferon-alpha, and inflammatory cytokines.[11],[12],[18],[19],[20] All these inflammatory markers also play an important role in the pathophysiology of dry eye syndrome.[11],[12],[22],[23] Continuous conjunctival inflammation may lead to collaterals, telangiectasia, conjunctival hyperemia, and corneal infiltrate/vascularization.[11],[12],[19],[22],[23] HP IgG antibodies were found in 81% cases of the AR with dyspepsia, but there is a debate whether this is a coincidence or not.[18],[19],[20],[21] There have been several investigations suggesting a possible etiologic role of HP infection in rosacea as the prevalence of HP infection in patients with rosacea is higher than that in controls.[19],[20],[21] HP eradication treatment has been found effective in reducing the severity of rosacea.[19],[20],[21] Mindel and Rosenberg, in 1997, for the first time, described the correlation of HP gastritis and ocular pathology.[21] HP infection is the primary cause of gastritis and peptic ulcer disease. HP antigens could affect extradigestive organs such as the eye.[19],[20],[21] HP can increase the serum or tissue levels of nitric oxide, inducing vasodilatation, inflammation, and immune modulation.[19],[20],[21] Erosive gastropathy causes hematemesis and through the nose, blood travel through punctum and may present as a case of bleeding from the eye.[9],[14]


  Conclusion Top


Increased serum levels of testosterone and DHEA-S in both genders should be considered as diagnostic markers for seborrheic MGD, acne vulgaris, and AR. Increased androgen activity is known for its role in telangiectatic vessel formation in the ocular surface. There is a strong correlation exist between HP infection, AR, and MGD. MGD and subsequent dry eye syndrome, conjunctival inflammation, and microtrauma to the telangiectatic vessels are thought to be the cause of eye bleeding in this rare case.

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Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Centers for Disease Control and Prevention (CDC). Swine influenza A (H1N1) infection in two children—Southern California, March-April 2009. MMWR Morb Mortal Wkly Rep 2009;58:400-2.  Back to cited text no. 1
    
2.
Lee HM, Naor J, De Angelis D, Rootman DS. Primary localized conjunctival amyloidosis presenting with recurrence of subconjunctival hemorrhage. Am J Ophthalmol 2000;129:245-7.  Back to cited text no. 2
    
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Barat M, Kwedar SA. Ocular vicarious menstruation. J Pediatr Ophthalmol Strabismus 1988;25:254-5.  Back to cited text no. 3
    
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Franchini M, Mannucci PM. Acquired haemophilia A: A 2013 update. Thromb Haemost 2013;110:1114-20.  Back to cited text no. 4
    
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Shields JA, Mashayekhi A, Kligman BE, Benjamin Kunz W, Criss J, Eagle RC Jr., et al. Vascular tumors of the conjunctiva in 140 cases. Ophthalmology 2011a; 118:1747-53.  Back to cited text no. 5
    
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Shearer MJ. Vitamin K deficiency bleeding (VKDB) in early infancy. Blood Rev 2009;23:49-59.  Back to cited text no. 6
    
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Soong HK, Pollock DA. Hereditary hemorrhagic telangiectasia diagnosed by the ophthalmologist. Cornea 2000;19:849-50.  Back to cited text no. 7
    
8.
Levine MR, Dinar Y, Davies R. Malignant melanoma of the lacrimal sac. Ophthalmic Surg Lasers 1996;27:318-20.  Back to cited text no. 8
    
9.
Comelli I, Vincenti V, Benatti M, Macri GF, Comelli D, Lippi G, et al. Influence of air temperature variations on incidence of epistaxis. Am J Rhinol Allergy 2015;29:e175-81.  Back to cited text no. 9
    
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Tarasova LN, Briukhina EV. A case of vicarious menstrual bleeding from the conjunctiva [in Russian]. Vestn Ophthalmol 1991;10:759.  Back to cited text no. 10
    
11.
Sullivan DA, Sullivan BD, Ullman MD, Rocha EM, Krenzer KL, Cermak JM, et al. Androgen influence on the meibomian gland. Invest Ophthalmol Vis Sci 2000;41:3732-42.  Back to cited text no. 11
    
12.
Placzek M, Arnold B, Schmidt H, Gaube S, Keller E, Plewig G, et al. Elevated 17-hydroxyprogesterone serum values in male patients with acne. J Am Acad Dermatol 2005;53:955-8.  Back to cited text no. 12
    
13.
Richards A, Guzman-Cottrill JA. Conjunctivitis. Pediatr Rev 2010;31:196-208.  Back to cited text no. 13
    
14.
Guarisco JL, Graham HD 3rd. Epistaxis in children: Causes, diagnosis, and treatment. Ear Nose Throat J 1989;68:522, 528-30, 532.  Back to cited text no. 14
    
15.
Cheung AT, Ramanujam S, Greer DA, Kumagai LF, Aoki TT. Microvascular abnormalities in the bulbar conjunctiva of patients with type 2 diabetes mellitus. Endocr Pract 2001;7:358-63.  Back to cited text no. 15
    
16.
McNinch A. Vitamin K deficiency bleeding: Early history and recent trends in the United Kingdom. Early Hum Dev 2010;86 Suppl 1:63-5.  Back to cited text no. 16
    
17.
Langlois M, Duprez D, Delanghe J, De Buyzere M, Clement DL. Serum Vitamin C concentration is low in peripheral arterial disease and is associated with inflammation and severity of atherosclerosis. Circulation 2001;103:1863-8.  Back to cited text no. 17
    
18.
Amedei A, Bergman MP, Appelmelk BJ, Azzurri A, Benagiano M, Tamburini C, et al. Molecular mimicry between Helicobacter pylori antigens and H+, K+--adenosine triphosphatase in human gastric autoimmunity. J Exp Med 2003;198:1147-56.  Back to cited text no. 18
    
19.
Gravina AG, Federico A, Ruocco E. Helicobacter pylori infection but not small intestinal bacterial overgrowth may play a pathogenic role in rosacea. United European Gastroenterol J 2015;3:17–24.  Back to cited text no. 19
    
20.
Szlachcic A, Sliwowski Z, Karczewska E, Bielański W, Pytko-Polonczyk J, Konturek SJ. Helicobacter pylori and its eradication in rosacea. J Physiol Pharmacol 1999;50:777-86.  Back to cited text no. 20
    
21.
Mindel JS, Rosenberg EW. Is Helicobacter pylori of interest to ophthalmologists? Ophthalmology 1997;104:1729-30.  Back to cited text no. 21
    
22.
Ghanem VC, Mehra N, Wong S, Mannis MJ. The prevalence of ocular signs in acne rosacea: Comparing patients from ophthalmology and dermatology clinics. Cornea 2003;22:230-3.  Back to cited text no. 22
    
23.
Chamaillard M, MortemousqueW B, Boralevi F, Marques da Costa C, Aitali F, Taïeb A, et al. Cutaneous and ocular signs of childhood rosacea. Arch Dermatol 2008;144:167-71.  Back to cited text no. 23
    
24.
Goto E, Endo K, Suzuki A, Fujikura Y, Matsumoto Y, Tsubota K. Tear evaporation dynamics in normal subjects and subjects with obstructive meibomian gland dysfunction. Invest Ophthalmol Vis Sci 2003;44:533-9.  Back to cited text no. 24
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

 
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