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血泪诊疗流程的中国专家共识（2024版）

Chinese expert consensus on the diagnosis and treatment procedures of bloody tears (2024)

来源期刊： 眼科学报 | 2025年1月 第40卷 第1期： 1-11 发布时间：2025-1-28 收稿时间：2025/1/17 9:32:15 阅读量：419
作者：
中国医师协会眼科分会泪器病专业委员会,
中国中西医结合学会眼科专业委员会泪器病学组,
关键词：
血泪诊疗流程专家共识
bloody tears expert consensus diagnosis and treatment procedures
DOI：
10.12419/24102302
收稿时间：
2024-10-23 
修订日期：
2024-11-19 
接收日期：
2024-12-02 
血泪是指因各种原因导致眼部流出血性泪液的症状，其病因和临床表现复杂多样，往往涉及多学科多专业。不同病因引起的血泪，无论是临床表现，还是诊治方法均差异很大。为了向临床医生提供可参考的血泪临床诊疗流程，中国医师协会眼科医师分会泪器病专业委员会及中国中西医结合学会眼科专业委员会泪器病学组组织有关专家以临床实践经验为基础，经过认真讨论建立本共识，对血泪的病因、临床特征及诊疗流程提出指导性意见。
Bloody tears refers to the symptoms of blooding tears flowing from the eye due to various reasons. Its etiology and clinical manifestations are complex and diverse, often involving multiple disciplines and specialties. In order to provide clinicians with a reference for the clinical diagnosis and treatment process of bloody tears, Lacrimal Diseases Professional Committee of Ophthalmologist Branch of Chinese Medical Doctor Association and Lacrimal Diseases Group of Ophthalmic Professional Committee of Chinese Association of Integrated Medicine organized relevant experts to establish this consensus based on clinical practice after serious discussion, and put forward guiding opinions on the etiology, clinical characteristics, and diagnosis and treatment process of bloody tears.

文章亮点

1. 关键发现

对于血泪病例诊治的国内外现状进行分析总结，发现血泪的病因复杂，且诊治欠规范，国内外尚缺乏对血泪进行较为系统的诊治指导。

2. 已知与发现

血泪病因和临床表现复杂多样，常常涉及多学科多专业。
不同病因引起的血泪，无论是临床表现，还是诊治方法均差异较大。

3. 意义与改变

整理血泪的临床特征和病因，建立规范的诊疗流程达成专家共识，指导临床医生对血泪病例进行规范的诊治。

        血泪是眼科疾病的症状之一，是指因各种原因导致眼部流出血性泪液的症状，常用的英文表达包括 Bloody tears和Haemolacria，患者可以表现为眼部大量出血，也可以表现为眼部隐匿性出血或血性分泌物。近年来，关于血泪的文献报道日益增多，有血泪症状的患者也呈逐渐增多的趋势[1-4]。由于血泪的病因和临床表现复杂多样，往往涉及多学科多专业，其病因不同，诊治迥异[1-4]，而长期以来国内外对其没有比较全面、系统的认识，大多数文献仅为个案报道，没有规范的诊疗流程可参考，导致临床医生在接诊这类患者时，特别是遇到流大量血泪的急诊患者时，无据可依。为了向临床医生提供可参考的血泪的临床诊疗规范流程，中国医师协会眼科医师分会泪器病专业委员会及中国中西医结合学会眼科专业委员会泪器病学组组织有关专家以临床实践经验为基础，总结国内外血泪诊治的研究成果，按照共识建立的规范流程[5-6]，达成共识如下。

1 血泪的病因

        血泪的来源可涉及眼球、眼附属器及鼻部，病因包括炎症、肿瘤、外伤、手术损伤、凝血功能异常、异常血管、异常黏膜、心理因素、药物因素及部分特发性因素等。详见表1。

1.1 局部病因

       1.1.1 眼表及其周围组织的病变或损伤
        受累部位包括眼睑、泪腺、结膜等。眼睑的病变、损伤、寄生虫等和涉及巩膜的病变或损伤也可以引发血泪[7-11]。泪腺的病变可导致血泪屏障破坏，血管通透性增加，或者病变直接破坏泪腺组织或血管结构等也可引起血泪。结膜的病变及损伤是血泪最常见的原因，通常有明确的病因，例如异物、炎症、肿瘤等，导致结膜损伤或被侵犯[1, 7, 12-20]。
       1.1.2 泪道及其周围组织的病变及损伤
        受累部位包括泪道系统、鼻腔、鼻窦、眼眶等。泪道系统的病变和损伤是引起严重血泪的最常见原因。来自泪道的自发性血性反流液需要考虑肿瘤，特别是恶性肿瘤[1, 21-30]。泪道炎症性病变、结核、肉芽肿、异物、医源性损伤、血管瘤、静脉曲张、乳头状瘤等良性病变也会引起血泪[1, 24, 26, 31-44]。还有特发性血泪，出血大多是来自泪道系统。鼻外伤或其他原因导致的鼻腔大量出血时，如果捏鼻或鼻腔填塞，可能导致血液逆向流入鼻泪管、泪囊，从同侧泪点流出，引发血泪[45-48]。鼻部的骨折也可能波及泪道，导致血液逆行自泪点溢出，引发血泪，患者可能同时伴有鼻出血[49]。鼻腔的炎性或其他病变也可波及鼻泪管、泪囊，导致血泪发生[37, 50]。上颌窦、筛窦病变和眼眶病变或异物均可能侵及泪道系统，出现自泪点的血性反流液[35, 50-52]。泪道系统及其周围组织的病变所引起的血泪有时可同时伴有鼻出血。
       1.1.3 其他病变
        颅底骨折可导致脑脊液和血液流入结膜囊或鼻腔，有时可引起血泪。另外，子宫内膜异位症的患者，若异位的子宫内膜存在于眼部或泪道，则可出现与月经期同步的血泪症状[53-54]，也有部分患者不与月经期同步，但呈现规律性出血表现[54- 55]。正常结膜有时可对激素敏感引起血泪，如雌激素性经前高血压引起血泪[56]。另外，还有眼部或泪道黏膜对刺激性气体或强光等敏感，导致血管通透性增加，引发血泪，特点是结膜呈现弥漫性渗血[57- 58]，可伴有其他部位出血[59]。

表 1 血泪的常见病因
Table1 Common causes of bloody tears

病因分类                                                          血泪常见病因

局部病因

眼表及其周围组织的病变或损伤

 

泪道及其周围组织的病变及损伤

 

其他病变

颅底骨折

子宫内膜异位症

激素相关

特殊刺激，如气体、气味、光线等

全身和系统性病变相关病因

凝血功能异常

 

血管形态及功能异常

 

其他系统性疾病

高血压

甲状腺功能障碍

糖尿病

其他特殊病因

药物相关

人为因素

精神、心理因素

特发性血泪

 

 1.2 全身和系统性病变相关病因

       这些疾病所引发的血泪，可能独立出现，也可能同时伴有其他部位的出血，如血汗、鼻出血、紫癜及消化道出血等，而血泪仅为这些疾病在眼部的表现。
       1.2.1 凝血功能异常
        有些血液系统疾病或免疫系统疾病可能导致凝血因子缺乏、血小板减少等，影响凝血功能，进而导致血泪[60-64]。长期使用抗凝药物也可能引起血泪[65]，机制与前者类似。
       1.2.2 血管形态及功能异常
        异常的毛细血管通常较为脆弱，容易破裂出血。若其存在于眼部或泪道，则可能因某些刺激导致血管破裂，发生血泪。如毛细血管扩张症、血管瘤、静脉曲张等[1, 15, 41, 66-68]。部分疾病会导致血管通透性增加， 引发血泪，如过敏性紫癜、药疹、血管炎、多形性红斑样药疹及急性出血性水肿[59, 69-70]等。另外，维生素C缺乏也可能引起血管通透性增加，导致血泪[71]。
       1.2.3 其他系统性疾病
        严重且控制不理想的高血压可能导致血泪或加重血泪[51, 72- 73]。甲状腺功能障碍也可能与血泪有关[74]，这可能与甲状腺功能障碍导致凝血功能障碍或引起血管通透性增加有关。糖尿病可导致血管内皮的损伤，肾衰竭可导致溶血性贫血、血小板功能异常、凝血异常等，这些系统性疾病均可能与血泪的发生有关。系统性疾病可以单独导致血泪发生，也可作为附加因素加重血泪的发生，而有时血泪可同时与多种系统性疾病相关[75]。

1.3 其他特殊病因

        1)药物相关：醋甲胆碱和乙酰胆碱均能够导致血管扩张，导致血泪[2]。2)人为因素：人为在结膜囊内放入异物或自伤结膜，可引起结膜破损，引发血泪， 如孟乔森综合征(Munchausen Syndrome)患者，这种患者会伪装或制造自身的疾病来赢得同情、获得照顾， 或控制他人[1, 34, 76]，在一定程度上也属于一种心理性疾病，有时可伴有其他的行为异常。3)精神及心理因素：精神心理因素可引发血泪[77-81]，机制可能是心理压力引起的小血管收缩(通过肾上腺素刺激)，随着心理压力消失，这些血管过度扩张达到破裂点、血管破裂或血管通透性改变、血液组织外渗等，可表现为血泪、血汗、消化道出血等多部位出血[78-79]。另外， Gardner-Diamond综合征(自身红细胞敏感综合征，又 称心因性紫癜)也会引起血泪[82]，与精神压力大有关系，可同时伴有头痛、眩晕、乏力复视等。另如，前文所述的孟乔森综合征[34, 83-84]也可归于属于精神及心理因素。4)特发性血泪[1, 85-96]：常见于青少年，女性略多见，出血原因不明确，具有自限性，有时可伴有其他部位出血，如血汗、鼻出血、鼓膜出血、头皮出血 等，也有学者认为其可能与心理因素相关。

2 血泪的临床特征

         血泪可以是孤立的临床表现，也可以伴随其他的临床表现，可单眼发生，也可双眼同时发生或先后发生，或同时伴有其他部位出血。局部组织病变引起的多为单眼，双眼或联合其他部位出血的通常提示与全身病变或其他因素相关，伴有其他行为异常的通常提示可能与精神心理因素相关。血泪的性状可以为稀薄的血性泪液，也可为血性分泌物，甚至为鲜血，有些 症状隐匿，容易被忽略，有些症状十分严重。稀薄的血性泪液通常提示泪湖周围组织的病变。血性分泌物者通常见于涉及泪道的系统病变，特别是同时伴有溢脓者。血管破裂造成的鲜血样血泪通常提示异常血管或恶性病变。有明确诱因如刺激性气味或气体等的血泪，提示可能与血管通透性增加有关。在女性患者， 血泪发生偶尔可表现为与月经同步或不同步的周期性 发作，通常提示为子宫内膜异位症。青少年发生者若排除器质性病变者，需要考虑精神心理因素相关性血泪和特发性血泪。
        血泪有时会伴随其他症状，如鼻出血、溢泪、 溢脓、泪囊区包块、视力下降等。与全身疾病相关的血泪往往伴有其他部位的出血、紫癜等，有些为可见部位，有些为不可见部位，如颅内出血、消化道出血等，根据伴随病变的部位，患者可能伴有其他的症状，如头痛、腹痛等。

3 血泪的诊疗流程

3.1 诊断流程

       3.1.1 患者个人资料及病史
        收集患者个人资料，包括性别、年龄，细致地询问患者病史，包括血泪眼别、性状、频率、发作的周期，是否有疼痛、瘙痒、复视等伴随症状，是否伴有其他部位的不适，如腹痛、头痛等。血泪发作的诱因，如用药史、手术史、头面部的外伤史(特别是眼部和鼻部)、异物接触史、家族史(特别是出血性疾病家族史)、生活环境(包括物理环境和人文环境)及精神心理状态。询问是否有其他部位的出血或紫癜。充分了解病情和病史，嘱患者详细记录出血情况，留存照片及视频。部分患者可能需要长时间随诊。在接诊过程中，需要仔细观察患者是否有异常的行为或语言表述，仔细询问是否有特殊的感情经历或生活经历等， 并向家属了解其是否有特殊经历和异常行为等。
       3.1.2 体格检查
       3.1.2.1 眼科检查
        常规眼科检查包括视力、眼压、验光、眼底检查。裂隙灯检查重点观察泪腺、眼睑、结膜及泪点， 明确是否有异物，肿物，损伤等，按压泪囊区皮肤观察是否有血性反流，初步判断出血来源和原因。检查需要双侧对比。注意内眦、眼眶是否能触及包块、是否有压痛。若怀疑出血来自泪道系统，可用泪点塞阻塞泪点，观察出血部位[97]。血泪往往为不定期发作，因此临床医生需要在发作时，详细检查患者眼表，寻找可能的血泪来源，或可以尝试使用Valsalva动作诱导出血[48]。
       3.1.2.2 全身检查
        重点在于明确患者是否有其他部位出血、紫癜、瘀斑等，注意检查鼻腔及口腔等黏膜组织。同时注意患者血压、血糖、呼吸、脉搏等生命体征情况。
       3.1.2.3 根据出血部位补充检查
        若怀疑出血来自泪腺，可行泪腺影像学检查， 明确是否有肿瘤及血管畸形，必要时行病理活组织检查。结膜囊出血给予细胞学检查，明确是否有异位的子宫内膜细胞、肿瘤细胞等异常细胞或人工物质[55]。 若出血来自泪点，需进行泪道病专科检查。泪道冲洗明确是否有泪道狭窄或阻塞，重点观察是否有血性反流;鼻腔内镜检查，观察鼻腔黏膜状态及是否有肿物 生长。必要时尚需补充泪道CT造影三维重建检查、眼部或头部磁共振、数字减影-血管造影等检查，明确是否有肿物生长及血管渗漏。亦可补充泪道内镜检查， 观察泪道内部是否有异物存留，及黏膜状态[61, 67]，是 否有异常血管及肿物生长等，该检查也可与手术同步进行，在明确病变后直接手术治疗。若结膜囊内发现特殊异物，则需要进一步了解患者是否有特殊生活经历并进行心理评估。
       3.1.3 实验室检查及辅助检查
        常规实验室检查包括血常规、生化全项、凝血全项、尿常规等。若常规检验结果异常，或考虑与全身病变相关时，需要补充其他相关的检查。如测定凝血因子全套，明确患者是否存在凝血因子异常或缺乏引起。行头部磁共振血管成像(magnetic resonance angiography, MRA)、CT血管造影(CT angiography, CTA) 若发现异常，必要时补充数字减影血管造影(digital subtraction angiography, DSA)明确患者是否存在血管畸形或血管通透性异常。毛细血管脆性试验可辅助诊断毛细血管缺陷性的疾病和凝血功能异常性疾病。若患者有过敏性疾病史，如过敏性鼻炎，需要行过敏原筛查、鼻腔内镜检查，明确鼻黏膜状态，评估是否有过敏性鼻炎，必要时可进行诊断性抗过敏治疗。对于有自身免疫性疾病史者可补充血液C-反应蛋白检测、病原学检测、免疫学检测、潜血试验、腹部影像学检查，明确患者是否存在自身免疫性疾病引起。补充甲状腺功能全项检查，若有异常，可继续补充眼眶CT 或MRI检查，明确甲状腺功能异常相关的血泪。必要时可补充彩色多普勒超声检查。皮下注射自身红细胞 或红细胞基质诱导瘀斑或出血，可辅助证明Gardner-Diamond综合征。若病史提示血泪为周期性发作，可进行醋酸甲羟孕酮试验，排除子宫内膜异位症。有些血泪涉及多科室，必要时请相关科室会诊协助明确诊断。
       3.1.4 其他检查
        患者伴有异常行为、精神心理疾病史，或有可能导致精神压力过大的生活史时，需要考虑精神心理因素，这些病例尚需进行心理学相关检查以明确是否患有相关疾病。有些尚需基因检测，明确与细胞外基质相关的基因以及胶原链、A-解整合素、金属蛋白酶、 金属肽酶、黏蛋白和血管性血友病因子相关的基因是否存在致病突变[6, 87]。
        有些病例在全面检查后，确实排除器质性疾病和心理疾病，可考虑为特发性，但需长期随诊，观察其病情变化，必要时重复相关检查。

3.2 治疗流程

        有些血泪既有局部病变，又有全身因素，或是全身系统性疾病在眼局部的表现，可能同时涉及多系统疾病，也可能同时涉及生理因素和心理因素，或仅与单一的精神心理因素相关，因此需要多方面考虑，多学科专业协作诊治。
       3.2.1 局部病变
        血泪的最常见病因为局部病变，对于由局部病变引起血泪者的治疗原则为彻底清除病灶，重视病理检查。由泪腺肿物引起者予切除肿物，送病理诊断， 必要时配合抗肿瘤治疗。对于存在泪腺炎性病变者需要辅以内科治疗。对于结膜病变和损伤者，可切除病变组织，积极治疗原发病。在局部病变引起的血泪中，泪道系统病变是引起严重血泪最多见的原因。对于来自泪小管的病变或异物，可行泪道内镜下探查、 清除病灶或异物，必要时行泪小管切开。对于来自泪囊及鼻泪管的病变，可行泪囊切开清除病灶，并行病理学检查，重点是完整切除病变组织，再行泪道修复手术，如泪囊鼻腔吻合术或泪道再造手术，若为恶性病变，则需扩大切除，不过多考虑保留功能，必要时可行二期泪道重建手术。对于由子宫内膜异位症引起者，需请妇科专科联合诊疗。
      3.2.2. 全身病变
        导致血泪的全身病变常见于血液系统疾病、免疫系统疾病、内分泌系统疾病等，它们可以作为独立因素引起血泪，也可作为混杂因素加重血泪，可以仅引起血泪发作，也可以同时导致其他部位的出血。涉及全身病变引起者需请专科协助诊治，必要时转其他科室进行专科诊治，眼科随访。异常血管的血管通透性 增加引起的血泪，需要在明确异常血管部位的情况下 进行治疗，必要时请相关专科进行治疗，眼科随诊。
       3.2.3 特殊病因
        对于药物源性引起者可予诊断性停药，眼科随 诊。对于考虑与维生素C缺乏有关的血泪，可给予相应补充维生素C的试验性治疗[59]。对精神心理因素相 关的血泪在排除或治疗明确的器质性疾病病因的情况下，需要请心理科专科诊断及治疗，眼科随诊[78]。对 无法明确病因的特发性血泪患者需要长期随诊，必要时辅以心理干预，减轻其心理压力，并建议其改变生 活环境，改善周围人际环境，必要时可给予药物治疗，例如普萘洛尔、酒石酸美托洛尔、谷维素、维生 素C及云南白药胶囊等。虽然普萘洛尔在血泪治疗中可能有一定的作用[78, 81, 89, 91, 98]，但需要注意的是，儿童患者和心脏疾病患者使用β-受体阻滞剂如普萘洛尔时，需要在心内科医生监控下使用，若出现不适，即刻停药。
       3.2.4 不明病因
        在各项检查未能明确血泪病因时，可首先积极治疗潜在的系统性疾病[86]，或许可以起到诊断性治疗的作用，但是否积极使用药物治疗，目前尚有争论。 尽管大多数病例提示，那些无法明确病因的青少年特发性血泪患者在成年后会逐渐停止发作，引起严重后果的较少，但不应因此放松警惕，应首先积极寻找病因，在确实无法查到明确病因的情况下，密切随访， 若随访过程中发作加重，则需要积极应对[58]。

3.3 血泪诊断和治疗流程

        血泪的临床特征复杂，病因多样，诊断和治疗各异，根据血泪的临床特征，专家组经过集体讨论建立该诊疗流程，以期帮助临床医生有序排查病因，选择合适的治疗。血泪诊断和治疗流程见图1。

图 1 血泪诊疗流程图
Figure 1 Diagnosis and treatment process of bloody tears

形成共识的专家组成员:

执笔专家

陶海 解放军总医院第三医学中心眼科医学部
白芳 解放军总医院第三医学中心眼科医学部

专家组成员

陶海 解放军总医院第三医学中心眼科医学部(专委会主任委员、学组组长，通信作者)
白芳 解放军总医院第三医学中心眼科医学部(专委会和学组委员兼秘书，执笔人)
杨代慧 南京医科大学第二附属医院眼科(专委会副主任委员、学组副组长)
叶琳 暨南大学附属深圳眼科医院眼整形与泪器病科(专委会副主任委员、学组副组长)
王智崇 中山大学中山眼科中心(专委会副主任委员)
李明武 北京大学人民医院眼科(学组副组长)
梁轩伟 中山大学中山眼科中心(专委会和学组特邀专家、候选委员)

中国医师协会泪器病专委会委员兼中西医结合泪器病学组委员(按姓氏拼音顺序)

陈建华 山东中医药大学附属眼科医院
程勉征 湖北武汉艾格眼科医院泪道病科
范金鲁 南京爱尔眼科医院泪道科
高晶 辽宁营口经济技术开发区中心医院眼科
耿爽 中国医学科学院北京协和医院眼科
郭胜 山西省大同市第五人民医院眼科
郝尚臣 郑州大学第一附属医院眼科
郝友娟 山东省烟台市烟台山医院眼科
黄波 北京中医药大学深圳医院眼科
姬明利 陕西省西安医学院第二附属医院眼科
贾宝云 云南省大理大学第一附属医院眼科
蒋劲 浙江省人民医院眼科
李光宇 吉林省吉林大学第二医院眼科中心
李晓东 贵州省人民医院
刘海 云南省第二人民医院眼科
刘建巨 哈尔滨医科大学附属第一医院眼科
刘名皎 海南省人民医院眼科
罗布次仁 西藏自治区拉萨市人民医院眼科
吕红玲 广东省佛山市第二人民医院眼科
莫亚 成都中医药大学附属医院眼科
欧阳高翔 辽宁省大连市第三人民医院眼科
潘荣海 江苏省徐州医科大学附属医院眼科
乔丽萍 武警医学特色中心眼科
庆惠玲 河南省人民医院眼科
单秀水 河北省唐山市眼科医院泪器病科
王海彬 河北省承德医学院附属医院眼科
王士军 内蒙古巴林左旗中医蒙医医院眼科
王婷婷 江苏省徐州市第一人民医院眼科
王艳 复旦大学附属眼耳鼻喉科医院眼科
王曜 黑龙江省佳木斯大学附属第二医院眼科
徐文双 黑龙江省齐齐哈尔市五官科医院眼科
徐朝阳 福建省福建中医药大学附属人民医院眼科
严松 内蒙古自治区鄂尔多斯市中心医院眼科
杨海军 南昌大学附属眼科医院
杨华 陕西省眼科研究所
杨俭伟 河北省眼科医院
央京 四川省甘孜藏族自治州人民医院康巴眼科中心
杨雯 辽宁省沈阳市第九人民医院眼科
杨文慧 天津医科大学总医院眼科
张宏 新疆医科大学第一附属医院眼科
张宗生 新疆哈密中心医院眼科
郑莎 陆军军医大学第一附属医院眼科
郑艳霞 河北省沧州中西医结合医院眼科
钟建光 浙江省杭州市第一医院眼科
朱宏伟 新疆阿克苏地区第一人民医院眼科

中西医结合泪器病学组委员

白萍 河北省眼科医院
陈琳琳 辽宁省沈阳市第四人民医院眼科
涂云海 温州医科大学附属眼视光医院

中西医结合泪器病学组青年委员

龚静文 浙江省人民医院眼科
刘红 广州中医药大学第一附属医院眼科
刘卫锋 邵阳爱尔眼科医院
潘淑玲 上海爱尔眼科医院
逄作祥 山东省潍坊市第二人民医院眼科
孙红梅 清华大学第一附属医院眼科
谭炬辉 华容爱尔眼科医院
王立华 解放军总医院第三医学中心眼科医学部
王新明 北京熙仁医院
王秀丽 莱芜爱尔眼科医院
王媛 暨南大学附属深圳眼科医院泪器病科
吴战斌 山西省运城眼科医院
肖盼 苏州大学附属第四医院眼科
熊士波 武汉艾格眼科医院
许广昌 天津医科大学第二医院眼科
闫春芳 山西省眼科医院
杨迪康 南昌普瑞眼科医院
杨晓钊 陕西省眼科研究所
杨雪莉 山东省烟台市烟台山医院眼科
银泉 鄂内蒙古自治区尔多斯市中心医院眼科
占志云 福建医科大学附属第一医院眼科
张文俊 解放军联勤保障部队第九四0医院眼科
张一 锦州爱尔眼科医院
郑群 南京爱尔眼科医院
郑颖洁 习水爱尔眼科医院
钟悦 辽宁省营口市中西医结合医院眼科
周丹 广东医科大学附属东莞第一医院眼科

参与建立共识的其他专家

王朋 解放军总医院第三医学中心眼科医学部
周希彬 解放军总医院第三医学中心眼科医学部
陈荣新 中山大学中山眼科中心

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26、Kaushik%20M%2C%20Juniat%20V%2C%20Ezra%20DG%2C%20et%20al.%20Blood-stained%20tears-a%20red%20flag%20for%20malignancy%3F%5B%20J%5D.%20Eye%2C%202023%2C%2037(8)%3A%201711-1716.%20DOI%3A10.1038%2Fs41433-%20022-02224-x.Kaushik%20M%2C%20Juniat%20V%2C%20Ezra%20DG%2C%20et%20al.%20Blood-stained%20tears-a%20red%20flag%20for%20malignancy%3F%5B%20J%5D.%20Eye%2C%202023%2C%2037(8)%3A%201711-1716.%20DOI%3A10.1038%2Fs41433-%20022-02224-x.I%E2%80%99m%20
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