Images from a patient with argyrosis. A, Bilateral ocular surface pigmentation is evident. B, The inferior fornix and the eyelid margin show gray-black pigmentation. Black debris (arrow) is seen on the eyelid margin. C, Periocular pigment debris (arrow) is evident. The superior fornix in both the left (D) and right (E) eyes has a normal appearance. F, Dental and gingival pigmentation is seen.
Scheimpflug images and histopathologic examination. A, Corneal pigment accumulation (arrow) is seen. B, A highly reflective area is evident in the Scheimpflug camera image. C and D, Extracellular silver particles are seen in the lamina propria of the conjunctiva (C, hematoxylin-eosin, original magnification ×200; D, hematoxylin-eosin, original magnification ×400).
Palamar M, Midilli R, Egrilmez S, Akalin T, Yagci A. Black Tears (Melanodacryorrhea) From Argyrosis. Arch Ophthalmol. 2010;128(4):503-505. doi:10.1001/archophthalmol.2010.37
Systemic and local diseases can affect the content and color of the tear film. Bloody tears (hematodacryorrhea) are a red discoloration of the tears associated with several conditions, including epistaxis, contact lens irritation, severe anemia, coagulopathies, conjunctival vascular tumors, Osler-Weber-Rendu disease, nasolacrimal sac tumors, and conjunctival melanoma.1,2 Additionally, some drugs and diagnostic dyes can also change the color of the tears. Ghassemi et al3 have recently reported black tears (melanodacryorrhea) due to necrotic uveal melanoma. In this article, we describe a patient with bilateral black tears who was found to have bilateral argyrosis of the conjunctiva.
An otherwise healthy 42-year-old longstanding silver worker was referred to our clinic with suspected conjunctival melanoma. He had blackish tears for 2 months and black pigmentation of both eyes for 6 months. Bilateral visual acuity was 20/20 and intraocular pressures were normal. The periocular skin and ocular surface displayed diffuse black-gray pigmentation in both eyes (Figure 1A and B). We also noted dried black debris at the roots of the cilia and inferior periocular skin caused by diffuse black tears (Figure 1C). Ocular melanocytosis-like pigmentation of the inferior fornix and bulbar conjunctiva was evident in both eyes, while the superior fornix and bulbar conjunctiva had a normal appearance (Figure 1D and E). Patchy pigmentation was present in the corneal epithelium, superficial stroma, and Descemet membrane bilaterally. Fundus examination revealed no pigmentation. Dental, oral mucosal, skin, and nail pigmentation were evident (Figure 1F). The diagnosis of argyrosis was confirmed by conjunctival biopsy. It was possibly due to occupational inhalation of silver.
The Scheimpflug image displayed hyperreflectivity corresponding to corneal pigment accumulation areas at the superficial layers (Figure 2A and B). Histopathologic examination of the incisional biopsy material revealed subepithelial extracellular silver particles in the lamina propria, which supported the diagnosis of argyrosis (Figure 2C and D). Systemic evaluation results were normal except for the presence of fatty degeneration of the liver.
The most common health effects with prolonged exposure to silver are the development of a characteristic irreversible pigmentation of the skin (argyria) and/or the eyes (argyrosis).4 Affected areas include hands, eyes, and mucous membranes in most patients. Discoloration of the ocular surface is the main ocular evidence in these patients.4 A direct relationship was shown between the amount of discoloration and total exposure time.4 If fine particles of silver are rubbed into the eyes, localized argyrosis may develop over time.4 Generalized argyria is recognized by a widespread pigmentation of the skin, eyes, and nails and may occur when silver compounds are applied to mucosal surfaces, inhaled, ingested, or injected into the body. Similarly, our patient had conjunctival, corneal pigmentation as well as skin, nail, and dental pigmentation resulting from occupational contact. Although the exact mechanism for black tears is not very clear, we believe that mechanical inoculation (rubbing into the eyes) is the cause.4 The pigmentation resulting from silver deposits is irreversible. Chelation therapy and dermabrasion are ineffective in removing silver deposits from the body. There is no known effective treatment for argyria. Besides argyria and argyrosis, exposure to soluble silver compounds may lead to other toxic effects such as liver and kidney damage, irritation of the eyes, skin, respiratory tract, and intestinal tract, and changes in blood cells. In systemic evaluation, only fatty degeneration of the liver was detected in our patient.
Melanodacryorrhea is extremely rare, and our review of the literature for melanodacryorrhea and argyrosis yielded no results. In the case of melanodacryorrhea, argyrosis should be taken into consideration in the differential diagnosis.
Correspondence: Dr Palamar, Ege Universitesi Tip Fakultesi Hastanesi, Goz Hastaliklari AD, 35040 Bornova, Izmir, Turkey (firstname.lastname@example.org).
Financial Disclosure: None reported.