What is the management and treatment for a patient with a subconjunctival hemorrhage?

Management and Treatment of Subconjunctival Hemorrhage

Subconjunctival hemorrhage requires no specific treatment and will resolve spontaneously within 1-2 weeks in most cases. 1 Observation is the standard of care for this common, benign condition.

Clinical Presentation and Diagnosis

• Subconjunctival hemorrhage appears as a bright red patch on the white of the eye (bulbar conjunctiva)
• Typically painless with no visual disturbance
• Usually unilateral but can be bilateral
• May be localized or diffuse depending on cause

Management Algorithm

Immediate Assessment

1. Determine if isolated finding or associated with other symptoms

   • Rule out trauma, infection, or systemic conditions
   • Check for pain, vision changes, or discharge (which would suggest other diagnoses)

2. Evaluate for risk factors

   • Common risk factors include:
     • Minor trauma (including eye rubbing)
     • Valsalva maneuvers (coughing, sneezing, vomiting)
     • Contact lens use
     • Hypertension (particularly in older patients)
     • Diabetes
     • Anticoagulant/antiplatelet medications

Treatment Approach

For Typical Subconjunctival Hemorrhage

• Reassurance that this is a benign, self-limited condition
• No specific treatment required - will resolve spontaneously within 1-2 weeks
• Artificial tears may be recommended if mild irritation is present
• Cold compresses in the first 24 hours may help reduce discomfort

For Recurrent or Extensive Subconjunctival Hemorrhage

• Blood pressure measurement - hypertension is a common cause in older patients 2, 3
• Consider discontinuation of anticoagulants/antiplatelets only if medically appropriate and after consultation with prescribing physician
• Laboratory testing only if recurrent or if systemic bleeding disorder is suspected:
  • Complete blood count with platelet count
  • Coagulation studies (PT/INR, aPTT)

Special Considerations

When to Refer to Ophthalmology

• Recurrent subconjunctival hemorrhages (>3 episodes)
• Associated with trauma
• Accompanied by vision changes or pain
• Suspected underlying ocular condition

When to Consider Systemic Evaluation

• Multiple or recurrent hemorrhages
• Concomitant bleeding from other sites
• Patient on anticoagulation therapy
• History of bleeding disorders
• Elderly patients with first presentation (to rule out hypertension) 3

Important Caveats

• While subconjunctival hemorrhage has been investigated for potential association with acute coronary syndrome, recent comprehensive studies show no significant association 4
• Traumatic subconjunctival hemorrhages tend to be more localized and predominantly affect temporal areas 5
• In rare cases, subconjunctival hemorrhage can be the first presenting sign of serious systemic conditions like idiopathic thrombocytopenic purpura 6
• Subconjunctival hemorrhage following strabismus surgery is considered a common postoperative finding that requires only observation 1

The benign nature of most subconjunctival hemorrhages should be emphasized to patients, as the dramatic appearance often causes disproportionate concern relative to the clinical significance.