Management of Subconjunctival Hemorrhage
Subconjunctival hemorrhage is a benign, self-limiting condition that typically resolves without treatment within 1-2 weeks and requires only reassurance and observation in most cases.
Clinical Presentation
- Sudden appearance of bright red blood under the conjunctiva
- Usually painless with normal vision
- May occur spontaneously, often during sleep
- Can be localized or diffuse, with inferior areas more commonly affected than superior areas 1
Initial Assessment
Key History Elements to Obtain:
- Onset and duration of the hemorrhage
- Associated symptoms (pain, vision changes, discharge)
- History of trauma or eye rubbing
- Contact lens use
- Recent episodes of coughing, vomiting, or straining
- Systemic conditions (hypertension, diabetes, bleeding disorders)
- Medication use (anticoagulants, aspirin, NSAIDs)
Physical Examination:
- Visual acuity assessment
- Blood pressure measurement
- Slit lamp examination to confirm diagnosis and rule out other causes of red eye
- Assessment for signs of trauma or infection
Management Approach
First-Line Management:
- Patient reassurance about the benign nature of the condition
- Observation without active intervention
- Artificial tears for any associated mild irritation
- Cold compresses for the first 24-48 hours if there is mild discomfort
When to Consider Further Evaluation:
- Recurrent or bilateral subconjunctival hemorrhages
- Large or persistent hemorrhages (>2-3 weeks)
- Associated with trauma
- Presence of pain or vision changes
- History of bleeding disorders or anticoagulant use
Special Considerations
Traumatic Subconjunctival Hemorrhage:
- Usually more localized and predominantly affects temporal areas 1
- Requires assessment for other ocular injuries
Recurrent Subconjunctival Hemorrhage:
- Warrants investigation for:
- Systemic hypertension
- Diabetes mellitus
- Bleeding disorders
- Medication side effects (anticoagulants)
- Systemic or ocular malignancies 2
Subconjunctival Hemorrhage in Patients on Anticoagulants:
- Monitor prothrombin time
- Usually does not require discontinuation of anticoagulation therapy
- Consider hematology consultation if hemorrhage is severe or recurrent 3
Patient Education
- Explain the benign nature of the condition
- Reassure that vision is not affected
- Advise that resolution typically occurs within 1-2 weeks
- The blood will gradually change color from bright red to yellow as it resolves
- Instruct to avoid rubbing the eyes
- Recommend to return if symptoms worsen or new symptoms develop
When to Refer to an Ophthalmologist
- Recurrent episodes (>3 in 6 months)
- Suspicion of underlying systemic disease
- Failure to resolve within 2-3 weeks
- Associated with vision changes or pain
- Extensive hemorrhage affecting most of the conjunctiva
Common Pitfalls to Avoid
- Overtreatment with unnecessary antibiotics or steroids
- Failure to identify underlying systemic conditions in recurrent cases
- Mistaking other causes of red eye (episcleritis, scleritis, conjunctivitis) for subconjunctival hemorrhage
- Missing signs of trauma that may indicate more serious injury
Remember that while most cases of subconjunctival hemorrhage are benign and self-limiting, recurrent episodes may be the first presenting sign of serious systemic conditions such as idiopathic thrombocytopenic purpura 4 or other bleeding disorders, warranting thorough investigation.