What is the recommended workup for a patient with recurrent subconjunctival (under the conjunctiva of the eye) hemorrhages?

Workup for Recurrent Subconjunctival Hemorrhages

A comprehensive workup for recurrent subconjunctival hemorrhages should include evaluation for both ocular and systemic causes, with particular attention to vascular disorders, coagulopathies, and potential malignancies.

Initial Evaluation

Detailed History

• Duration and frequency of hemorrhages
• Unilateral vs bilateral presentation
• Associated symptoms (pain, vision changes, discharge)
• History of trauma or contact lens use
• Valsalva-inducing activities (coughing, vomiting, heavy lifting)
• Medication history, particularly anticoagulants 1

Ocular Examination

• Complete slit-lamp examination of conjunctiva and eyelids
• Look for:
  • Salmon-pink colored lesions (potential lymphoma) 2
  • Conjunctival nodules or masses
  • Conjunctival scarring
  • Eyelid abnormalities (potential sebaceous carcinoma) 3
  • Follicular reaction suggesting viral etiology 3

Vitreous Examination

• Examine for:
  • Presence of blood or pigmented cells (highly specific for vitreous hemorrhage) 4
  • Vitreous detachment
  • Peripheral retinal examination with scleral depression to rule out retinal tears 3, 4

Laboratory Testing

Blood Tests

• Complete blood count with platelet count (to rule out thrombocytopenia) 5
• Coagulation profile (PT/INR, aPTT)
• Blood pressure measurement (hypertension is a common cause) 6
• Glucose levels and HbA1c (diabetes screening) 4

Additional Testing Based on Clinical Suspicion

• If unilateral and persistent:
  • Consider biopsy for suspected malignancy 3
  • Cultures of eyelid margins for recurrent severe inflammation 3
• If bilateral and severe:
  • Evaluate for blood dyscrasias or clotting disorders 1

Imaging Studies

When Indicated

• B-scan ultrasonography if media opacity prevents adequate retinal examination 3, 4
• MRI or CT scan if orbital pathology or mass is suspected 2
• OCT to evaluate macular edema or other retinal pathologies 4
• Fluorescein angiography if vascular abnormalities are suspected 4

Specialized Testing

For Recurrent/Persistent Cases

• Microscopic evaluation of epilated eyelashes for Demodex mites if blepharitis is suspected 3
• Immunofluorescence studies if ocular mucous membrane pemphigoid is suspected 3
• Ophthalmology referral for specialized testing including:
  • OCT angiography for non-invasive assessment of retinal vasculature 4
  • Indocyanine green angiography for choroidal circulation evaluation 4

Follow-up Protocol

• If no abnormalities are found on initial examination, follow up every 1-2 weeks initially 4
• For patients with vitreous hemorrhage, consider weekly follow-up until resolution or until a thorough peripheral examination can be performed 4

Red Flags Requiring Urgent Attention

• Recurrent unilateral hemorrhages (potential malignancy) 2
• Extremely low platelet count (potential idiopathic thrombocytopenic purpura) 5
• Associated diplopia or orbital pain (potential orbital hematoma) 7
• Presence of pigmented cells or blood in vitreous (80% correlation with retinal tears) 4

Remember that while most subconjunctival hemorrhages are benign, recurrent episodes warrant thorough investigation as they may be the first presenting sign of serious systemic conditions such as blood dyscrasias, malignancies, or vascular disorders 6, 5.