What is the evaluation and treatment for subconjunctival (subconjunctival hemorrhage) hemorrhage?

Evaluation and Treatment of Subconjunctival Hemorrhage

Subconjunctival hemorrhage requires no specific treatment and will resolve spontaneously within 1-2 weeks in most cases. Observation and patient reassurance are the primary management approaches for this common and benign condition 1.

Evaluation

Clinical Presentation

• Sudden onset of painless, bright red blood patch on the white of the eye
• Usually unilateral but can be bilateral
• No visual changes
• May be accompanied by mild irritation or foreign body sensation
• Often noticed upon waking or after episodes of coughing/straining

Risk Factors to Assess

1. Trauma - most common cause in younger patients 2

   • Direct eye injury
   • Foreign body
   • Vigorous eye rubbing

2. Contact lens wear - common in younger patients 2

   • Extended wear
   • Improper insertion/removal

3. Systemic conditions - more common in elderly 2

   • Hypertension
   • Diabetes
   • Arteriosclerosis

4. Medications

   • Anticoagulants/antiplatelets (aspirin, warfarin) 3, 4
   • NSAIDs

5. Other factors

   • Valsalva maneuvers (coughing, vomiting, straining)
   • Conjunctival vessel fragility

When to Consider Further Workup

Further evaluation is warranted only in specific circumstances:

• Recurrent or persistent subconjunctival hemorrhages
• Bilateral extensive hemorrhages
• Associated with other bleeding manifestations
• Suspicion of child abuse
• Suspected ocular or orbital malignancy

Treatment

Primary Management

• Observation - most cases resolve spontaneously within 1-2 weeks
• Patient reassurance about the benign nature of the condition
• Artificial tears for mild irritation (preservative-free formulations)
• Cold compresses for the first 24-48 hours to reduce discomfort

Specific Scenarios

For Traumatic Subconjunctival Hemorrhage

• Assess for associated ocular injuries (corneal abrasion, hyphema, etc.)
• Rule out globe perforation if high-velocity trauma
• Consider protective eyewear to prevent recurrence

For Contact Lens-Related Hemorrhage

• Temporary discontinuation of contact lens wear until resolved
• Review proper contact lens hygiene and handling
• Consider changing lens type or wearing schedule

For Medication-Related Hemorrhage

• Do not discontinue anticoagulants without consulting the prescribing physician 1
• Benefits of anticoagulation typically outweigh the risk of benign subconjunctival hemorrhage

For Hypertension-Related Hemorrhage

• Blood pressure measurement
• Referral to primary care for hypertension management if elevated

Follow-up

When to Return

• Routine follow-up is not necessary for simple subconjunctival hemorrhage
• Patients should return if:
  • Vision changes develop
  • Pain develops or worsens
  • Hemorrhage doesn't resolve within 2-3 weeks
  • New hemorrhages develop while the initial one is resolving

Patient Education

1. Explain the benign nature of the condition
2. Advise that the blood will gradually change color (like a bruise) before clearing
3. Warn that the hemorrhage may appear to worsen before improving as blood spreads
4. Reassure that vision is not affected

Special Considerations

Recurrent Subconjunctival Hemorrhage

For patients with recurrent episodes, consider:

• Blood pressure monitoring
• Coagulation studies (though studies show bleeding disorders are rarely the cause) 5
• Evaluation of medication effects
• Assessment for systemic vascular diseases

Extensive or Bilateral Hemorrhage

May warrant investigation for:

• Severe hypertension
• Blood dyscrasias
• Anticoagulant overdose 3
• Systemic bleeding disorders (though these are rare causes) 5

Pediatric Patients

• Consider non-accidental trauma in unexplained cases
• Evaluate for connective tissue disorders in recurrent cases

Common Pitfalls to Avoid

1. Unnecessary antibiotic prescriptions (not effective for subconjunctival hemorrhage)
2. Discontinuing necessary anticoagulants without medical consultation
3. Failing to recognize when hemorrhage is a manifestation of serious systemic disease
4. Overlooking associated ocular trauma in traumatic cases
5. Excessive testing in isolated, non-recurrent cases

Remember that while alarming in appearance, subconjunctival hemorrhage is typically a benign, self-limiting condition that resolves without specific intervention.