Subconjunctival Hemorrhage
A subconjunctival hemorrhage is a benign condition characterized by bleeding beneath the conjunctiva, appearing as a bright red patch on the white of the eye, typically resolving on its own within 1-2 weeks without treatment or complications. 1
Clinical Presentation
- Appearance: Bright red, well-demarcated area of blood beneath the conjunctiva
- Symptoms:
- Usually asymptomatic
- May cause mild irritation or foreign body sensation
- No pain, visual changes, or discharge
- No pupillary abnormalities
Etiology and Risk Factors
Common Causes
- Trauma: Most common cause in younger patients 1
- Minor eye trauma (rubbing eyes)
- Contact lens usage
- Foreign body
- Blunt trauma
- Spontaneous rupture: Due to fragile conjunctival vessels
- Valsalva maneuvers: Coughing, sneezing, vomiting, heavy lifting 2
- Conjunctival inflammation: Including infectious conjunctivitis 3
Age-Related Risk Factors
- Children: Primarily due to trauma (83%) and inflammation (13%) 3
- Adults: Often spontaneous or related to minor trauma
- Elderly: More commonly associated with systemic vascular diseases 1
- Hypertension
- Diabetes
- Arteriosclerosis
Less Common Causes
- Bleeding disorders: Coagulopathies, thrombocytopenia 4
- Anticoagulant medications: Can cause recurrent or severe hemorrhages 2
- Orbital or conjunctival lesions: Rarely associated (2% in children) 3
Evaluation
When to Suspect Underlying Conditions
- Recurrent or bilateral subconjunctival hemorrhages
- Severe or extensive hemorrhages
- Associated systemic symptoms
- History of bleeding disorders
- Use of anticoagulant medications
Concerning Features Requiring Further Evaluation
- Recurrent episodes without clear cause
- Associated with headache or elevated blood pressure
- Abnormal bleeding elsewhere in the body
- Concurrent use of blood thinners
- History of blood disorders
Management
Typical Cases
- Reassurance about benign nature and self-resolution
- No specific treatment required
- Artificial tears for mild irritation
- Cold compresses may help with discomfort
- Resolution typically occurs within 1-2 weeks
Special Considerations
- Blood pressure check: Particularly important in older patients 5
- Medication review: Especially anticoagulants or antiplatelet drugs
- Workup for recurrent cases: Consider evaluation for:
- Hypertension
- Bleeding disorders
- Systemic or ocular malignancies 1
When to Refer to an Ophthalmologist
- No improvement after 2 weeks
- Recurrent episodes
- Associated with vision changes
- Signs of infection
- History of bleeding disorders
- Suspected trauma in children (to rule out abuse) 3
Patient Education
- Explain benign nature of condition
- Discuss expected timeline for resolution
- Advise against eye rubbing
- Reassure that vision is not affected
- Explain that blood will gradually be reabsorbed
Subconjunctival hemorrhages, while alarming in appearance, are typically harmless and self-limiting. However, recurrent episodes warrant further investigation, particularly in older adults where they may signal underlying vascular disease.