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

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.

Definition and Presentation

• A subconjunctival hemorrhage appears as a bright red patch on the white of the eye (sclera)
• Blood accumulates between the conjunctiva and sclera due to rupture of small blood vessels
• Usually painless with no visual changes
• May be localized or diffuse, depending on cause

Etiology

Subconjunctival hemorrhages can occur due to various causes:

• Spontaneous/Idiopathic (most common)
• Trauma (including minor trauma like eye rubbing)
• Valsalva maneuver (coughing, sneezing, straining)
• Contact lens use
• Systemic conditions:
  • Hypertension
  • Diabetes
  • Arteriosclerosis
  • Bleeding disorders
  • Anticoagulant medications
• Rare causes:
  • Ocular adnexal lymphoma 1
  • Idiopathic thrombocytopenic purpura 2

Assessment

1. History:

   • Onset and duration
   • History of trauma or Valsalva maneuver
   • Contact lens use
   • Medication history (anticoagulants)
   • Systemic diseases (hypertension, diabetes)
   • Previous episodes

2. Examination:

   • Visual acuity assessment
   • Slit lamp examination to determine extent and location
   • Blood pressure measurement
   • Assessment for other ocular pathology

Management Algorithm

For First-Time, Uncomplicated Subconjunctival Hemorrhage:

1. Reassurance:

   • Explain benign nature of condition
   • Inform patient about expected resolution within 1-2 weeks

2. Supportive Care:

   • Artificial tears for comfort if mild irritation is present
   • Cold compresses for the first 24-48 hours to reduce swelling
   • Avoid eye rubbing

3. No specific medication required

For Recurrent or Extensive Subconjunctival Hemorrhage:

1. Evaluate for underlying causes:

   • Check blood pressure
   • Consider blood work (complete blood count, coagulation profile)
   • Review medication history (especially anticoagulants)

2. Management based on cause:

   • Hypertension: Optimize blood pressure control
   • Bleeding disorders: Refer to hematology
   • Medication-induced: Consider medication adjustment in consultation with prescribing physician

Special Considerations:

• If associated with trauma: Perform thorough ocular examination to rule out other injuries
• If recurrent or persistent: Consider workup for systemic hypertension, bleeding disorders, systemic and ocular malignancies 3

Follow-up

• Routine follow-up is not necessary for first-time, uncomplicated cases
• Follow-up in 1-2 weeks if:
  • Hemorrhage is extensive
  • Patient is on anticoagulants
  • There are recurrent episodes
  • Patient has known bleeding disorder

Patient Education

• Reassure that vision is not affected
• Explain expected timeline for resolution (1-2 weeks)
• Advise to return if:
  • Pain develops
  • Vision changes
  • Hemorrhage does not resolve within 2-3 weeks
  • New hemorrhages develop

Clinical Pearls

• Subconjunctival hemorrhages tend to be more common in the inferior areas of the conjunctiva, except in traumatic cases where they are more common in the temporal areas 4
• Age-related increase in extent of hemorrhage has been observed 4
• In patients undergoing intravitreal injections, topical oxymetazoline 30 minutes before the procedure can reduce the incidence of subconjunctival hemorrhage 5

When to Refer to Ophthalmology

• Recurrent episodes without clear etiology
• Associated with significant ocular pain or vision changes
• Suspicion of underlying ocular pathology
• Failure to resolve within expected timeframe (2-3 weeks)