What is the management of subconjunctival hemorrhage?

Management of Subconjunctival Hemorrhage

Subconjunctival hemorrhage is a benign, self-limiting condition that typically resolves without treatment within 1-2 weeks and does not require specific medical intervention in most cases.

Definition and Etiology

• Subconjunctival hemorrhage (SCH) appears as a bright red patch on the white of the eye due to blood leaking from small blood vessels between the conjunctiva and sclera 1
• Common causes include:
  • Trauma 2
  • Contact lens usage (especially in younger patients) 2
  • Valsalva maneuvers (coughing, sneezing, straining) 2
  • Systemic vascular diseases (hypertension, diabetes, arteriosclerosis) in elderly patients 2
  • Anticoagulation therapy 3
  • Viral conjunctivitis 1

Clinical Assessment

• Determine if the SCH is isolated or associated with other conditions:
  • Check for signs of viral conjunctivitis (preauricular lymphadenopathy, follicular reaction) 1
  • Assess for trauma history 2
  • Review medication history, especially anticoagulants 3
  • Evaluate for systemic conditions like hypertension or diabetes 2
  • Note recurrence patterns, as frequent recurrences may indicate underlying pathology 2

Management Approach

First-line Management

• Reassurance that the condition is benign and self-limiting 2
• No specific treatment is required for isolated SCH 1, 2
• Artificial tears can be used to relieve any mild irritation 1
• Patient education about the natural course (typically resolves within 1-2 weeks) 1

When Associated with Viral Conjunctivitis

• If SCH is associated with viral conjunctivitis, management should focus on the underlying viral infection:
  • Avoid antibiotics as they are ineffective for viral infections 1
  • Consider topical lubricants to improve comfort 1
  • For severe viral conjunctivitis with marked chemosis, eyelid swelling, or membranous conjunctivitis, topical corticosteroids may be considered under close supervision 1

For Recurrent or Persistent SCH

• Further evaluation is warranted for:

  • Systemic hypertension 2
  • Bleeding disorders 2
  • Systemic and ocular malignancies 4, 2
  • Drug side effects, especially anticoagulants 3
  • Conjunctivochalasis (redundant conjunctiva) 5

• Patients with three or more recurrent episodes of SCH should be evaluated for:

  • Moderate or severe conjunctivochalasis 5
  • Activities that may cause dry eye (prolonged visual display terminal use, reading) 5

Surgical Intervention

• For patients with frequent recurrences associated with conjunctivochalasis, surgical correction of the redundant conjunctiva may be beneficial 5
• Studies show that more than 80% of eyes that underwent surgery for conjunctivochalasis had no recurrence of hemorrhages 5

Special Considerations

Anticoagulation Therapy

• Patients on anticoagulants may experience more severe or recurrent SCH 3
• For patients requiring procedures while on anticoagulants, SCH is considered a minor bleeding risk and generally does not require discontinuation of therapy 1
• For ophthalmologic procedures, most bleeds in anticoagulated patients are self-limiting (dot hyphemas or subconjunctival bleeds) without compromised visual acuity 1

Warning Signs Requiring Further Investigation

• Recurrent, bilateral, or severe conjunctival hemorrhages 3
• SCH associated with visual changes 2
• SCH with persistent pain 1
• SCH with signs of infection 1
• SCH in the setting of known malignancy 4

Follow-up Recommendations

• Routine follow-up is not necessary for isolated, first-time SCH 2
• For recurrent SCH (≥2 episodes), consider evaluation for underlying causes 5, 2
• If associated with viral conjunctivitis, follow-up within 1-2 weeks if symptoms persist 1

Remember that while alarming in appearance, most subconjunctival hemorrhages are benign and self-resolving without the need for specific medical intervention.