What are the treatment options for bleeding under the sclera?

Treatment of Subconjunctival Hemorrhage

Most cases of subconjunctival hemorrhage (bleeding under the sclera) are benign and self-limiting, requiring only observation and reassurance as they typically resolve spontaneously within 1-2 weeks without specific treatment.

Initial Management

• Subconjunctival hemorrhage appears as a bright red patch on the white of the eye, often without pain or visual disturbance 1
• For typical cases, observation is the primary approach with reassurance that the condition will resolve on its own 1
• Bilateral patching and/or elevation of the head while sleeping may help clear the hemorrhage more quickly 2, 3
• Artificial tears can be used to reduce any associated irritation or foreign body sensation 4

Evaluation for Underlying Causes

• For first-time, isolated subconjunctival hemorrhage, detailed history should focus on:

  • Recent trauma (accounts for 83% of cases in children) 5
  • Contact lens usage (common risk factor in younger patients) 1
  • Valsalva maneuvers (coughing, vomiting, heavy lifting) 6
  • Systemic vascular diseases (hypertension, diabetes, arteriosclerosis) 1
  • Current medications (anticoagulants, antiplatelets, NSAIDs) 6

• For recurrent or bilateral subconjunctival hemorrhages, further evaluation is warranted:

  • Blood pressure measurement to rule out hypertension 1
  • Complete blood count to assess platelet levels 7
  • Coagulation studies (PT/INR, PTT) if on anticoagulants or suspected bleeding disorder 6

When to Refer to a Specialist

• Immediate ophthalmology referral is indicated for:

  • Subconjunctival hemorrhage associated with trauma and suspected globe rupture 4
  • Hemorrhage with concurrent vision loss 4
  • Severe pain (not typical of simple subconjunctival hemorrhage) 4
  • Signs of infection (purulent discharge, significant chemosis) 4

• Hematology referral may be necessary for:

  • Recurrent, spontaneous subconjunctival hemorrhages without identified cause 8
  • Concurrent bleeding from other sites 7
  • Extremely low platelet count discovered during workup 7

Treatment Based on Underlying Cause

• For trauma-related subconjunctival hemorrhage:

  • Evaluate for other ocular injuries, including retinal tears or detachment 2
  • B-scan ultrasonography if media opacity precludes adequate examination 2, 3

• For anticoagulant-related hemorrhage:

  • Check INR levels if on warfarin 6
  • Generally, no need to adjust anticoagulation unless INR is supratherapeutic 6
  • More frequent monitoring may be warranted in recurrent cases 6

• For hypertension-related hemorrhage:

  • Optimize blood pressure control through coordination with primary care 3, 1

Surgical Considerations

• Surgery is rarely indicated for isolated subconjunctival hemorrhage 4
• In cases where subconjunctival hemorrhage is associated with vitreous hemorrhage:
  • Early vitrectomy may be considered if dense hemorrhage obscures retinal details 2
  • Repeat ultrasonographic examination should be performed within 1-2 weeks if retinal tear is suspected but not visualized due to hemorrhage 2, 3

Complications and Follow-up

• Most subconjunctival hemorrhages resolve without complications within 2 weeks 1
• Patients should be advised to return if:
  • The hemorrhage doesn't resolve within 2-3 weeks 1
  • Vision becomes affected 4
  • Pain develops 4
  • The hemorrhage recurs frequently 1, 8

Special Considerations

• In children, subconjunctival hemorrhage is uncommon (prevalence 0.4%) and most cases (83%) are due to trauma 5
• In rare cases, subconjunctival hemorrhage can be the first presenting sign of serious systemic disorders like idiopathic thrombocytopenic purpura 7
• The prevalence of hemostatic alterations in patients with recurrent spontaneous subconjunctival hemorrhage is not significantly different from the general population, suggesting that extensive hemostatic screening is not routinely necessary 8