What is the management approach for a patient with subconjunctival hemorrhage?

Management of Subconjunctival Hemorrhage

Subconjunctival hemorrhage requires no specific treatment as it is a benign, self-limiting condition that resolves spontaneously within 1-2 weeks. 1

Initial Assessment

When evaluating a patient with subconjunctival hemorrhage, focus on:

• Visual acuity testing - Critical to detect associated injuries, as visual acuity <20/40 increases the probability of additional ocular damage by more than 5-fold 2
• Blood pressure measurement - Systemic hypertension is one of the most common underlying causes, particularly in older patients 3
• Signs of viral conjunctivitis - Check for preauricular lymphadenopathy and follicular reaction, as subconjunctival hemorrhage can be associated with viral infection 1
• History of trauma - Even minor local trauma is a frequent cause 3
• Medication review - Document use of anticoagulants, antiplatelet agents, NSAIDs, or aspirin 4

Treatment Approach

For isolated subconjunctival hemorrhage:

• No specific treatment is required - The American Academy of Ophthalmology recommends observation only 1
• Artificial tears can be used for mild irritation or comfort 1
• Cold application may be beneficial for comfort in the first 24-48 hours - apply ice water in a bag surrounded by a damp cloth for 20-30 minutes per session with a barrier (thin towel) between the cold source and skin to prevent cold injury 1
• Patient education about the natural course (resolution within 1-2 weeks) is essential 1

For subconjunctival hemorrhage with viral conjunctivitis:

• Topical lubricants to improve comfort 1
• Avoid antibiotics - they are ineffective for viral infections 1
• Topical corticosteroids may be considered only for severe cases with marked chemosis, eyelid swelling, or membranous conjunctivitis, and only under close ophthalmologic supervision 1

Special Populations

Patients on anticoagulation:

• Do not discontinue anticoagulation - subconjunctival hemorrhage is considered a minor bleeding risk, and most bleeds are self-limiting without compromised visual acuity 1
• These patients may experience more severe or recurrent hemorrhages, but this does not warrant changes in anticoagulation management unless other serious bleeding occurs 1, 5

Red Flags Requiring Further Investigation

Immediate ophthalmologic referral is warranted for:

• Persistent pain - suggests more serious pathology 1
• Signs of infection - purulent discharge, severe inflammation 1
• Visual acuity worse than 20/40 - indicates high probability (66%) of additional ocular injuries requiring specialized evaluation 2
• Bilateral, recurrent, or severe hemorrhages - may indicate underlying blood dyscrasia or clotting disorder, though hemostatic screening is generally not useful in isolated recurrent cases 4, 5

Follow-up

• No routine follow-up needed for uncomplicated cases 1
• Follow-up within 1-2 weeks if symptoms of viral conjunctivitis persist 1
• Blood pressure monitoring in older patients or those with newly identified hypertension 3

Common Pitfalls to Avoid

• Do not perform routine hemostatic screening - the prevalence of hemostatic abnormalities in patients with recurrent spontaneous subconjunctival hemorrhage is not different from the general population 4
• Do not assume absence of serious injury based on appearance alone - always check visual acuity, as 43% of eyes with subconjunctival hemorrhage from trauma have additional injuries 2
• Do not prescribe antibiotics for presumed infection without clear bacterial signs, as viral conjunctivitis is a common association 1