Management of Frequent Subconjunctival Hemorrhage
For patients with frequent subconjunctival hemorrhages, observation with artificial tears for comfort is the primary management approach, as these are benign and self-limiting, but recurrent cases warrant investigation for underlying systemic conditions including hypertension, diabetes, bleeding disorders, anticoagulation therapy, and rarely, ocular malignancies. 1, 2
Initial Management
No specific treatment is required for isolated subconjunctival hemorrhage. 1 The condition is benign and self-limiting, typically resolving within 1-2 weeks without intervention. 1
Symptomatic Relief
- Artificial tears can be used to relieve mild irritation 1
- Cold application may provide comfort when applied for 20-30 minutes per session using ice and water in a bag surrounded by a damp cloth, with a barrier (thin towel) between the cold source and skin to prevent cold injury 1
- Patient education about the natural resolution timeline (1-2 weeks) is essential 1
When to Investigate Further
Recurrent or persistent subconjunctival hemorrhages require evaluation for underlying causes. 2 The approach differs by age and presentation:
Red Flags Requiring Immediate Investigation
- Persistent pain accompanying the hemorrhage 1
- Signs of infection 1
- Bilateral, recurrent, and severe hemorrhages 3
- Hemorrhages that persist beyond expected resolution time 2
Systematic Workup for Recurrent Cases
In younger patients (under 60): 2
In elderly patients: 2
For all patients with recurrent hemorrhages: 2
- Bleeding disorders - though notably, hemostatic screening shows no higher prevalence of abnormalities in recurrent SCH patients compared to the general population 4
- Anticoagulation therapy status and prothrombin time if on warfarin 3
- Systemic and ocular malignancies - particularly ocular adnexal lymphoma, which can present initially as recurrent subconjunctival hemorrhage with a salmon-pink conjunctival lesion 5, 6
- Drug side effects 2
- Idiopathic thrombocytopenic purpura - though rare, subconjunctival hemorrhage can be the first presenting sign 7
Important Clinical Pitfalls
Do not routinely order hemostatic screening tests. Research demonstrates that the prevalence of hemostatic alterations in patients with recurrent spontaneous subconjunctival hemorrhage is not different from the general population, making routine coagulation studies, platelet function tests, or von Willebrand factor testing of no clinical utility. 4
Look for associated findings that suggest serious pathology: 5, 6
- A salmon-pink lesion in the conjunctiva suggests possible lymphoma 5, 6
- Conjunctival nodules or granulomas warrant biopsy 6
- Retinal hemorrhages in addition to subconjunctival hemorrhage may indicate thrombocytopenia 7
Special Populations
Patients on Anticoagulation
Anticoagulation therapy does not need to be discontinued for subconjunctival hemorrhage. 1 These hemorrhages are generally considered a minor bleeding risk, are self-limiting, and do not compromise visual acuity. 1 However, severe or recurrent hemorrhages may occur more frequently in anticoagulated patients. 1
For strabismus surgery context: Many surgeons do not routinely stop anticoagulants, though temporary discontinuation may reduce bleeding; consultation with the prescribing physician is advised, and anticoagulation should be restarted immediately or shortly after procedures. 6
Associated Viral Conjunctivitis
When subconjunctival hemorrhage occurs with viral conjunctivitis (check for preauricular lymphadenopathy and follicular reaction): 1
- Focus management on the underlying viral infection 1
- Use topical lubricants for comfort 1
- Avoid antibiotics (ineffective for viral infections) 1
- Consider topical corticosteroids only for severe cases with marked chemosis, eyelid swelling, or membranous conjunctivitis, under close supervision 1