Diagnosis: Subconjunctival Hemorrhage
The most likely diagnosis is D - Subconjunctival hemorrhage, which presents as a painless bright red spot in the eye without visual changes or signs of infection, and is strongly associated with hypertension as a major risk factor. 1
Clinical Reasoning
The clinical presentation is pathognomonic for subconjunctival hemorrhage:
- Bright red spot appearance: This represents blood beneath the conjunctiva, creating the characteristic vivid red patch against the white sclera 1
- Absence of pain: Subconjunctival hemorrhage is painless, which immediately excludes scleritis and episcleritis (both cause discomfort) 2
- No visual changes: Vision remains completely normal, distinguishing this from serious intraocular pathology 1
- No infection signs: Rules out infectious conjunctivitis 2
Why Hypertension Matters Here
Hypertension is one of the most common risk factors for subconjunctival hemorrhage in elderly patients, along with diabetes and arteriosclerosis 1. The elevated blood pressure causes spontaneous rupture of small conjunctival vessels, leading to bleeding that is confined to the subconjunctival space 1.
Excluding Other Diagnoses
- Conjunctivitis (A): Would present with diffuse redness, discharge, and irritation rather than a discrete bright red patch 2
- Scleritis (B): Causes severe, boring eye pain that is not relieved easily, often with photophobia and visual disturbance - none of which are present here 2
- Episcleritis (C): Presents with sectoral redness and mild discomfort, but the eye appears more pink than bright red, and there is typically mild tenderness 2
Important Clinical Pitfall
While subconjunctival hemorrhage is typically benign and self-limiting, recurrent or persistent cases warrant further evaluation for systemic hypertension control, bleeding disorders, and rarely systemic malignancies 1. In this hypertensive patient, ensure blood pressure is adequately controlled to prevent recurrence 1.
Management Approach
- Reassurance is the primary intervention - the hemorrhage will spontaneously resolve over 1-2 weeks as the blood reabsorbs 1
- Optimize hypertension management to prevent future episodes 1
- No specific ocular treatment is required - the condition is self-limited 2
- Consider workup for bleeding disorders only if hemorrhages are recurrent 1