What to do after a subconjunctival hemorrhage?

Management of Subconjunctival Hemorrhage

For isolated subconjunctival hemorrhage, no specific treatment is required—this is a benign, self-limiting condition that resolves within 1-2 weeks without intervention. 1

Immediate Management

Reassure the patient and provide artificial tears for comfort. 1 The bright red appearance, while alarming, represents blood leaking from small vessels between the conjunctiva and sclera and poses no threat to vision. 1

Symptomatic Relief Options

• Apply artificial tears to relieve mild irritation or foreign body sensation 1
• Cold compresses 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

Clinical Assessment Required

Rule Out Associated Conditions

Check for signs of viral conjunctivitis, including preauricular lymphadenopathy and follicular reaction, as subconjunctival hemorrhage can be associated with viral infection. 1 If viral conjunctivitis is present:

• Focus management on the underlying viral infection 1
• Use topical lubricants for comfort 1
• Avoid antibiotics as they are ineffective for viral infections 1
• Consider topical corticosteroids only for severe cases with marked chemosis, eyelid swelling, or membranous conjunctivitis, under close supervision 1
• Follow-up within 1-2 weeks if symptoms persist 1, 2

Warning Signs Requiring Further Investigation

Immediately investigate further if the patient has: 1

• Persistent pain (suggests more serious pathology)
• Signs of infection
• Recurrent episodes without clear cause

Management of Recurrent Subconjunctival Hemorrhage

For patients with frequent or recurrent hemorrhages, observation with artificial tears remains the primary approach, but investigation for underlying systemic conditions is mandatory. 2

Systematic Workup for Recurrent Cases

Evaluate for: 2, 3

• Hypertension (common in elderly patients)
• Diabetes mellitus
• Bleeding disorders (though prevalence is not higher than general population) 4
• Anticoagulation therapy status
• Systemic and ocular malignancies

Critical Pitfall to Avoid

Look for a salmon-pink conjunctival lesion, which suggests possible ocular adnexal lymphoma—this can present initially as recurrent subconjunctival hemorrhage. 2 Any conjunctival nodules or granulomas warrant biopsy. 2

Special Populations

Patients on Anticoagulation

Do not discontinue anticoagulation therapy for subconjunctival hemorrhage—these hemorrhages are considered a minor bleeding risk, are self-limiting, and do not compromise visual acuity. 1, 2 Most bleeds in anticoagulated patients resolve without intervention. 1

Trauma-Related Cases

In traumatic subconjunctival hemorrhage, visual acuity assessment is mandatory to detect coexisting injuries—visual acuity less than 20/40 increases the probability of additional ocular damage requiring specialized evaluation. 5 Even when open globe injury is not evident, 42.7% of traumatic cases have additional injuries. 5

Pediatric Considerations

In children presenting with subconjunctival hemorrhage plus facial petechiae, consider traumatic asphyxia from increased intrathoracic pressure or non-accidental trauma, especially without clear history of accidental injury. 6

Follow-Up Strategy

• No follow-up needed for isolated, first-time subconjunctival hemorrhage that resolves as expected 2
• Follow-up within 1-2 weeks if symptoms of viral conjunctivitis persist 1, 2
• Immediate referral for recurrent cases to investigate underlying systemic conditions 2, 3