Initial 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 Steps
Reassurance is the cornerstone of management. Patients should be educated that the bright red appearance, while alarming, represents blood trapped between the conjunctiva and sclera that will spontaneously reabsorb 1. The hemorrhage typically resolves completely within 1-2 weeks without any intervention 1, 2.
Symptomatic Relief
- Apply artificial tears for mild irritation or foreign body sensation 1, 2
- Cold compresses may be used for comfort in the first 24-48 hours: apply ice and 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, 2
Critical Assessment: Rule Out Serious Pathology
While most subconjunctival hemorrhages are benign, you must actively look for warning signs that require further investigation:
Red Flags Requiring Immediate Workup
- Persistent pain (isolated subconjunctival hemorrhage should be painless) 1
- Signs of infection (purulent discharge, severe chemosis) 1
- Salmon-pink conjunctival lesion accompanying the hemorrhage—this suggests possible ocular adnexal lymphoma 2, 3
- Recurrent hemorrhages warrant systematic investigation 2, 4
Associated Viral Conjunctivitis
Check for signs of viral conjunctivitis, which can present with subconjunctival hemorrhage 1:
If viral conjunctivitis is present:
- Focus management on the underlying viral infection 1, 2
- Use topical lubricants for comfort 1, 2
- Avoid antibiotics—they are ineffective for viral infections 1, 2
- Consider topical corticosteroids only for severe cases with marked chemosis, eyelid swelling, or membranous conjunctivitis, under close supervision 1
Special Populations
Patients on Anticoagulation
Do not discontinue anticoagulation therapy for subconjunctival hemorrhage 1, 2. These hemorrhages are considered a minor bleeding risk, are self-limiting, and do not compromise visual acuity 1, 2. The hemorrhages may be more severe or recurrent in anticoagulated patients, but this does not warrant stopping therapy 1.
Recurrent Cases
For patients with frequent subconjunctival hemorrhages, observation with artificial tears remains the primary approach, but you must investigate for underlying conditions 2:
- Systemic hypertension (most common in older patients) 2, 5, 4
- Diabetes mellitus 2, 4
- Bleeding disorders 2, 4
- Ocular malignancies (particularly ocular adnexal lymphoma presenting as salmon-pink lesion) 2, 3
- Systemic malignancies 2, 4
Important caveat: The prevalence of hemostatic abnormalities in patients with recurrent spontaneous subconjunctival hemorrhage is not different from the general population 6. Routine hemostatic screening or second-level coagulation tests are not useful in patients with recurrent subconjunctival hemorrhage who have no other bleeding manifestations 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 if salmon-pink lesion or conjunctival nodules are present—these warrant biopsy 2
Common Pitfalls to Avoid
- Do not prescribe antibiotics for isolated subconjunctival hemorrhage—there is no role for them 1, 2
- Do not order coagulation studies for first-time or even recurrent hemorrhages unless there are other bleeding manifestations 6
- Do not miss the salmon-pink lesion that may accompany recurrent hemorrhages—this is the hallmark of ocular adnexal lymphoma 2, 3
- Do not stop anticoagulation without consulting the prescribing physician, as the risk-benefit strongly favors continuing therapy 1, 2