What is the management for a patient with a subconjunctival hemorrhage at 12 o’clock?

Management of Isolated Subconjunctival Hemorrhage at 12 O'Clock

For an isolated subconjunctival hemorrhage at 12 o'clock with no other concerning features, no specific treatment is required as this is a benign, self-limiting condition that will resolve spontaneously within 1-2 weeks. 1

Immediate Assessment

Rule out concerning features that would require further workup:

• Check for persistent pain – if present, further investigation is needed to exclude globe injury, elevated intraocular pressure, or other pathology 1
• Assess for signs of infection – purulent discharge, severe conjunctival injection, or systemic symptoms warrant additional evaluation 1
• Examine for viral conjunctivitis – look specifically for preauricular lymphadenopathy and follicular reaction, as subconjunctival hemorrhage can be associated with viral conjunctivitis 1
• Document extent and location – a single hemorrhage at 12 o'clock in an otherwise healthy eye is reassuring 2

Conservative Management

Symptomatic relief only:

• Artificial tears can be used for mild irritation or foreign body sensation 1
• Cold compresses may provide comfort if applied for 20-30 minutes per session with a barrier (thin towel) between the cold source and skin to prevent cold injury 1
• Patient education is critical – explain that the blood will reabsorb naturally over 1-2 weeks, similar to a bruise on the skin 1

What NOT to Do

• Avoid prescribing antibiotics – they are ineffective for this condition and contribute to antimicrobial resistance 1
• Do not discontinue anticoagulation – even in patients on anticoagulation therapy, subconjunctival hemorrhage is considered a minor bleeding risk that does not require stopping therapy 1
• No hemostatic workup needed – for isolated, non-recurrent subconjunctival hemorrhage, screening for bleeding disorders is not indicated as the prevalence of hemostatic abnormalities is no different from the general population 3

When to Investigate Further

Recurrent or persistent hemorrhages warrant additional evaluation:

• Two or more episodes should prompt assessment for systemic hypertension, diabetes, arteriosclerosis, bleeding disorders, or conjunctivochalasis 2, 4
• Moderate to severe conjunctivochalasis combined with activities requiring visual concentration (computer work, reading, driving) are risk factors for recurrent hemorrhages 4
• Persistent hemorrhage beyond 2-3 weeks or salmon-pink lesions should raise concern for ocular adnexal lymphoma, though this is rare 5

Follow-Up

No routine follow-up is necessary for isolated subconjunctival hemorrhage. 1 However, instruct the patient to return if:

• Pain develops
• Vision changes occur
• Signs of infection appear
• The hemorrhage has not resolved within 2-3 weeks
• Additional hemorrhages occur in either eye

If viral conjunctivitis is present, follow-up within 1-2 weeks is recommended if symptoms persist 1