What are the next steps for an elderly male with a subconjunctival hemorrhage?

Management of Subconjunctival Hemorrhage in an Elderly Male

For an elderly male with subconjunctival hemorrhage, observation with artificial tears for comfort is the primary management approach, as this is a benign, self-limiting condition that requires no specific treatment. 1

Immediate Management

No intervention is required for isolated subconjunctival hemorrhage. The condition resolves spontaneously within 1-2 weeks without treatment. 1

Symptomatic Relief Options

• Artificial tears can be used 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 between the cold source and skin to prevent cold injury 1
• Patient education about the natural resolution timeline (1-2 weeks) is essential 1

Critical Assessment for Recurrent or Persistent Cases

If this is a recurrent or persistent subconjunctival hemorrhage, systematic investigation for underlying conditions is mandatory. 1, 2

Specific Conditions to Evaluate

• Hypertension - measure blood pressure 1, 2
• Diabetes mellitus - check blood glucose/HbA1c 1, 2
• Anticoagulation therapy status - review medication list for warfarin, DOACs, aspirin, NSAIDs 1, 2
• Bleeding disorders - consider CBC with platelet count, PT/INR, aPTT if recurrent 1, 3, 2
• Ocular malignancies - examine for salmon-pink conjunctival lesions suggesting lymphoma 1, 4
• Systemic malignancies - consider if other bleeding manifestations present 1, 2

Key Clinical Pitfalls to Avoid

Look carefully for a salmon-pink lesion in the conjunctiva, which suggests possible ocular adnexal lymphoma. 1, 4 Lymphoma can present initially as recurrent subconjunctival hemorrhage before other manifestations appear. 4

Any conjunctival nodules or granulomas warrant biopsy. 1

Do not routinely order extensive hemostatic workup for isolated subconjunctival hemorrhage. The prevalence of hemostatic abnormalities in patients with recurrent spontaneous subconjunctival hemorrhage is not different from the general population, and screening tests are of no use in patients with recurrent hemorrhage and no other bleeding manifestations. 5

Management of 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

Follow-Up Strategy

• No follow-up needed for isolated, first-time subconjunctival hemorrhage that resolves as expected 1
• Schedule follow-up within 1-2 weeks if the hemorrhage is recurrent, persistent beyond 2 weeks, or if you identify concerning features requiring further investigation 1