What is the management and treatment for a subconjunctival hemorrhage?

Management and Treatment of Subconjunctival Hemorrhage

Primary Management Approach

For uncomplicated subconjunctival hemorrhage, observation alone is the appropriate management, as the condition is benign and self-limiting, typically resolving within 1-2 weeks without intervention. 1

Symptomatic Relief Measures

• Artificial tears can be used to relieve mild irritation or discomfort associated with the hemorrhage 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 to provide reassurance 1

When to Investigate Further

Red Flags Requiring Workup

For patients with recurrent or persistent subconjunctival hemorrhages, a systematic investigation for underlying conditions is mandatory. 1, 2

Specific conditions to evaluate include:

• Systemic hypertension and diabetes - common causes in elderly patients 2
• Bleeding disorders - though research shows hemostatic abnormalities are not more prevalent in recurrent SCH patients than the general population 3
• Anticoagulation therapy status - warfarin and direct oral anticoagulants are known medication-related causes 4
• Ocular and systemic malignancies - particularly important in recurrent cases 1, 2

Critical Warning Signs

Look for a salmon-pink conjunctival lesion, which strongly suggests ocular adnexal lymphoma - this can initially present as recurrent subconjunctival hemorrhage 1, 4, 5

• Any conjunctival nodules or granulomas warrant biopsy to rule out malignancy 1
• Sebaceous carcinoma may appear as yellowish discoloration with subconjunctival multilobulated yellow mass 4
• Conjunctival melanoma presents as painless brown or fleshy-pink lesions 4

Special Clinical Scenarios

Patients on Anticoagulation

Anticoagulation therapy does not need to be discontinued for subconjunctival hemorrhage, as these hemorrhages are generally considered a minor bleeding risk, are self-limiting, and do not compromise visual acuity 1

Associated Viral Conjunctivitis

When subconjunctival hemorrhage occurs with viral conjunctivitis (particularly adenoviral conjunctivitis, which frequently causes petechial and subconjunctival hemorrhage 4):

• Focus management on the underlying viral infection 1
• Use topical lubricants for comfort 1
• Avoid antibiotics - the majority of acute infectious conjunctivitis cases are viral and self-limited, not requiring antimicrobial treatment 6

Follow-Up Strategy

• No follow-up needed for isolated, first-time subconjunctival hemorrhage that resolves as expected 1
• Follow-up within 1-2 weeks if symptoms of viral conjunctivitis persist 1
• Recurrent cases without identifiable cause warrant further workup and closer monitoring 4, 2

Common Pitfalls to Avoid

The most critical pitfall is dismissing recurrent subconjunctival hemorrhages without proper investigation. While isolated hemorrhages are benign, recurrence may be the first sign of serious pathology including lymphoma 5. A thorough examination looking specifically for salmon-pink lesions, nodules, or masses is essential in recurrent cases 1, 4. Additionally, avoid routinely ordering hemostatic screening tests in patients with only recurrent SCH and no other bleeding manifestations, as the prevalence of hemostatic alterations is not different from the general population 3.