What is the treatment for a subconjunctival hemorrhage?

Treatment of Subconjunctival Hemorrhage

Subconjunctival hemorrhage requires no specific treatment, as it is a benign, self-limiting condition that resolves spontaneously within 1-2 weeks; management consists of observation with artificial tears for comfort, but recurrent cases mandate investigation for underlying systemic conditions including hypertension, diabetes, bleeding disorders, and rarely ocular malignancies. 1

Primary Management Approach

• Observation is the cornerstone of treatment - no active intervention is required for isolated subconjunctival hemorrhage 1
• The hemorrhage will resolve spontaneously within 1-2 weeks without any medical or surgical intervention 1
• Patient education about the natural resolution timeline is essential to prevent unnecessary anxiety 1

Symptomatic Relief Measures

• 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
• Avoid topical antibiotics unless there is concurrent infectious conjunctivitis 1

When to Investigate Further: Red Flags for Recurrent Cases

For patients with recurrent or persistent subconjunctival hemorrhages, a systematic workup is mandatory to identify potentially serious underlying conditions 1, 2:

• Systemic vascular diseases: Check blood pressure for hypertension, screen for diabetes and arteriosclerosis 2
• Bleeding disorders: Consider coagulation studies, though routine hemostatic screening in isolated recurrent cases has not shown increased prevalence of abnormalities compared to the general population 3
• Medication review: Evaluate anticoagulation therapy, antiplatelet agents, and NSAIDs 2
• Ocular malignancies: Look specifically for a salmon-pink conjunctival lesion, which is pathognomonic for ocular adnexal lymphoma 1, 4
• Systemic malignancies: Consider workup if other systemic signs are present 2

Critical Clinical Pitfalls to Avoid

• Do not miss ocular adnexal lymphoma: This can present initially as recurrent subconjunctival hemorrhage with a characteristic salmon-pink conjunctival lesion 1, 4
• Biopsy any conjunctival nodules or granulomas that accompany recurrent hemorrhages 1
• In traumatic cases with subconjunctival hemorrhage, visual acuity less than 20/20 significantly increases the probability of additional ocular injuries (OR 5.27); these eyes require specialized evaluation even without obvious signs of open globe injury 5
• In children, 83% of non-surgical subconjunctival hemorrhages are due to trauma, and all children with SCH should be closely examined for other ocular or non-ocular signs of trauma 6

Special Populations and Contexts

Patients on Anticoagulation

• Do not discontinue anticoagulation therapy for subconjunctival hemorrhage 1
• These hemorrhages are considered a minor bleeding risk, are self-limiting, and do not compromise visual acuity 1
• For patients undergoing strabismus surgery, consultation with the prescribing physician is advised, though many surgeons do not routinely stop anticoagulants 1

Concurrent Viral Conjunctivitis

• When subconjunctival hemorrhage occurs with adenoviral conjunctivitis (occasionally observed per ophthalmology guidelines), focus management on the underlying viral infection 7
• Use topical lubricants for comfort and avoid unnecessary antibiotics 1
• Follow-up within 1-2 weeks if symptoms of viral conjunctivitis persist 1

Follow-up Strategy

• No follow-up is needed for isolated, first-time subconjunctival hemorrhage that resolves as expected 1
• Schedule follow-up for recurrent cases to complete the systematic workup described above 1, 2
• Immediate ophthalmology referral is warranted if a salmon-pink lesion or other suspicious findings are present 1, 4