Management of Subconjunctival Hemorrhage
Subconjunctival hemorrhage requires no specific treatment—reassurance and observation are the primary management approach, as this is a benign, self-limiting condition that resolves spontaneously within 1-2 weeks. 1, 2
Initial Management
- Observation alone is sufficient for isolated subconjunctival hemorrhage, with no intervention required 1, 2
- Artificial tears may be used for mild irritation or comfort 1, 2
- Cold compresses can be applied in the first 24-48 hours (20-30 minutes per session using ice and water in a bag with a damp cloth barrier to prevent cold injury) to reduce bleeding extension and provide comfort 1, 2
- Patient education about the natural resolution timeline (1-2 weeks) is essential 1
When to Investigate Further
For recurrent or frequent subconjunctival hemorrhages, a systematic workup is mandatory to identify underlying systemic conditions 1, 3:
- Hypertension (most common in elderly patients) 1, 3
- Diabetes mellitus 1, 3
- Bleeding disorders or coagulopathies 1, 3
- Review anticoagulation therapy status (though anticoagulation does NOT need to be discontinued for subconjunctival hemorrhage) 1
- Systemic and ocular malignancies (particularly ocular adnexal lymphoma, which can present initially as recurrent subconjunctival hemorrhage) 1, 3
Critical Pitfall to Avoid
Look for a salmon-pink conjunctival lesion accompanying the hemorrhage—this suggests possible ocular adnexal lymphoma and warrants immediate biopsy 1. Any conjunctival nodules or granulomas also require biopsy 1.
Special Populations
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
- Anticoagulation should be continued or restarted immediately after any procedures 1
Traumatic Subconjunctival Hemorrhage
- Visual acuity < 20/40 significantly increases the probability of additional ocular injuries (odds ratio 5.27) 4
- Evaluate visual acuity in every injured eye to help detect eyes requiring specialized evaluation, even when open globe injury is not evident 4
- 42.7% of traumatic subconjunctival hemorrhages have additional injuries 4
Associated with Viral Conjunctivitis
- Focus management on the underlying viral infection 1
- Use topical lubricants for comfort 1
- Avoid antibiotics 1
Follow-up Strategy
- No routine follow-up is necessary for uncomplicated, first-time cases 2
- Instruct patients to return if the hemorrhage does not resolve within 2-3 weeks 2
- Instruct patients to return immediately if vision changes occur 2
- For recurrent cases with viral conjunctivitis, follow-up within 1-2 weeks if symptoms persist 1
Important Clinical Note
Hemostatic screening or second-level coagulation tests are not useful in patients with recurrent subconjunctival hemorrhage who have no other bleeding manifestations, as the prevalence of hemostatic alterations is not different from the general population 5.