Treatment for Subconjunctival Hemorrhage
Subconjunctival hemorrhage requires no specific treatment as it is benign and self-limiting, typically resolving within 1-2 weeks without intervention. 1
Primary Management Approach
Observation with artificial tears for comfort is the primary management strategy. 1 The condition resolves spontaneously without any active intervention, and patients should be reassured about the benign nature of this presentation. 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 to prevent unnecessary anxiety. 1
When to Investigate Further
Recurrent Subconjunctival Hemorrhage
For patients with frequent or recurrent hemorrhages, a systematic workup for underlying systemic conditions is mandatory. 1 This includes:
- Hypertension screening - a major risk factor in elderly patients. 2
- Diabetes evaluation - commonly associated with recurrent hemorrhages. 2
- Bleeding disorder assessment - though research shows hemostatic abnormalities are not more prevalent in recurrent SCH patients than the general population, severe cases warrant evaluation. 3
- Medication review - particularly anticoagulation therapy, NSAIDs, aspirin, and antiplatelet agents. 3
- Systemic and ocular malignancy screening - especially if other concerning features are present. 1, 2
Critical Red Flags
Look for a salmon-pink conjunctival lesion, which suggests possible ocular adnexal lymphoma - this can present initially as recurrent subconjunctival hemorrhage. 1 Any conjunctival nodules or granulomas warrant biopsy. 1
Spontaneous subconjunctival hemorrhage can be the first presenting sign of idiopathic thrombocytopenic purpura - particularly if accompanied by other bleeding manifestations like hematuria or retinal hemorrhages. 4
Special Clinical Scenarios
Patients on Anticoagulation
Anticoagulation therapy does not need to be discontinued for subconjunctival hemorrhage. 1 These hemorrhages are self-limiting, do not compromise visual acuity, and are generally considered a minor bleeding risk. 1
Long-term Topical Corticosteroid Users
Patients using long-term topical steroids (particularly prednisolone acetate 1%) have substantially increased prevalence of spontaneous or minimal-trauma subconjunctival hemorrhage due to steroid-induced vascular fragility. 5 This is an expected side effect and does not require discontinuation unless hemorrhages are severe or frequent.
Associated Viral Conjunctivitis
When subconjunctival hemorrhage occurs with viral conjunctivitis, focus management on the underlying viral infection using topical lubricants for comfort, and avoid antibiotics. 1
Follow-up Strategy
- No follow-up is needed for isolated, first-time subconjunctival hemorrhage that resolves as expected. 1
- Follow-up within 1-2 weeks if symptoms of viral conjunctivitis persist or if the hemorrhage does not resolve. 1
- Immediate further evaluation if recurrent hemorrhages occur or if concerning features like salmon-pink lesions are identified. 1
Common Pitfalls to Avoid
Do not order routine hemostatic screening or second-level coagulation tests in patients with recurrent subconjunctival hemorrhage who have no other bleeding manifestations - the prevalence of hemostatic alterations is not different from the general population. 3
Do not overlook trauma or contact lens usage as risk factors in younger patients presenting with subconjunctival hemorrhage. 2