Treatment of Subconjunctival Hemorrhage (Bleeding into Sclera)
Subconjunctival hemorrhage requires no specific treatment in the vast majority of cases, as it resolves spontaneously within 1-3 weeks without intervention.
Immediate Assessment
The critical first step is distinguishing benign subconjunctival hemorrhage from serious ocular trauma requiring urgent intervention:
- Check for globe rupture or scleral laceration by examining for visual acuity reduction to light perception or worse, ocular hypotension, limitation of eye movement, hyphema, pupil distortion, and vitreous hemorrhage 1
- Perform B-mode ultrasonography if scleral rupture is suspected, looking for ill-defined scleral margins, interrupted eyeball wall, or shortened ocular axis 1, 2
- Obtain CT imaging when clinical examination suggests occult rupture, as it may reveal interruption of the ocular ring or uneven ocular density 1
Management Based on Clinical Scenario
Isolated Subconjunctival Hemorrhage (No Globe Injury)
No treatment is necessary - this is a self-limited condition that resolves spontaneously 3:
- The blood reabsorbs naturally over 7-21 days without intervention
- Reassure the patient that this is benign and does not affect vision
- No topical medications, patches, or other interventions accelerate resolution 3
Subconjunctival Hemorrhage with Confirmed Scleral Rupture
Immediate surgical repair is mandatory when scleral rupture is identified 1:
- Perform stage I debridement and suturing surgery as soon as the rupture is confirmed by operative exploration 1
- Minimize time between injury and surgical intervention to prevent complications, as delayed intervention worsens outcomes 4, 5
- Plan for stage II vitrectomy in cases with vitreous hemorrhage, retinal detachment, or lens dislocation - this significantly improves visual outcomes (85.7% improvement rate versus 21.4% with stage I surgery alone) 1
Post-Procedural Subconjunctival Hemorrhage
Observation only for routine post-surgical subconjunctival hemorrhage 3:
- This occurs in 8.5-9.7% of patients on anticoagulation undergoing ocular procedures 3
- No intervention is required unless there is active ongoing bleeding requiring direct compression 6
- Scleral incisions produce more subconjunctival hemorrhage than corneal incisions, but both resolve without treatment 3
Critical Pitfalls to Avoid
- Never assume isolated subconjunctival hemorrhage indicates serious injury - but always examine carefully for associated signs of globe rupture (hypotony, restricted motility, severe vision loss, hyphema) 1, 2
- Do not delay surgical exploration when occult scleral rupture is suspected based on clinical signs, even if initial imaging is equivocal 1
- Avoid performing procedures in areas of severe subconjunctival hemorrhage when possible, as this increases risk of conjunctival laceration 7
- Never discontinue necessary anticoagulation due to subconjunctival hemorrhage alone, as this benign condition does not justify increased thrombotic risk 3