What is the recommended treatment for a patient with a subconjunctival hemorrhage, possibly taking anticoagulant medications?

Treatment of Subconjunctival Hemorrhage

No specific treatment is required for isolated subconjunctival hemorrhage, as it is a benign, self-limiting condition that resolves spontaneously within 1-2 weeks. 1

Initial Management Approach

Reassurance and observation are the cornerstones of management. The American Academy of Ophthalmology explicitly recommends no specific treatment for isolated subconjunctival hemorrhage. 1 This is a critical point—the condition resolves on its own without intervention.

Symptomatic Relief Measures

• Artificial tears can be used to relieve mild irritation or foreign body sensation associated with the hemorrhage. 1, 2
• Cold compresses may be applied for comfort, limited to 20-30 minutes per session with a barrier (thin towel) between the cold source and skin to prevent cold injury. 1 Use a bag filled with ice and water surrounded by a damp cloth for optimal effect. 1
• Head elevation while sleeping and bilateral patching may help clear the hemorrhage more quickly, though this is optional. 2

Patient Education

Inform patients that:

• The hemorrhage typically resolves within 1-2 weeks without treatment. 1
• They should return immediately if vision becomes affected or severe pain develops. 2
• The bright red appearance, while alarming, does not indicate serious pathology in isolated cases. 1

Special Considerations for Anticoagulated Patients

Continue anticoagulation therapy without interruption. Subconjunctival hemorrhage in patients on anticoagulants (warfarin, DOACs) or antiplatelet agents is generally considered a non-major bleed that does not meet criteria for stopping therapy. 3

Management Algorithm for Anticoagulated Patients

The American College of Cardiology guidelines classify bleeding severity based on three criteria: 3

1. Bleeding at a critical site
2. Hemodynamic instability
3. Hemoglobin decrease ≥2 g/dL or transfusion of ≥2 units RBCs

Isolated subconjunctival hemorrhage does NOT meet these criteria. 3

• Continue oral anticoagulation without dose adjustment. 3
• Provide local therapy (artificial tears, cold compresses). 3
• Do NOT administer reversal agents (vitamin K, prothrombin complex concentrates, idarucizumab, or andexanet alfa) for isolated subconjunctival hemorrhage. 3
• Most bleeds in anticoagulated patients undergoing ophthalmologic procedures are self-limiting without compromised visual acuity. 3, 1

The evidence from perioperative ophthalmology studies shows that even during invasive procedures like cataract surgery, bleeds in anticoagulated patients (including subconjunctival hemorrhages) are almost always self-limiting with no compromise to visual acuity. 3

Red Flags Requiring Immediate Ophthalmology Referral

Refer immediately if any of the following are present:

• Concurrent vision loss 2
• Severe or persistent pain (not mild irritation) 1, 2
• History of trauma with suspected globe rupture 2
• Signs of infection (purulent discharge, severe chemosis) 1
• Associated vitreous hemorrhage (requires B-scan ultrasonography if media opacity prevents examination) 2

These features suggest the hemorrhage is not isolated and may indicate serious underlying pathology requiring specialist evaluation.

Associated Viral Conjunctivitis

If subconjunctival hemorrhage occurs with viral conjunctivitis (check for preauricular lymphadenopathy and follicular reaction): 1

• Focus management on the underlying viral infection. 1
• Use topical lubricants for comfort. 1
• Avoid antibiotics—they are ineffective for viral infections. 1
• Consider topical corticosteroids only for severe cases with marked chemosis, eyelid swelling, or membranous conjunctivitis, under close ophthalmologic supervision. 1
• Follow up within 1-2 weeks if viral symptoms persist. 1

Common Pitfalls to Avoid

• Do not stop anticoagulation for isolated subconjunctival hemorrhage—the thrombotic risk outweighs the minimal bleeding risk. 3, 1
• Do not prescribe antibiotics unless there are clear signs of bacterial superinfection. 1
• Do not use reversal agents (vitamin K, PCCs) for this non-major bleed. 3
• Do not overlook trauma history—always evaluate for occult globe injury if trauma is reported. 2