What is the recommended management approach for a patient with a subconjunctival hemorrhage, possibly taking anticoagulant medications such as aspirin (acetylsalicylic acid) or warfarin, and experiencing discomfort?

Management of Subconjunctival Hemorrhage

Subconjunctival hemorrhage requires no specific treatment and anticoagulation should be continued without interruption, as this is a non-major bleed that does not meet criteria for anticoagulation modification. 1

Classification and Anticoagulation Management

Subconjunctival hemorrhage does not qualify as a major bleed by ACC criteria, which requires either: bleeding at a critical site, hemodynamic instability, or hemoglobin decrease ≥2 g/dL. 1 Therefore:

• Continue oral anticoagulants (warfarin, aspirin, DOACs) without interruption 1
• Do not administer reversal agents (vitamin K, fresh frozen plasma, or prothrombin complex concentrates) 1
• Provide local therapy/manual compression only 1

The 2020 ACC Expert Consensus explicitly states that for non-major bleeds not at critical sites, anticoagulation should be continued while providing local measures to control bleeding. 1

Specific Anticoagulation Considerations

For Patients on Warfarin:

• Continue warfarin at current dose 1
• Check INR to ensure it is within therapeutic range (2.0-3.0 for most indications) 2, 3
• If INR is supratherapeutic (>3.5-4.0) but <5.0, reduce the next dose but do not stop warfarin 3
• Do not administer vitamin K unless INR >5.0 with additional bleeding risk factors 3
• One case report described subconjunctival hemorrhage with bleeding requiring vitamin K and fresh frozen plasma, but this represented severe hemorrhage with active oozing—not typical subconjunctival hemorrhage 4

For Patients on Aspirin or Other Antiplatelets:

• Continue aspirin without interruption 1
• Aspirin should only be discontinued for ultra-high risk procedures, which subconjunctival hemorrhage is not 1

For Patients on DOACs:

• Continue DOAC without dose adjustment 1
• No reversal agents indicated 1

Symptomatic Management

For discomfort associated with subconjunctival hemorrhage:

• Apply cold compresses in the first 24-48 hours (general ophthalmology practice)
• Artificial tears for irritation (general ophthalmology practice)
• Reassure the patient that resolution occurs spontaneously in 1-2 weeks 5

When to Investigate Further

Subconjunctival hemorrhage in anticoagulated patients warrants investigation only if: 5, 6, 7

• Recurrent episodes (multiple occurrences) 5, 6
• Bilateral presentation 6
• Severe hemorrhage with active bleeding/oozing (extremely rare) 4, 6
• INR consistently >4.0 despite appropriate dosing 7

In a study of warfarin patients, 76.9% had INRs within goal range when subconjunctival hemorrhage occurred, and no ophthalmic complications were identified. 7 The event rate was only 0.35% among anticoagulated patients. 7

Critical Pitfalls to Avoid

• Do not stop anticoagulation - this exposes patients to thromboembolism risk that far exceeds any risk from subconjunctival hemorrhage 1
• Do not administer vitamin K reflexively - subconjunctival hemorrhage alone does not warrant reversal 1, 3
• Do not withhold antiplatelet agents - these should be continued 1
• Do not order extensive coagulation workup unless hemorrhages are recurrent or bilateral 5, 6

The key principle is that subconjunctival hemorrhage represents a benign, self-limited condition that does not justify interrupting thromboprophylaxis in patients with established indications for anticoagulation. 1, 5