What is the recommended treatment for a patient with a subconjunctival hemorrhage, possibly on anticoagulant therapy?

Management of Subconjunctival Hemorrhage

For isolated subconjunctival hemorrhage, no specific treatment is required as it is a benign, self-limiting condition that resolves spontaneously within 1-2 weeks, and anticoagulation therapy should be continued without interruption. 1

Initial Assessment

Determine if this is truly an isolated subconjunctival hemorrhage or part of a more serious bleeding event by evaluating for:

• Hemodynamic instability 2
• Hemoglobin decrease ≥2 g/dL or need for ≥2 units RBC transfusion 2
• Persistent pain (requires further investigation) 1
• Signs of infection (requires further investigation) 1
• Associated viral conjunctivitis (check for preauricular lymphadenopathy and follicular reaction) 1

Isolated subconjunctival hemorrhage does not meet criteria for major bleeding and requires no intervention beyond symptomatic management. 1

Management for Patients NOT on Anticoagulation

• Reassure the patient that this is benign and will resolve within 1-2 weeks 1
• Artificial tears for mild irritation or discomfort 1
• Cold compresses may be applied for comfort (20-30 minutes per session with a barrier between ice and skin) 1
• No antibiotics are indicated unless there are signs of infection 1

Management for Patients ON Anticoagulation

Continue anticoagulation without interruption or dose adjustment. 1 This is the critical management decision that differs from other bleeding scenarios.

Rationale for Continuing Anticoagulation

• Subconjunctival hemorrhage is classified as a non-major bleed that does not meet American College of Cardiology criteria for stopping therapy 1
• Most ophthalmologic bleeds in anticoagulated patients are self-limiting without compromised visual acuity 1
• The thrombotic risk from stopping anticoagulation outweighs the minimal risk from this benign bleeding 1

Symptomatic Management

• Artificial tears for comfort 1
• Cold compresses for symptomatic relief 1
• Patient education about the natural course and expected resolution 1

What NOT to Do in Anticoagulated Patients

Do not administer reversal agents including: 1

• Vitamin K
• Prothrombin complex concentrates (PCC)
• Idarucizumab (for dabigatran)
• Andexanet alfa (for apixaban/rivaroxaban)

Do not stop or adjust anticoagulation dosing 1

Common Pitfalls to Avoid

• Do not discontinue anticoagulation for isolated subconjunctival hemorrhage, even if it appears dramatic—the bright red appearance is alarming to patients but clinically insignificant 1, 3
• Do not order coagulation studies or adjust warfarin dosing based solely on subconjunctival hemorrhage 4
• Do not prescribe antibiotics unless there are clear signs of infection 1
• Avoid confusing this with more serious conditions like retrobulbar hemorrhage or intraocular bleeding, which would present with pain, vision changes, and proptosis 5

When to Investigate Further

Evaluate for underlying systemic conditions if: 3

• Recurrent episodes occur
• Persistent hemorrhage beyond 2-3 weeks
• Patient has no known risk factors (trauma, Valsalva, anticoagulation)

In these cases, consider workup for: 3

• Undiagnosed hypertension
• Bleeding disorders
• Systemic or ocular malignancies
• Medication side effects

Follow-Up

• No routine follow-up is needed for isolated subconjunctival hemorrhage 1
• Return in 1-2 weeks only if symptoms of viral conjunctivitis persist 1
• Patients should return immediately if they develop pain, vision changes, or signs of infection 1