Management of Subconjunctival Hemorrhage After Airplane Landing in a Patient with Hypertension and Possible Bleeding Disorder
For a patient with subconjunctival hemorrhage after airplane landing, reassurance and symptomatic treatment with NSAIDs or acetaminophen is the appropriate management, as routine screening for bleeding disorders is not indicated even in patients with recurrent episodes. 1, 2
Immediate Management
The primary treatment is pain control and reassurance, as subconjunctival hemorrhage is a benign, self-limited condition. 3, 4
- Administer NSAIDs (ibuprofen) or acetaminophen at fixed intervals for any associated ocular discomfort, as pain is easier to prevent than treat 5
- NSAIDs are superior to acetaminophen alone because they address both pain and inflammation 5
- Initiate preservative-free artificial tears (if using more than 4 times daily) to address ocular surface dryness from low-humidity cabin air exposure 5
No Need for Bleeding Disorder Workup
The prevalence of hemostatic abnormalities in patients with spontaneous subconjunctival hemorrhage is not different from the general population, making routine screening unnecessary. 1, 2
- A study of 105 patients with recurrent spontaneous subconjunctival hemorrhage found no increased prevalence of hemostatic alterations compared to healthy controls 2
- Type I von Willebrand disease was diagnosed in only 3.8% of patients with subconjunctival hemorrhage, which is not statistically different from the normal population frequency 1
- Hemostatic screening or second-level coagulation tests are of no use in patients with recurrent subconjunctival hemorrhage who have no other bleeding manifestations 2
When to Consider Further Evaluation
Further workup is only warranted if the hemorrhage is recurrent or persistent, or if there are other systemic bleeding manifestations. 3
- Evaluate for uncontrolled hypertension, as systemic vascular diseases are common risk factors in elderly patients 3
- Consider medication review for anticoagulants, antiplatelet agents, or NSAIDs that may contribute to bleeding 2
- Assess for systemic or ocular malignancies only if hemorrhages are truly recurrent and persistent 3
Expected Course and Follow-up
Subconjunctival hemorrhage typically resolves spontaneously within 1-2 weeks without intervention. 3, 4
- The blood appears as sudden, painless bright red discoloration under the clear conjunctiva 4
- No specific treatment accelerates resolution 3
- Reassure the patient that this is a benign condition with excellent prognosis 3, 4
Common Pitfalls to Avoid
- Do not order routine coagulation studies or bleeding disorder workup for isolated subconjunctival hemorrhage, as the yield is extremely low and not cost-effective 1, 2
- Do not prescribe antibiotics, as subconjunctival hemorrhage is not infectious 5
- Do not use artificial tears with preservatives if frequent applications are needed (>4 times/day), as preservatives can worsen the ocular surface 5