Management of Scleral Bleeding
For scleral bleeding (subconjunctival hemorrhage), observation with reassurance is the appropriate management, as this is typically a benign, self-limited condition that resolves spontaneously within 1-3 weeks without intervention.
Initial Assessment and Classification
When evaluating scleral bleeding, distinguish between:
- Subconjunctival hemorrhage: Bleeding between the conjunctiva and sclera, appearing as bright red blood on the white of the eye 1
- Intraocular hemorrhage: Bleeding within the eye (choroidal, vitreous, or retinal), which requires urgent ophthalmologic evaluation 2
- Post-surgical bleeding: Occurring after strabismus or other ocular surgery 1
Management Based on Clinical Context
Spontaneous Subconjunctival Hemorrhage (Most Common)
Conservative management is appropriate:
- No specific treatment required; the hemorrhage will reabsorb spontaneously 1
- Reassure the patient that this is benign and does not affect vision 1
- Artificial tears may provide comfort if irritation is present 1
Evaluate for underlying causes:
- Check blood pressure, as hypertension can contribute to spontaneous bleeding 3
- Review anticoagulant/antiplatelet medications (warfarin, aspirin, clopidogrel, DOACs) 1
- Assess for bleeding disorders if recurrent or bilateral 1, 4
- Consider trauma history, even minor (Valsalva, coughing, rubbing) 1
Post-Surgical Scleral Bleeding
Following strabismus or other ocular surgery:
- Mild visible sclera or persistent injection over the surgical site is common and self-limited 1
- Monitor for more serious complications including 1:
- Postoperative orbital hemorrhage (very rare but potentially vision-threatening)
- Subconjunctival abscess or preseptal cellulitis (1 in 1,100 to 1 in 1,900)
- Surgically induced necrotizing scleritis (1 in 4,000, more common in adults)
Immediate ophthalmology consultation required if:
- Hemodynamic instability or severe pain develops 5
- Vision changes occur 2
- Signs of infection present (fever, purulent discharge, increasing pain) 1
- Proptosis or restricted eye movements develop 1
Bleeding in Anticoagulated Patients
For patients on anticoagulation with minor scleral bleeding:
- Continue anticoagulation without interruption, as subconjunctival hemorrhage is minor bleeding 1
- Do not reverse anticoagulation for isolated subconjunctival hemorrhage 1
- Document the episode as it predicts risk of subsequent major bleeding 1
Reversal is only indicated for:
- Severe intraocular hemorrhage with vision threat 1, 5
- Hemodynamic instability from blood loss 5
- Hemoglobin decrease ≥2 g/dL 5
Red Flags Requiring Urgent Ophthalmology Referral
Immediate specialist evaluation needed for:
- Decreased visual acuity 2, 4
- Severe eye pain disproportionate to findings 1, 2
- Choroidal or vitreous hemorrhage (requires imaging confirmation) 2
- Globe perforation concern (history of trauma with sharp object) 1
- Signs of endophthalmitis (1 in 30,000 to 1 in 185,000 post-surgery) 1
- Anterior segment ischemia (1 in 6,000, higher with vascular risk factors) 1
Common Pitfalls to Avoid
Do not:
- Reverse anticoagulation for simple subconjunctival hemorrhage 1
- Prescribe antibiotics for uncomplicated subconjunctival hemorrhage 1
- Order extensive coagulation studies for isolated, first-time occurrence 4
- Delay ophthalmology consultation if intraocular bleeding is suspected 2, 4
Do:
- Differentiate superficial from deep hemorrhage by examining for vision changes 2, 4
- Document medication history, particularly anticoagulants and antiplatelets 1, 3
- Measure blood pressure in all patients 3
- Consider hematology consultation for recurrent unexplained bleeding 4
Special Populations
Patients with connective tissue disorders (e.g., Ehlers-Danlos syndrome):
- Higher risk of scleral rupture from minor trauma 6
- Increased bleeding tendency from fragile blood vessels 6
- Require careful monitoring and early specialist involvement 6
Diabetic patients or those with carotid stenosis: