What is the recommended treatment for a patient with moderate subconjunctival hemorrhage secondary to trauma?

Treatment for Moderate Subconjunctival Hemorrhage Secondary to Trauma

Moderate traumatic subconjunctival hemorrhage requires no active treatment beyond observation and reassurance, as it resolves spontaneously within 1-3 weeks; however, a thorough examination to exclude associated serious ocular injuries is mandatory. 1, 2

Immediate Management Approach

Primary Assessment Requirements

• Visual acuity must be documented immediately in every patient with traumatic subconjunctival hemorrhage, as visual acuity less than 20/40 increases the probability of additional serious ocular injuries by more than 5-fold (OR 5.27). 1

• Perform a comprehensive ocular examination to identify coexisting injuries, as 42.7% of eyes with traumatic subconjunctival hemorrhage have additional damage, rising to 66.2% when visual acuity is reduced. 1

• Specifically evaluate for:

  • Globe rupture or penetrating injury 1, 2
  • Hyphema (blood in anterior chamber) 1
  • Corneal abrasion or laceration 1
  • Traumatic iritis 1
  • Lens dislocation 1
  • Retinal injury 1

Treatment Protocol

No active intervention is required for the subconjunctival hemorrhage itself. 3, 4 The blood reabsorbs spontaneously without treatment.

• Artificial tears or lubricating drops may be used for symptomatic relief if the patient experiences foreign body sensation or discomfort. 3

• Cold compresses can be applied in the first 24-48 hours if there is associated periocular swelling, though this does not accelerate hemorrhage resolution. 3

• Avoid aspirin and NSAIDs unless medically necessary, as these may theoretically prolong bleeding, though evidence is limited. 4

Critical Pitfalls to Avoid

Never dismiss traumatic subconjunctival hemorrhage without measuring visual acuity and performing a complete examination, as this is the most common error leading to missed serious injuries. 1 Eyes with normal visual acuity (20/20-20/40) still have a 27.1% rate of additional injuries requiring specialized care. 1

Do not assume the hemorrhage is the only injury based on its dramatic appearance—the bright red blood often distracts from more serious underlying pathology. 1, 2

Recurrent or persistent hemorrhages beyond 2-3 weeks warrant investigation for underlying systemic conditions (hypertension, coagulopathy) or, rarely, occult malignancy. 5, 4

Follow-Up Strategy

• Routine follow-up is unnecessary for isolated subconjunctival hemorrhage with normal examination findings and normal visual acuity. 3, 4

• Ophthalmology referral is indicated if:

  • Visual acuity is reduced 1
  • Additional ocular injuries are identified 1, 2
  • The hemorrhage recurs multiple times 5, 4
  • The hemorrhage persists beyond 3 weeks 4

• Patient education should emphasize that the hemorrhage will worsen in appearance over 24-48 hours as blood spreads, then gradually fade from red to yellow-brown over 1-3 weeks. 3

Special Considerations in Pediatric Trauma

In children of all ages, including infants, 94-97% of traumatic subconjunctival hemorrhages are due to accidental trauma or ocular surface inflammation. 2 However, all children with subconjunctival hemorrhage must be examined for other signs of trauma (ocular and non-ocular) to identify potential non-accidental injury. 2