What is the management approach for a patient with subconjunctival hemorrhage, particularly those with a history of bleeding disorders or taking anticoagulant medications?

Management of Subconjunctival Hemorrhage

For patients with subconjunctival hemorrhage on anticoagulation, continue the anticoagulant without interruption while providing reassurance, as this is a non-major bleed that does not meet criteria for anticoagulation reversal or suspension. 1

Classification of Bleeding Severity

Subconjunctival hemorrhage is classified as a non-major bleed because it does not meet any of the following major bleeding criteria 1:

• Bleeding at a critical site (intracranial, intraspinal, intraocular, pericardial, intra-articular, intramuscular with compartment syndrome, or retroperitoneal)
• Hemodynamic instability
• Clinically overt bleeding with hemoglobin decrease ≥2 g/dL or administration of ≥2 units RBCs

Note: While subconjunctival hemorrhage involves the eye, it is not considered "intraocular bleeding" (which refers to bleeding inside the globe such as vitreous or retinal hemorrhage), and therefore does not qualify as bleeding at a critical site. 1

Management Algorithm for Patients on Anticoagulation

For Non-Major Subconjunctival Hemorrhage (Standard Presentation)

Continue oral anticoagulation without interruption if there is an appropriate indication for anticoagulation (e.g., atrial fibrillation, venous thromboembolism). 1

Provide local therapy/manual compression as needed, though subconjunctival hemorrhage typically resolves spontaneously without intervention. 1

Assess for and manage comorbidities that could contribute to bleeding, including thrombocytopenia, uremia, and liver disease. 1

Determine if dosing of oral anticoagulant is appropriate to ensure the patient is not supratherapeutic. 1

If patient is on concomitant antiplatelet therapy, assess risks and benefits of stopping the antiplatelet agent, though this is generally not necessary for isolated subconjunctival hemorrhage. 1

For Recurrent Subconjunctival Hemorrhage

Do not routinely screen for bleeding disorders in patients with recurrent spontaneous subconjunctival hemorrhage, as the prevalence of hemostatic abnormalities is not higher than in the general population. 2, 3

Consider alternative diagnoses if hemorrhages are persistent or recurrent over many months, including ocular adnexal lymphoma, which can rarely present with recurrent subconjunctival hemorrhage as the initial manifestation. 4

Maintain anticoagulation even with recurrent episodes, as these remain non-major bleeds that do not warrant anticoagulation interruption. 1

Management for Patients NOT on Anticoagulation

Provide reassurance that subconjunctival hemorrhage is typically benign and self-limited. 2, 3

No hemostatic workup is indicated for isolated or even recurrent subconjunctival hemorrhage in the absence of other bleeding manifestations, as studies show no increased prevalence of von Willebrand disease or other bleeding disorders compared to the general population. 2, 3

Evaluate for secondary causes including hypertension, trauma, conjunctivitis, Valsalva maneuver, and use of NSAIDs or aspirin. 2, 3

Critical Pitfalls to Avoid

Do not stop anticoagulation for isolated subconjunctival hemorrhage, as this exposes patients to thrombotic risk without meaningful benefit. 1

Do not administer reversal agents (vitamin K, prothrombin complex concentrates, idarucizumab, or andexanet alfa) for subconjunctival hemorrhage, as these are reserved for major or life-threatening bleeding. 1, 5

Do not perform extensive hemostatic testing (bleeding time, PFA-100, platelet aggregometry, von Willebrand studies) in patients with isolated or recurrent subconjunctival hemorrhage without other bleeding symptoms, as this has no diagnostic yield. 2, 3

Do not confuse subconjunctival hemorrhage with intraocular hemorrhage (vitreous hemorrhage, retinal hemorrhage, or submacular hemorrhage), which would constitute bleeding at a critical site requiring anticoagulation suspension and urgent ophthalmologic intervention. 1, 6

When to Escalate Care

Refer to ophthalmology urgently if there is concern for intraocular bleeding (vision changes, floaters, decreased visual acuity, or hemorrhage that appears to be behind the conjunctiva rather than under it). 6

Consider hematology referral only if the patient has other unexplained bleeding manifestations beyond subconjunctival hemorrhage, suggesting a systemic bleeding disorder. 2, 3

Investigate for malignancy if subconjunctival hemorrhages are persistent (lasting months) or associated with a salmon-pink conjunctival lesion, which may indicate ocular adnexal lymphoma. 4