How should a subconjunctival hemorrhage be managed, especially in patients with underlying conditions like hypertension or diabetes?

Management of Subconjunctival Hemorrhage

Most subconjunctival hemorrhages are benign and self-limited, requiring only reassurance and observation without specific treatment, regardless of underlying conditions like hypertension or diabetes. 1, 2

Initial Assessment

When a patient presents with subconjunctival hemorrhage, focus your history on:

• Trauma history (including minor trauma like eye rubbing or contact lens use) 1, 2
• Valsalva-inducing activities (heavy lifting, coughing, vomiting, straining) 1, 2
• Anticoagulant or antiplatelet medications (aspirin, warfarin, clopidogrel, NSAIDs) 3, 1
• Known bleeding disorders or easy bruising elsewhere 3, 1
• Systemic diseases: hypertension, diabetes, arteriosclerosis 1

Management Algorithm

For First-Time, Isolated Subconjunctival Hemorrhage:

• Provide reassurance that the condition is benign and will resolve spontaneously in 1-3 weeks 1, 2
• No specific treatment is required - the blood will reabsorb naturally 1, 2
• Artificial tears may be used for comfort if mild irritation is present 2
• No laboratory workup is needed for a single episode 3, 1

For Recurrent or Persistent Subconjunctival Hemorrhage:

This requires further investigation, as it may indicate underlying pathology. 4, 1

Evaluate for:

• Uncontrolled hypertension - check blood pressure and optimize control if elevated 1
• Diabetes control - assess glycemic management in diabetic patients 1
• Bleeding disorders - though prevalence is NOT higher than general population, consider if other bleeding manifestations exist 3
• Occult malignancy - particularly ocular adnexal lymphoma, which can present as recurrent subconjunctival hemorrhage with a salmon-pink conjunctival lesion 4
• Medication review - reassess anticoagulant/antiplatelet therapy necessity and dosing 3, 1

Critical Red Flags Requiring Immediate Referral

Refer urgently to ophthalmology if:

• Recurrent hemorrhages in the same location with any conjunctival mass or salmon-pink lesion (concern for lymphoma) 4
• Associated vision changes, pain, or diplopia (may indicate orbital pathology) 5
• Bilateral hemorrhages with orbital signs postpartum or post-Valsalva (evaluate for orbital hematoma) 5
• Hemorrhage following significant trauma (rule out globe rupture or other serious injury) 2

Special Considerations for Patients with Hypertension or Diabetes

Hypertension:

• Subconjunctival hemorrhage is more common in elderly patients with systemic vascular disease 1
• Optimize blood pressure control to target <130/80 mmHg to reduce recurrence risk 1
• The hemorrhage itself does NOT indicate hypertensive emergency unless accompanied by other end-organ damage 1

Diabetes:

• Subconjunctival hemorrhage is NOT related to diabetic retinopathy 1
• Do NOT confuse with retinal hemorrhage - subconjunctival hemorrhage is anterior to the globe and benign 1
• Use this visit as an opportunity to ensure the patient has had appropriate dilated retinal examination for diabetic retinopathy screening 1

Common Pitfalls to Avoid

• Do NOT order extensive hemostatic workup (bleeding time, PFA-100, platelet aggregometry, von Willebrand studies) for isolated or even recurrent subconjunctival hemorrhage without other bleeding manifestations - the yield is extremely low 3
• Do NOT discontinue aspirin for cardiovascular protection in diabetic or hypertensive patients due to subconjunctival hemorrhage - the benefits outweigh this benign complication 3, 1
• Do NOT mistake subconjunctival hemorrhage for more serious intraocular hemorrhage - perform careful examination to ensure the blood is beneath the conjunctiva, not in the anterior chamber or vitreous 2