What should be done for a patient with subconjunctival bleeding, considering their medical history, including conditions such as hypertension, bleeding disorders, or anticoagulant use?

Management of Subconjunctival Hemorrhage

Subconjunctival hemorrhage is a benign, self-limited condition that requires no specific treatment in the vast majority of cases, including in patients on anticoagulation or with bleeding disorders, as the prevalence of underlying hemostatic abnormalities is no different from the general population. 1, 2

Initial Assessment

Clinical Evaluation

• Document visual acuity to ensure no vision compromise, which would suggest more serious intraocular pathology 3
• Perform slit-lamp biomicroscopy to confirm the hemorrhage is limited to the subconjunctival space and exclude intraocular bleeding 3
• Check for signs of trauma, contact lens use in younger patients, or vascular risk factors (hypertension, diabetes, arteriosclerosis) in elderly patients 4
• Assess for hemodynamic stability only if there are systemic bleeding concerns—isolated subconjunctival hemorrhage does not cause hemodynamic compromise 3

Key Clinical Distinction

Subconjunctival hemorrhage is classified as a non-major bleed because it does not occur at a critical site, does not cause hemodynamic instability, and does not result in hemoglobin drop ≥2 g/dL 3, 5. This classification is crucial for management decisions in anticoagulated patients.

Management for Patients on Anticoagulation

Continue Anticoagulation

Do not discontinue anticoagulant or antiplatelet therapy for isolated subconjunctival hemorrhage, as the thrombotic risk of stopping anticoagulation far outweighs the minimal bleeding risk 5. This applies to:

• Warfarin and other vitamin K antagonists 5
• Direct oral anticoagulants (DOACs) 5
• Antiplatelet agents 5

What NOT to Do

• Do not administer vitamin K, prothrombin complex concentrates, or DOAC reversal agents for subconjunctival hemorrhage—these interventions are reserved exclusively for major bleeding 5
• Do not routinely transfuse platelets in patients on antiplatelet therapy, as this has not been shown to improve outcomes 5
• Do not order extensive coagulation studies unless the hemorrhage is recurrent or persistent, as the prevalence of hemostatic abnormalities is not elevated in this population 1, 2

Management for Recurrent or Persistent Cases

When to Investigate Further

If subconjunctival hemorrhage is recurrent (≥2 episodes) or persistent beyond 2-3 weeks, consider evaluation for 4:

• Systemic hypertension with blood pressure measurement 4
• Bleeding disorders only if there are other bleeding manifestations or family history 4
• Systemic or ocular malignancies, particularly in patients >60 years with salmon-pink conjunctival lesions 6
• Medication side effects including NSAIDs, aspirin, or excessive anticoagulation 4

Laboratory Testing (Only for Recurrent Cases)

The evidence shows no increased prevalence of hemostatic abnormalities in patients with recurrent spontaneous subconjunctival hemorrhage compared to healthy controls 1, 2. Therefore:

• Routine hemostatic screening is not indicated for isolated or even recurrent subconjunctival hemorrhage 1, 2
• Von Willebrand disease prevalence (3.8%) in subconjunctival hemorrhage patients is not statistically different from the general population 2
• Consider targeted testing only if there are additional bleeding symptoms or strong family history 1, 2

Supportive Care

Patient Reassurance

• Explain the benign, self-limited nature of the condition—most resolve spontaneously within 1-2 weeks 4
• Reassure that vision is not affected unless there are other concerning findings 3
• Advise that the hemorrhage may appear worse before improving as blood spreads and changes color 4

Symptomatic Management

• Artificial tears may provide comfort if mild irritation is present 4
• Cold compresses in the first 24-48 hours may limit hemorrhage spread 4
• Avoid Valsalva maneuvers (straining, heavy lifting, vigorous coughing) during the acute phase 4

Critical Pitfalls to Avoid

• Do not confuse subconjunctival hemorrhage with intraocular bleeding, which presents with vision loss, pain, and requires urgent ophthalmologic evaluation 3
• Do not stop anticoagulation reflexively—the case report of warfarin-associated subconjunctival hemorrhage requiring fresh frozen plasma 7 represents an extreme outlier and should not guide routine practice
• Do not order extensive workups for single episodes in otherwise healthy patients, as this leads to unnecessary testing without clinical benefit 1, 2
• Do not miss underlying malignancy in cases with persistent salmon-pink lesions or recurrent unilateral hemorrhages 6