How should a subconjunctival hemorrhage that is matted and actively draining be managed?

Management of Subconjunctival Hemorrhage with Matting and Drainage

Immediate Assessment and Red Flags

A subconjunctival hemorrhage that is "matted and draining" requires urgent ophthalmology evaluation to rule out serious underlying pathology, as this presentation is atypical for benign subconjunctival hemorrhage and suggests possible infection, severe inflammation, or malignancy. 1

The term "matted and draining" is concerning because:

• Standard subconjunctival hemorrhage does not drain – it is contained blood under the conjunctiva that reabsorbs over 1-2 weeks 1
• Matted appearance with drainage suggests purulent discharge, which indicates infectious conjunctivitis or more serious pathology 2
• This presentation warrants investigation for signs of infection, persistent pain, or underlying systemic disease 1, 3

Critical Differential Diagnoses to Exclude

When subconjunctival hemorrhage presents with atypical features like matting and drainage, you must actively investigate:

• Infectious conjunctivitis (bacterial or viral) with secondary hemorrhage – look for preauricular lymphadenopathy, follicular reaction, purulent discharge 1
• Ocular adnexal lymphoma – presents with recurrent subconjunctival hemorrhage and a characteristic salmon-pink conjunctival lesion 4, 5
• Severe viral conjunctivitis with marked chemosis, eyelid swelling, or membranous conjunctivitis 1
• Bleeding disorders or thrombocytopenia – subconjunctival hemorrhage can be the first sign of idiopathic thrombocytopenic purpura 6
• Systemic conditions including hypertension, diabetes, anticoagulation therapy 4, 3

Management Algorithm

Step 1: Determine if This is Infectious vs. Non-Infectious

If purulent drainage is present:

• This is likely bacterial conjunctivitis with secondary hemorrhage
• Start topical broad-spectrum antibiotics immediately (e.g., fluoroquinolone drops)
• Culture if severe or not responding to initial therapy
• Do not use topical corticosteroids until infection is ruled out 1

If clear/watery drainage with viral symptoms:

• Likely viral conjunctivitis with subconjunctival hemorrhage
• Management focuses on the underlying viral infection with topical lubricants for comfort 1
• Avoid antibiotics as they are ineffective for viral infections 1
• Consider topical corticosteroids only for severe cases with marked chemosis, eyelid swelling, or membranous conjunctivitis, under close ophthalmology supervision 1

Step 2: Look for Warning Signs of Serious Pathology

Examine specifically for:

• Salmon-pink conjunctival lesion – highly suggestive of ocular adnexal lymphoma 4, 5
• Conjunctival nodules or granulomas – warrant biopsy 4
• Persistent pain – requires further investigation 1
• Recurrent hemorrhages – necessitate workup for bleeding disorders, hypertension, diabetes, malignancies 4, 3

Step 3: Symptomatic Management

While investigating the underlying cause:

• Artificial tears for comfort and irritation relief 1, 4
• Cold compresses for 20-30 minutes per session using ice and water in a bag with a damp cloth barrier to prevent cold injury 1, 4
• Patient education about expected resolution timeline (1-2 weeks for uncomplicated cases) 1, 4

Step 4: Systemic Workup if Recurrent or Persistent

For recurrent or persistent cases, investigate:

• Complete blood count with platelet count (rule out thrombocytopenia) 6
• Blood pressure measurement (hypertension) 4, 3
• Coagulation studies if on anticoagulation or suspected bleeding disorder 4, 3
• Review medications (anticoagulants, antiplatelet agents) 3

Anticoagulation Considerations

Do not stop anticoagulation for isolated subconjunctival hemorrhage – it is considered a minor bleed that does not meet criteria for therapy interruption 1, 4. However, if the presentation is atypical with drainage and matting suggesting infection or other pathology, this is no longer "isolated" subconjunctival hemorrhage and requires different management.

Follow-Up Strategy

• Urgent ophthalmology referral for atypical presentation with matting and drainage 1
• Follow-up within 1-2 weeks if viral conjunctivitis symptoms persist 1, 4
• Immediate return if pain develops, vision changes, or symptoms worsen 1

Common Pitfalls to Avoid

• Assuming all subconjunctival hemorrhage is benign – matting and drainage are NOT typical features 1, 3
• Using topical corticosteroids before ruling out infection – can worsen bacterial or fungal infections 1
• Prescribing antibiotics for viral conjunctivitis – ineffective and promotes resistance 1
• Missing the salmon-pink lesion of lymphoma in recurrent cases 4, 5
• Failing to check platelet count when hemorrhage is severe or recurrent 6