I have a conjunctival hemorrhage on the white of my eye; how should it be managed, especially if I am otherwise healthy and taking anticoagulant or antiplatelet medication?

Management of Conjunctival Hemorrhage

For an otherwise healthy patient with conjunctival hemorrhage who is taking anticoagulant or antiplatelet medication, continue the medication without interruption and provide reassurance, as this is a benign, self-limiting condition that does not meet criteria for major bleeding. 1, 2

Classification of Bleeding Severity

Conjunctival hemorrhage (subconjunctival hemorrhage) does not constitute major bleeding by established criteria. Major bleeding requires at least one of: bleeding at a critical site (intracranial, intraocular, spinal, etc.), hemodynamic instability, or hemoglobin decrease ≥2 g/dL. 2 Isolated conjunctival hemorrhage—blood between the conjunctiva and sclera appearing as a bright red patch—does not meet any of these thresholds. 1, 2

Anticoagulation Management

Do not discontinue or adjust anticoagulation therapy. The American College of Cardiology explicitly recommends continuing oral anticoagulation without dose adjustment for isolated subconjunctival hemorrhage, as it is classified as a non-major bleed. 1, 2 This applies to:

• Warfarin (vitamin K antagonists): Continue without reversal agents 1
• Direct oral anticoagulants (DOACs): Continue without interruption 1
• Antiplatelet agents (aspirin, clopidogrel, prasugrel, ticagrelor): Continue without modification 1, 2

Do not administer reversal agents such as vitamin K, prothrombin complex concentrates, idarucizumab, or andexanet alfa for isolated conjunctival hemorrhage. 1, 2 These are reserved exclusively for major bleeding events with hemodynamic compromise. 2

Symptomatic Treatment

Provide local supportive care for comfort:

• Artificial tears to relieve mild irritation 1
• Cold compresses applied for 20-30 minutes per session with a barrier (thin towel) between ice and skin to prevent cold injury 1
• Patient education that the hemorrhage typically resolves spontaneously within 1-2 weeks without treatment 1

The American Academy of Ophthalmology recommends no specific treatment for isolated subconjunctival hemorrhage, as it is benign and self-limiting. 1

Clinical Assessment

Perform a focused examination to exclude serious pathology:

• Check for pain: Persistent pain requires further investigation for globe injury or other pathology 1
• Assess for infection signs: Purulent discharge, matting, or signs of conjunctivitis warrant conjunctival culture 1
• Examine for viral conjunctivitis: Look for preauricular lymphadenopathy and follicular reaction, as subconjunctival hemorrhage can be associated with viral conjunctivitis 1
• Rule out recurrent bilateral hemorrhages: Multiple episodes or family history of recurrent nosebleeds may suggest hereditary hemorrhagic telangiectasia and warrant specialist referral 3

Warning Signs Requiring Urgent Evaluation

Refer immediately to ophthalmology if any of the following are present:

• Visual loss 3
• Moderate or severe pain 3, 1
• Signs of globe penetration or trauma 3
• Irregular pupil after trauma 3
• Intraocular bleeding (distinct from subconjunctival) 3

Special Considerations for Anticoagulated Patients

While patients on anticoagulation may experience more frequent or extensive subconjunctival hemorrhages, research shows these remain self-limiting without compromised visual acuity. 1, 4 The prevalence of spontaneous ocular hemorrhage is higher with prasugrel (7.2%) and rivaroxaban (3.1%) compared to other agents, but these events do not require medication adjustment. 4

Critical pitfall to avoid: Do not automatically classify visible bleeding as major bleeding—this requires objective hemodynamic or laboratory parameters (systolic BP <90 mmHg, hemoglobin drop ≥2 g/dL, or transfusion requirement). 2

Follow-Up

• Routine follow-up is not required for isolated subconjunctival hemorrhage 1
• Return in 1-2 weeks only if symptoms persist or if associated viral conjunctivitis is present 1
• Seek immediate care if new pain, vision changes, or signs of infection develop 1

Rare Presentations Requiring Investigation

While extremely uncommon, recurrent or persistent subconjunctival hemorrhages have been reported as initial presentations of:

• Ocular adnexal lymphoma (salmon-pink lesion with recurrent hemorrhage) 5
• Idiopathic thrombocytopenic purpura (check platelet count if systemic bleeding signs) 6
• Essential thrombocythemia (severe spontaneous bleeding with orbital involvement) 7

These diagnoses should be considered only if hemorrhages are recurrent, bilateral, associated with mass lesions, or accompanied by systemic bleeding manifestations. 5, 6, 7