How should a sudden painless bright red patch on the sclera (subconjunctival hemorrhage) be managed?

Subconjunctival Hemorrhage Management

A subconjunctival hemorrhage requires no treatment and resolves spontaneously within 1-3 weeks; reassurance is the primary intervention unless the hemorrhage is recurrent, persistent, or associated with other concerning features.

Initial Assessment and Reassurance

• Subconjunctival hemorrhage is a benign, self-limited condition that presents as a painless bright red patch on the sclera with no associated vision changes, discharge, or photophobia 1
• The condition typically resolves spontaneously without intervention, and serious complications are rare 1
• No specific treatment accelerates resolution; observation alone is appropriate for isolated, first-time occurrences 2, 1

Key Diagnostic Features to Confirm Benign Nature

• Vision should be completely normal - any vision loss suggests a different, more serious diagnosis such as retinal artery occlusion or vitreous hemorrhage 3, 4
• The eye should be painless - pain indicates alternative diagnoses like keratitis, iritis, scleritis, or acute angle-closure glaucoma 1
• No pupillary abnormalities - a relative afferent pupillary defect would suggest retinal or optic nerve pathology 3
• Normal intraocular pressure - elevated pressure suggests glaucoma rather than simple subconjunctival hemorrhage 1

When Further Evaluation Is Warranted

Recurrent or Persistent Hemorrhages

• If hemorrhages recur or persist beyond 2-3 weeks, investigate for underlying systemic causes 2
• In younger patients, trauma and contact lens use are the major risk factors to explore 2
• In elderly patients, evaluate for hypertension, diabetes, and arteriosclerosis as common underlying causes 2
• Despite theoretical concerns, there is no significant association between subconjunctival hemorrhage and acute coronary syndrome, so cardiac workup is not routinely indicated 5

Hemostatic Evaluation

• Routine hemostatic screening is NOT recommended for patients with recurrent subconjunctival hemorrhage who have no other bleeding manifestations 6
• The prevalence of hemostatic abnormalities in recurrent subconjunctival hemorrhage patients is no different from the general population 6
• Consider hemostatic workup only if the patient has other bleeding symptoms or is on anticoagulation/antiplatelet therapy 2, 6

Red Flags Requiring Ophthalmology Referral

• Persistent or recurrent hemorrhages with an associated salmon-pink conjunctival lesion may indicate ocular adnexal lymphoma and requires biopsy 7
• Any vision loss, severe pain not relieved by topical anesthetics, corneal involvement, or distorted pupil requires emergent ophthalmology referral 1
• Bilateral hemorrhages or hemorrhages associated with systemic bleeding warrant hematologic evaluation 2

Common Pitfalls to Avoid

• Do not confuse subconjunctival hemorrhage with more serious causes of red eye - the key distinguishing features are painless presentation, normal vision, and localized blood under the conjunctiva without diffuse injection 1
• Do not order extensive coagulation studies for isolated or even recurrent subconjunctival hemorrhage in the absence of other bleeding symptoms 6
• Do not miss giant cell arteritis in patients over 50 with vision changes - but note that subconjunctival hemorrhage itself is not a feature of GCA, which presents with vision loss, not isolated redness 8, 3