What is the appropriate initial management of a subconjunctival hemorrhage in an elderly woman, including assessment of blood pressure and anticoagulant therapy?

Management of Subconjunctival Hemorrhage in an Elderly Woman

Subconjunctival hemorrhage in an elderly patient requires blood pressure measurement and assessment of anticoagulant use, but the condition itself is benign and requires no specific treatment beyond reassurance and observation. 1

Initial Assessment

Blood Pressure Evaluation

• Measure blood pressure immediately in all elderly patients presenting with subconjunctival hemorrhage, as systemic hypertension is one of the most common underlying causes in this age group. 1, 2
• Hypertension is particularly prevalent among older patients with subconjunctival hemorrhage and warrants evaluation even in isolated cases. 2

Anticoagulation History

• Document all anticoagulant and antiplatelet medications, including warfarin, direct oral anticoagulants (DOACs), aspirin, and clopidogrel. 1
• Do not discontinue or reverse anticoagulation for isolated subconjunctival hemorrhage, as this is a minor bleeding event that does not indicate systemic hemorrhagic risk requiring intervention. 1
• The presence of anticoagulation does not change management of simple subconjunctival hemorrhage, though it may be a contributing factor. 1

When to Investigate Further

Indications for Extended Workup

• Pursue additional investigation only if the subconjunctival hemorrhage is recurrent or persistent, not for a single isolated episode. 1
• In recurrent cases, evaluate for:
  • Uncontrolled systemic hypertension 1
  • Bleeding disorders (obtain complete blood count with platelet count, PT/INR, aPTT) 1, 3
  • Diabetes and arteriosclerosis 1
  • Drug side effects beyond standard anticoagulation 1
  • Systemic or ocular malignancies in rare cases 1

Red Flags Requiring Immediate Hematologic Evaluation

• If subconjunctival hemorrhage appears spontaneously without trauma or obvious cause and is accompanied by other bleeding manifestations (such as petechiae, mucosal bleeding, or hematuria), obtain an urgent complete blood count to rule out thrombocytopenia or other serious hematologic disorders. 3
• Subconjunctival hemorrhage can rarely be the first presenting sign of idiopathic thrombocytopenic purpura or other severe systemic bleeding disorders. 3

Treatment Approach

Conservative Management

• Provide reassurance that subconjunctival hemorrhage is a benign, self-limited condition that will resolve spontaneously over 1-3 weeks. 1
• No topical or systemic medications are indicated for uncomplicated subconjunctival hemorrhage. 1
• Artificial tears may be used for comfort if mild irritation is present, but they do not accelerate resolution. 1

Blood Pressure Management

• If hypertension is newly identified or poorly controlled, refer for appropriate medical management, but this is a separate issue from the subconjunctival hemorrhage itself. 2

Critical Pitfalls to Avoid

• Do not order extensive coagulation studies or hematologic workup for a single, isolated subconjunctival hemorrhage in an otherwise well patient—this represents unnecessary testing and cost. 1
• Do not hold or reverse anticoagulation based solely on subconjunctival hemorrhage—the bleeding is superficial and self-limited, and the thromboembolic risk of stopping anticoagulation far outweighs any benefit. 1
• Do not confuse subconjunctival hemorrhage with more serious intraocular hemorrhages (vitreous or subretinal)—subconjunctival hemorrhage is external to the globe, does not affect vision, and requires no ophthalmologic intervention. 4, 5