Subconjunctival hemorrhage

Background

• Bleeding of the conjunctival vessels into the subconjunctival space
• Can be spontaneous or related to trauma
  • Spontaneous can be secondary to anticoagulation, bleeding diathesis, etc.
• If large and associated with trauma, see hemorrhagic chemosis
  • Need to maintain suspicion for occult globe rupture (obscured by hemorrhage)
• Bilateral and recurrent subconjunctival hemorrhage should have bleeding diathesis and uncontrolled hypertension workup

Risk Factors

• Ocular trauma
• Contact lens usage
• Systemic vascular diseases
  • Hypertension
  • Diabetes
  • Arteriosclerosis

Clinical Features

Subconjunctival hemorrhage

Subconjunctival hemorrhage

Bilateral subconjunctival hemorrhage: (a) at presentation, (b) after 5 days, and (c) complete resolution after 1 month.

• Painless
• No effect on vision
• Frequently atraumatic, although may recall a history of mild trauma or valsalva
• Examination
  • Fresh red blood on a white sclera with clear borders
  • Masks the conjunctival vessels
• Not significantly raised (see hemorrhagic chemosis if large amount raised)

Differential Diagnosis

Unilateral red eye

• Nontraumatic
  • Acute angle-closure glaucoma^
  • Anterior uveitis
  • Conjunctivitis
  • Corneal erosion
  • Corneal ulcer^
  • Endophthalmitis^
  • Episcleritis
  • Herpes zoster ophthalmicus
  • Inflamed pinguecula
  • Inflamed pterygium
  • Keratoconjunctivitis
  • Keratoconus
  • Nontraumatic iritis
  • Scleritis^
  • Subconjunctival hemorrhage
• Orbital trauma
  • Caustic keratoconjunctivitis^^
  • Corneal abrasion, Corneal laceration
  • Conjunctival hemorrhage
  • Conjunctival laceration
  • Globe rupture^
  • Hemorrhagic chemosis
  • Lens dislocation
  • Ocular foreign body
  • Posterior vitreous detachment
  • Retinal detachment
  • Retrobulbar hemorrhage
    • Ocular compartment syndrome
  • Traumatic hyphema
  • Traumatic iritis
  • Traumatic mydriasis
  • Traumatic optic neuropathy
  • Vitreous detachment
  • Vitreous hemorrhage
  • Ultraviolet keratitis

^Emergent diagnoses
^^Critical diagnoses

Evaluation

• Clinical diagnosis
• Consider fluorescein staining to evaluate for corneal injury if suggested by history or if patient complains of pain
• For recurrent or persistent subconjunctival hemorrhage, further evaluation, including workup for systemic hypertension, bleeding disorders, systemic and ocular malignancies, and drug side effects, is warranted.

Management

• Reassurance (will generally resolve within 10-14d)

Disposition

• Outpatient

See Also

• Eye Algorithm (Main)
• Hemorrhagic chemosis