How should I manage a patient of subconjunctival hemorrhage?
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Here is a comprehensive, evidence-based management guide for subconjunctival hemorrhage (SCH):
Subconjunctival Hemorrhage - Management
Subconjunctival hemorrhage: blood smoothly elevating the overlying conjunctiva with no vessels visible behind it. (Rosen's Emergency Medicine, Fig. 57.3)
1. Recognition and Clinical Features
- Bright red blood beneath the conjunctiva; vessels are NOT visible through the blood (this distinguishes it from conjunctivitis)
- Often found incidentally (patient notices it in the mirror on waking)
- Vision is not affected
- Symptoms, if any: mild diffuse foreign body sensation; usually asymptomatic
- May be associated with chemosis in larger bleeds
2. Etiology - Always Identify the Cause
| Category | Examples |
|---|---|
| Valsalva | Coughing, sneezing, vomiting, straining at stool, heavy lifting |
| Trauma | Direct blunt/penetrating injury; eye rubbing |
| Systemic | Hypertension, diabetes, bleeding disorders |
| Medications | Aspirin, clopidogrel, warfarin, ticagrelor, dabigatran, rivaroxaban, apixaban, edoxaban, topical steroids |
| Idiopathic | Very common; no cause found |
3. History and Examination (Workup)
History to take:
- Any bleeding or clotting problems?
- Current medications (especially anticoagulants/antiplatelets)?
- Trauma, eye rubbing, heavy lifting, or Valsalva?
- Is this a recurrent episode?
- Acute or chronic cough?
Examination:
- Check blood pressure - hypertension is a common precipitant
- Visual acuity - should be normal; any reduction warrants urgent evaluation
- Ocular examination:
- Check extraocular motility
- IOP (if large/traumatic bleed)
- Look for signs of globe rupture: abnormally deep or shallow anterior chamber, hyphema, vitreous hemorrhage, uveal prolapse, severe bullous SCH
- 360-degree hemorrhage with chemosis, pain, or reduced vision = evaluate for globe perforation
- Slit lamp + fluorescein: mandatory in trauma to rule out corneal abrasions, globe perforation (Seidel's test), and retained foreign bodies; evert eyelids to check fornices
When to do Seidel's test: If fluorescein dye on the conjunctival surface is focally displaced by leaking aqueous fluid (positive test), or brownish-black uveal tissue is visible in a scleral wound, globe perforation is present - manage accordingly.
4. Treatment
For simple, non-traumatic SCH:
- No specific treatment is required - this is the most important point
- Cool compresses may be applied for comfort; there is no evidence they hasten resolution
- Artificial tears (q.i.d.) may be given if the patient has mild ocular irritation or foreign body sensation
- Advise the patient the blood will gradually resolve over 10 to 14 days (up to 2-4 weeks), changing colours as it does (from bright red → orange/yellow → resolution)
- No patching, no antibiotic drops, no steroids needed
Medications:
- Elective use of aspirin and NSAIDs should be discouraged unless required for coexisting medical conditions
- Do NOT stop anticoagulants or antiplatelets without clearance from the patient's primary physician - the risk of stopping these (e.g. stroke, MI) usually far outweighs the benefit
5. Investigations - When Are They Needed?
Routine investigations are NOT warranted in a first, simple, spontaneous SCH.
Order coagulation studies (PT, aPTT, CBC with differential, LFTs, Protein C and S) if:
- Recurrent subconjunctival hemorrhages
- History of bleeding problems or bruising elsewhere
- Patient on anticoagulants (consider checking INR/drug levels)
- No identifiable cause in a child (consider non-accidental injury)
Imaging (CT/MRI orbits with and without contrast):
- If orbital signs are present in a non-traumatic case: proptosis, restricted extraocular motility, elevated IOP - investigate for orbital mass (e.g., neuroblastoma in children, lymphangioma in adults)
- In traumatic cases: image as guided by mechanism and clinical findings
6. Red Flags Requiring Urgent Ophthalmology Referral
- Reduced visual acuity
- 360-degree hemorrhage
- Significant chemosis
- Restricted eye movements or proptosis
- Elevated IOP
- Evidence of globe perforation on Seidel's test
- Hyphema or uveal prolapse visible
- Traumatic SCH with high-velocity mechanism (compressed air tool, hammer strike deflection) - suspect occult penetrating injury
7. Differential Diagnosis to Consider
- Kaposi sarcoma: red/purple, slightly elevated subconjunctival lesion - test for HIV
- Conjunctival lymphoma or amyloid with secondary hemorrhage
- Scleritis/episcleritis: vessels visible through injection; pain; does not have the smooth, flat blood-pool appearance
- Conjunctival abrasion or laceration
8. Follow-Up and Referral
- No routine follow-up is needed for simple SCH
- Advise patient to return if blood does not fully resolve or if a recurrence occurs
- Recurrent SCH or one that fails to resolve: refer to ophthalmologist to rule out conjunctival lesion (e.g., early Kaposi, amyloid, lymphoma)
- Refer to internist/family physician if hypertension or bleeding diathesis is suspected or identified
Sources:
- The Wills Eye Manual, 8e - section 5.5
- Rosen's Emergency Medicine, 10e - Chapter 57
- Tintinalli's Emergency Medicine, 9e - Chapter 241
- Roberts and Hedges' Clinical Procedures in Emergency Medicine, 7e - Chapter 62
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