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Describe etiology, clinical features and management of Sub-Conjunctival hemmorage 5 marks

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Subconjunctival Hemorrhage

Subconjunctival hemorrhage - blood beneath the bulbar conjunctiva surrounding the cornea
Fig. Subconjunctival hemorrhage. (Rosen's Emergency Medicine)

Definition

Subconjunctival hemorrhage (SCH) is bleeding beneath the bulbar conjunctiva due to rupture of small subconjunctival blood vessels, resulting in a bright red patch on the white of the eye.

Etiology

Causes are grouped as follows:
1. Valsalva/Increased Venous Pressure
  • Forceful coughing, sneezing, vomiting
  • Bearing down (constipation, childbirth, heavy lifting)
  • Vigorous eye rubbing
2. Traumatic
  • Blunt or penetrating eye injury - the most common cause in emergency settings
  • May be isolated or associated with retrobulbar hemorrhage or ruptured globe
  • Rule out globe perforation when there is 360-degree involvement, chemosis, pain, or reduced vision
3. Systemic Conditions
  • Hypertension (check BP in all patients)
  • Diabetes mellitus
  • Bleeding disorders (thrombocytopenia, coagulopathy, leukemia)
4. Medications
  • Antiplatelet agents: aspirin, clopidogrel, ticagrelor
  • Anticoagulants: warfarin, dabigatran, rivaroxaban, apixaban, edoxaban
  • Topical steroids (prolonged use)
5. Others
  • Orbital mass (rare - hemorrhage due to underlying lesion)
  • Idiopathic - most spontaneous cases have no identifiable cause

Clinical Features

Symptoms:
  • Usually asymptomatic - patient typically notices a red eye while looking in the mirror
  • Mild diffuse foreign body sensation may occur depending on size and location
  • No change in visual acuity (if vision is affected, suspect associated injury)
  • No pain in spontaneous cases
Signs:
  • Bright red, well-demarcated patch of blood beneath the bulbar conjunctiva
  • Blood appears smooth and flat; no vessels visible behind the hemorrhage (distinguishes it from conjunctivitis)
  • May be localized to one sector or involve the entire visible sclera
  • Overlying conjunctiva is minimally and smoothly raised
  • No discharge, no corneal involvement
Warning signs suggesting serious underlying injury (especially in trauma):
  • 360-degree involvement with chemosis
  • Pain or decreased vision
  • Abnormally deep or shallow anterior chamber
  • Hyphema or uveal prolapse - raise suspicion for globe rupture

Management

Workup

  1. History: Trauma, medications, bleeding history, Valsalva events, recurrent episodes, cough
  2. Blood pressure measurement in all patients
  3. Ocular examination: Slit-lamp exam; check visual acuity, IOP, extraocular movements; slit-lamp with fluorescein to rule out corneal abrasion, globe perforation (Seidel's test)
  4. Lab investigations (if recurrent or bleeding history): PT, aPTT, CBC with peripheral smear, liver function tests, protein C and S
  5. Imaging (CT/MRI orbits with contrast): only if orbital signs are present (proptosis, restricted motility, elevated IOP) to rule out orbital mass

Treatment

  • No treatment required for uncomplicated spontaneous SCH
  • Artificial tears (lubricant drops q.i.d.) if mild irritation is present
  • Discourage elective use of aspirin and NSAIDs - do not stop prescribed anticoagulants without clearance from the primary physician
  • Treat underlying cause (control hypertension, manage systemic illness)

Follow-Up

  • Resolves spontaneously within 2 to 4 weeks as blood reabsorbs; may turn yellow-green as it resolves (similar to a bruise)
  • Advise patient to return if blood does not fully resolve or recurrence occurs
  • Refer to internist/GP if hypertension or bleeding diathesis is suspected
Sources: The Wills Eye Manual, 7th ed. (Section 5.5); Rosen's Emergency Medicine, 9th ed. (Chapter 57)
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