Subconjunctival Hemorrhage

Subconjunctival Hemorrhage - Bloody Eye Basics

Blood accumulation between conjunctiva and sclera. Anatomically limited posteriorly by Tenon's capsule fusion at limbus; does not cross the limbus.

• Etiology:
  • Spontaneous (most common)
  • Valsalva maneuver (coughing, sneezing, straining, vomiting)
  • Trauma (direct ocular, head injury, barotrauma)
  • Hypertension (sudden BP ↑)
  • Bleeding disorders/Coagulopathy (e.g., hemophilia, liver disease, vitamin K deficiency)
  • Anticoagulant/Antiplatelet medications (e.g., warfarin, aspirin, clopidogrel)
  • Infections (viral conjunctivitis e.g., Adenovirus; Enterovirus 70 - Acute Hemorrhagic Conjunctivitis (AHC))
  • Idiopathic
• 📌 Mnemonic - SCH CAUSES:
  • S: Spontaneous/Strain
  • C: Clotting issues/Coumadin
  • H: Hypertension/Head trauma

⭐ Subconjunctival hemorrhage, though visually dramatic, is typically painless and does not affect vision.

Clinical Picture - Seeing Red Clearly

• Symptoms: Often none!

  • Patient notices red spot or told by others.
  • Mild foreign body sensation or fullness possible.
  • Crucially: NO pain, NO photophobia, NO vision loss, NO discharge (unless co-existing conjunctivitis).

• Signs:

  • Bright, flat, homogenous red area on sclera; sharply defined.
  • Posterior edge usually visible (unless massive).
  • Conjunctiva mobile over hemorrhage.
  • Cornea: Clear.
  • Pupil: Normal, reactive.
  • Anterior Chamber: Quiet.
  • Visual Acuity (VA): Normal.
  • Intraocular Pressure (IOP): Normal.

⭐ The absence of pain and unchanged visual acuity are hallmark features distinguishing subconjunctival hemorrhage from more serious causes of acute red eye.

Red Eye Mimics - Spot The Difference

Treatment Plan - Calming The Crimson

• General Management:
  • Reassurance: Benign, self-limiting.
  • Conservative: Usually none needed.
  • Artificial tears for mild irritation.
  • Avoid Aspirin/NSAIDs if possible (unless medically necessary).
• Specific Management & When to Investigate:
  • Hypertension: Check & manage BP.
  • Anticoagulants: Check INR/PT; consult before stopping.
  • Consider further investigation (CBC, PT/INR, PTT) or referral if:
    • Recurrent or bilateral SCH.
    • History of bleeding disorder.
    • Significant ocular trauma (rule out globe rupture, retrobulbar hemorrhage).
    • Associated systemic symptoms or diagnostic uncertainty.

• Prognosis:
  • Excellent; resolves spontaneously in 1-3 weeks.
  • Color changes: Red → orange → yellowish (like a bruise).

⭐ No specific treatment is usually required for subconjunctival hemorrhage; the primary intervention is reassurance and patient education about its benign nature and resolution time.

High‑Yield Points - ⚡ Biggest Takeaways

• Painless, bright red subconjunctival patch; vision is unaffected.
• Caused by ruptured conjunctival capillaries; often from Valsalva, minor trauma, or spontaneously.
• Key associations: hypertension, diabetes, bleeding disorders, anticoagulant use.
• Self-resolves typically within 1-2 weeks; no specific treatment needed.
• Reassurance is primary; investigate if recurrent, extensive, or with systemic signs.
• Absence of pain, visual loss, and discharge is characteristic.