SUBCONJUNCTIVAL HEMORRHAGE

Cara Marshall, MD

 BASICS

DESCRIPTION

•  Subconjunctival hemorrhage (SCH) is bleeding from small blood vessels underneath the conjunctiva, the thin clear skin covering the sclera of the eye.

•  SCH is diagnosed clinically:

–  Flat, well-demarcated areas of extravasated blood can be seen just under the surface of the conjunctiva of the eye (red patch of blood sign).

–  SCH is more common in the inferior and temporal regions (1).

•  Typically, SCH resolves spontaneously within 1 to 2 weeks.

EPIDEMIOLOGY

•  Male = female; no gender predilection found

•  Common; 3% rate of diagnosis in outpatient eye clinic (2)

Incidence

Incidence increases

•  With increasing age

•  In contact lenses wearers (5% of cases) (3)

•  With systemic diseases such as diabetes, hypertension (HTN), and coagulation disorders

•  During summer months, possibly due to trauma (2)

ETIOLOGY AND PATHOPHYSIOLOGY

•  Direct trauma to the blood vessels of the conjunctiva from blunt or penetrating trauma

•  Direct trauma to the conjunctiva from improper contact lens placement or improper cleaning

•  Increased BP in the vessels of the conjunctiva from HTN or from the temporary increase in BP from a Valsalva type maneuver (e.g., vomiting)

•  Damaged vessels from diabetes and atherosclerotic disease

•  Increased bleeding tendencies from either thrombocytopenia or elevated prothrombin time (PT)/elevated international normalized ratio (INR) (4)

•  Trauma to the eye

•  Valsalva maneuvers causing sudden severe venous congestion such as coughing, sneezing, vomiting, straining, severe asthma or COPD exacerbation, weightlifting or childbirth/labor (1)

•  HTN

•  Atherosclerotic disease and diabetes

•  Bleeding factors such as thrombocytopenia or elevated PT (from either disease or medication side effects)

•  In patients age >60 years, HTN is the most common etiology.

•  In patients age <40 years, trauma/Valsalva and contact lenses use are the most common etiologies.

•  In patients age >40 years, conjunctivochalasis (redundant conjunctival folds) and presence of pinguecula are strongly associated (3).

RISK FACTORS

•  Age

•  Contact lenses wearer

•  Systemic diseases

•  Bleeding disorders (2)

•  Recent cataract surgery

GENERAL PREVENTION

•  Correct cleaning and maintenance of contact lenses.

•  Protective eyewear in sports and hobbies

•  Control of high BP

•  Optimizing control of systemic diseases such as diabetes and atherosclerotic disease

•  Control of PT/INR in patients on Coumadin therapy (5)

 DIAGNOSIS

HISTORY

•  Generally asymptomatic; usually the patient notices the redness in the mirror or another person mentions it to the patient.

•  There should be little to no pain involved (5)[C].

•  Obtain history of trauma. SCH can occur 12 to 24 hours after orbital fracture (1).

•  Obtain history of contact lenses usage or recent cataract, laser-assisted in situ keratomileusis (LASIK), or other ocular surgery (2)[C].

•  Comprehensive past medical history to evaluate if at risk for systemic diseases or taking medications that might increase risk

•  Obtain history for current systemic symptomatology.

PHYSICAL EXAM

•  Evaluate BP to assess control (2)[C].

•  Measure visual acuity; this should be normal in a simple SCH (5)[C].

•  Verify that the pupils are equal and reactive to light and accommodation; this should be normal with an SCH (5)[C].

•  There should be no discharge or exudate noted (5)[C].

•  Look at sclera for a bright red demarcated patch.

–  Demarcated area is most often on inferior aspect of eye due to gravity (3)[C].

•  If penetrating trauma is a consideration, do a gentle digital assessment of the integrity of the globe (4)[C].

•  Slit-lamp exam should be performed if there is a history of trauma (1).

Geriatric Considerations

In older adults, the area of SCH will be more widespread across the sclera (3). Elastic and connective tissues are more fragile with age, and underlying conditions such as HTN and diabetes may contribute.

DIFFERENTIAL DIAGNOSIS

•  Viral, bacterial, allergic, or chemical conjunctivitis (enterovirus and coxsackie virus most common) (1)[B]

•  Foreign body to conjunctiva

•  Penetrating trauma

•  Acute angle glaucoma

•  Iritis

•  Recent ocular surgery

•  Contact lenses induced

•  Child abuse (particularly if bilateral in an infant or toddler) (1)

•  May occur in newborns after vaginal delivery

DIAGNOSTIC TESTS & INTERPRETATION

•  Typically no testing is indicated; SCH is a clinical diagnosis. If a foreign body is suspected, perform a fluorescein exam.

•  Fluorescein exam of a patient with an SCH should show no uptake of staining (5)[C].

•  If an orbital fracture is suspected, may obtain plain facial bone films or CT scan (4)[C]

Follow-Up Tests & Special Considerations

If history and physical exam suggest a bleeding etiology (5)[C]

•  CBC

•  PT/INR

ALERT

If a penetrating injury is suspected, may obtain a CT scan of the orbits but not an MRI (if object may be metal) (4)[C]

 TREATMENT

GENERAL MEASURES

•  Control BP.

•  Control blood glucose.

•  Control INR.

•  Wear protective eyewear.

MEDICATION

No prescription medications are useful in treatment of SCH.

ISSUES FOR REFERRAL

•  If a penetrating eye injury is suspected, send the patient to the emergency room for emergent ophthalmology consultation.

•  If the patient complains of any decreased visual acuity or visual disturbances, refer to an ophthalmologist as soon as possible.

•  If there is no resolution of SCH within 2 weeks, patient may need referral to an ophthalmologist.

ADDITIONAL THERAPIES

•  Warm compresses

•  Eye lubricants (5)[C]

 ONGOING CARE

FOLLOW-UP RECOMMENDATIONS

•  Follow up only if the area does not resolve within 2 weeks.

•  If SCH recurs, then work up patient for systemic sources such as bleeding disorders (5)[C].

PATIENT EDUCATION

•  Reassurance of the self-limited nature of the problem and typical time frame for resolution

•  Education to return to clinic if the area does not heal or recurs

•  Correct cleaning and maintenance of contact lenses

PROGNOSIS

Excellent

COMPLICATIONS

Rare

REFERENCES

1.  Tarlan B, Kiratli H. Subconjunctival hemorrhage: risk factors and potential indicators. Clin Ophthalmol. 2013;7:1163–1170.

2.  Mimura T, Usui T, Yamagami S, et al. Recent causes of subconjunctival hemorrhage. Ophthalmologica. 2010;224(3):133–137.

3.  Mimura T, Yamagami S, Mori M, et al. Contact lens-induced subconjunctival hemorrhage. Am J Ophthalmol. 2010;150(5):656.e1–665.e1.

4.  Wirbelauer C. Management of the red eye for the primary care physician. Am J Med. 2006;119(4):302–306.

5.  Cronau H, Kankanala RR, Mauger T. Diagnosis and management of red eye in primary care. Am Fam Physician. 2010;81(2):137–144.

ADDITIONAL READING

•  Mimura T, Usui T, Yamagami S, et al. Subconjunctival hemorrhage and conjunctivochalasis. Ophthalmology. 2009;116(10):1880–1886.

•  Mimura T, Yamagami S, Usui T, et al. Location and extent of subconjunctival hemorrhage. Ophthalmologica. 2010;224(2):90–95.

 CODES

ICD10

•  H11.30 Conjunctival hemorrhage, unspecified eye

•  H11.31 Conjunctival hemorrhage, right eye

•  H11.32 Conjunctival hemorrhage, left eye

CLINICAL PEARLS

•  SCH is a clinical diagnosis. The condition is typically asymptomatic and will resolve spontaneously in 1 to 2 weeks.

•  Always check BP in a patient with SCH, as HTN is a risk factor.

•  Indications for immediate referral to an ophthalmologist are eye pain, change in vision, lack of pupil reactivity, and/or penetrating eye trauma.

•  Reassurance and comfort measures are key.

•  Contact lenses wearers should not wear contact lenses until the SCH resolves completely.