Subconjunctival Haemorrhage Summary

Definition

  • Bleeding into subconjunctival space
  • From conjunctival/episcleral vessels
  • Usually spontaneous
  • Benign in most cases

Risk Factors

  • Valsalva maneuvers
  • Hypertension
  • Anticoagulant medications
  • Bleeding disorders
  • Trauma (minor)

Clinical Features

  • Asymptomatic (usually)
  • Mild discomfort at onset
  • Bright red patch in white of eye
  • Well-demarcated borders
  • Normal vision and pupils

Key Examination

  • Visual acuity - normal
  • Pupil reactions - normal
  • Cornea - clear, no staining
  • No pain
  • Blood pressure measurement

Management

  • Reassurance - main treatment
  • Cold compresses for comfort
  • Resolves in 5-10 days
  • No specific medication needed

Red Flags

  • Recurrent episodes
  • Failure to resolve
  • Associated trauma
  • Bleeding from other sites
  • Vision changes

Follow-up Advice

  • Return if no resolution in 2 weeks
  • Seek help if recurs frequently
  • Monitor blood pressure if elevated
  • Review anticoagulation if indicated

Subconjunctival Haemorrhage

Bleeding into the subconjunctival space - usually benign and self-limiting

Overview

Subconjunctival haemorrhage results from bleeding of the conjunctival or the episcleral blood vessels into the subconjunctival space.

Key Point: This condition is usually benign, self-limiting, and resolves spontaneously within 1-2 weeks without specific treatment.

Anatomy

  • Conjunctiva: Clear membrane covering white of eye
  • Subconjunctival space: Potential space between conjunctiva and sclera
  • Blood vessels: Fragile conjunctival and episcleral vessels

Pathophysiology

  • Rupture of small conjunctival vessels
  • Blood accumulates in subconjunctival space
  • Creates characteristic bright red appearance
  • No connection to anterior chamber

Risk Factors

Subconjunctival haemorrhage usually occurs spontaneously. There may or may not be a history of a contributory factor.

Common Precipitants

  • Valsalva maneuvers
    • Straining with coughing
    • Vomiting
    • Constipation
    • Sneezing
    • Heavy lifting
  • Minor trauma
    • Eye rubbing
    • Contact lens insertion/removal
    • Minor accidental trauma

Medical Factors

  • Systemic hypertension
  • Bleeding abnormalities
    • Coagulopathies
    • Thrombocytopenia
    • Von Willebrand disease
  • Anticoagulant medication
    • Warfarin
    • DOACs (apixaban, rivaroxaban, etc.)
    • Antiplatelets (aspirin, clopidogrel)

Other Associations

  • Diabetes mellitus
  • Increasing age (vessel fragility)
  • Conjunctivitis
  • Recent eye surgery

Clinical Features

Symptoms

  • Usually asymptomatic
  • May notice redness in mirror
  • Occasionally mild discomfort
  • "Popping" sensation at onset (sometimes)
  • No pain (important negative)

Examination Findings

  • Localised, well-demarcated haemorrhage in one eye
  • Bright red colour initially
  • Visible posterior border
  • Flat (not elevated)
  • No associated eyelid swelling

Critical Assessment Points

Must confirm all of the following:

  • No pain (distinguishes from more serious conditions)
  • No reduction of visual acuity
  • Normal pupil reactions
  • No corneal staining (if fluorescein available)
  • No associated trauma (unless minor explained trauma)

Essential: Blood pressure should be measured in all patients with subconjunctival haemorrhage to screen for hypertension.

Differential Diagnosis

Other Red Eye Conditions

  • Conjunctivitis
    • Diffuse redness
    • Discharge present
    • Itching/gritty sensation
  • Episcleritis
    • Sectoral or diffuse redness
    • Mild discomfort
    • Injected vessels blanch with phenylephrine
  • Scleritis
    • Deep violaceous hue
    • Severe pain
    • Vision may be affected

Serious Conditions to Exclude

  • Traumatic hyphema
    • Blood in anterior chamber
    • Usually traumatic
    • Requires urgent ophthalmology
  • Ruptured globe
    • Significant trauma
    • Peaked pupil
    • Deep anterior chamber
  • Orbital fracture
    • Trauma history
    • Restricted eye movements
    • Enophthalmos

Management

Reassure the patient that the condition usually clears within 5-10 days and a cold compress may reduce any discomfort.

Immediate Management

Step-by-Step Approach
  1. Confirm diagnosis - ensure no red flags
  2. Measure blood pressure - treat if elevated
  3. Provide reassurance - explain benign nature
  4. Cold compresses - for first 24-48 hours if discomfort
  5. Avoid eye rubbing - prevent extension of bleed
  6. Artificial tears - if mild irritation present

Patient Advice

What to Expect

  • Resolution within 5-10 days (usually 1-2 weeks)
  • Colour changes from red → darker red → yellow/brown as resolves
  • No permanent damage to vision
  • No scarring of the eye

Self-care Measures

  • Cold compresses for first 24-48 hours
  • Avoid strenuous activity for few days
  • Avoid blood-thinning medications if possible (check with doctor)
  • No specific eye drops required

When to Seek Further Help

Advise the patient to return/seek further help if:

  • Problem does not resolve within 2 weeks
  • It recurs frequently
  • Vision becomes blurred
  • Pain develops
  • Bleeding occurs in both eyes simultaneously
  • There is bleeding from other sites

Special Considerations

Anticoagulated Patients

  • Common in patients on anticoagulants
  • Usually no need to stop medication
  • Check INR if on warfarin (ensure therapeutic)
  • Consider haematology review if recurrent
  • Document in anticoagulation record

Hypertensive Patients

  • Check blood pressure in all cases
  • If elevated, arrange follow-up for BP management
  • Consider as possible hypertensive urgency sign
  • No need for emergency treatment unless severely elevated

Recurrent Cases

  • Consider bleeding disorder workup
  • Review medication list
  • Check blood pressure monitoring
  • Consider ophthalmology referral if frequent recurrences

Referral Indications: Usually no referral needed. Consider ophthalmology referral only for recurrent episodes, associated trauma, or diagnostic uncertainty.