Subconjunctival Hemorrhage

BASICS

Definition: Bleeding from small vessels beneath the conjunctiva (the thin clear skin over the sclera).
Clinical: Appears as well-demarcated, bright red patches under the conjunctiva; can be flat, elevated, or bullous.
Course: Self-resolves in days to weeks depending on severity.

Mechanism: Damage to conjunctival/episcleral vessels from direct or indirect injury.
Risk factors: Anticoagulated states, blood dyscrasias, thrombocytopenia, anemia, antiplatelet/anticoagulant use.
Causes:
Idiopathic (most common)
Trauma (blunt/penetrating, contact lenses, eye rubbing, foreign body, ocular procedures)
Valsalva (coughing, sneezing, vomiting, straining, heavy lifting)
Ocular surface infection (esp. viral)
Systemic disease: HTN, diabetes, atherosclerosis
Age associations:
<40 yrs: trauma, Valsalva, contacts
40 yrs: conjunctivochalasis, pinguecula, systemic disease (esp. HTN >60 yrs)

Noticed by patient or others as “red eye”
Usually painless, no vision changes or photophobia
Possible mild irritation or foreign body sensation
Key questions: trauma, contact lens use, Valsalva, systemic disease, meds (antiplatelets, anticoagulants)

Visual acuity, IOP, pupils: Normal
Slit lamp: Bright red, sharply demarcated patch under conjunctiva (often inferior)
Color changes: Bright red (fresh), darkens, then yellow as resorbs
Fluorescein: No uptake with simple SCH
BP: Measure for underlying HTN
Older adults: Lesion may be more widespread
ALERT: If concern for globe rupture, immediate ophthalmology referral

ALERT: Avoid MRI if metallic foreign body possible

SCH is a clinical diagnosis; typically asymptomatic and self-resolving.
Risk factors: trauma, Valsalva, HTN, diabetes.
Immediate referral for pain, vision changes, abnormal pupil, or suspected penetrating injury.
Mainstays: reassurance and ocular lubrication.