Management of Subconjunctival Hemorrhage

Definition and Etiology

Subconjunctival hemorrhage appears as a bright red patch on the white of the eye due to blood leaking from small blood vessels between the conjunctiva and sclera, and can be associated with viral conjunctivitis 1

Checking for signs of viral conjunctivitis, such as preauricular lymphadenopathy and follicular reaction, is important in the clinical assessment of subconjunctival hemorrhage 1

The American Academy of Ophthalmology recommends no specific treatment for isolated subconjunctival hemorrhage, as it is a benign and self-limiting condition 1
Artificial tears can be used to relieve mild irritation in patients with subconjunctival hemorrhage 2
Patient education about the natural course of subconjunctival hemorrhage, which typically resolves within 1-2 weeks, is an important part of management 1
For subconjunctival hemorrhage associated with viral conjunctivitis, management should focus on the underlying viral infection, and may include topical lubricants to improve comfort 2
Topical corticosteroids may be considered for severe viral conjunctivitis with marked chemosis, eyelid swelling, or membranous conjunctivitis, under close supervision 2
Avoiding antibiotics is recommended, as they are ineffective for viral infections 2

Patients on anticoagulation therapy may experience more severe or recurrent subconjunctival hemorrhage, but it is generally considered a minor bleeding risk and does not require discontinuation of therapy 3
For ophthalmologic procedures, most bleeds in anticoagulated patients are self-limiting without compromised visual acuity 3

Subconjunctival hemorrhage with persistent pain requires further investigation 1
Subconjunctival hemorrhage with signs of infection requires further investigation 2

Follow-up within 1-2 weeks is recommended if symptoms of viral conjunctivitis persist 2

Local cold therapy can be useful for injuries to the extremity or scalp, and cold application may be beneficial for comfort in subconjunctival hemorrhage, with application limited to 20-30 minutes per session to avoid cold injury, as recommended by general first aid principles 4, 5
A barrier, such as a thin towel, should be placed between the cold container and the skin to prevent cold injury 6
The greatest tissue cooling is achieved using a bag filled with ice and water surrounded by a damp cloth, which can be applied for comfort in subconjunctival hemorrhage 5

The American College of Cardiology guidelines classify bleeding severity based on three criteria: bleeding at a critical site, hemodynamic instability, and hemoglobin decrease ≥2 g/dL or transfusion of ≥2 units RBCs, and isolated subconjunctival hemorrhage does not meet these criteria 7, 8

Continue anticoagulation therapy without interruption in patients with subconjunctival hemorrhage, as it is considered a non-major bleed that does not meet criteria for stopping therapy 7
The American College of Cardiology recommends continuing oral anticoagulation without dose adjustment for isolated subconjunctival hemorrhage 7
Provide local therapy, such as artificial tears and cold compresses, for symptomatic relief in anticoagulated patients with subconjunctival hemorrhage 7
Do not administer reversal agents, such as vitamin K, prothrombin complex concentrates, idarucizumab, or andexanet alfa, for isolated subconjunctival hemorrhage 7
Most bleeds in anticoagulated patients undergoing ophthalmologic procedures, including subconjunctival hemorrhages, are self-limiting without compromised visual acuity 9

A matted appearance with drainage in a subconjunctival hemorrhage suggests purulent discharge, indicating an infectious conjunctivitis or a more serious underlying pathology. 10

When purulent drainage is present and the hemorrhage is severe or fails to improve with initial treatment, a conjunctival culture should be obtained to identify the causative organism. 10