Subconjunctival haemorrhage results from bleeding of the conjunctival or the episcleral blood vessels into the subconjunctival space. The cause is usually unknown but may be the result of trauma or related to systemic illness.

Epidemiology

• Occurs frequently.
• Subconjunctival haemorrhage can occur at all ages but is more common with increasing age.

Causes

• The cause is usually unknown
• Valsalva manoeuvre (e.g. coughing, straining)
• Trauma - surgical or accidental (isolated or associated with retrobulbar haemorrhage or ruptured globe)¹
• Hypertension²
• Bleeding disorders
• Various drugs, e.g. warfarin, non-steroidal anti-inflammatory drugs (NSAIDs), steroids
• Normal sequelae of ocular surgery even if no conjunctival incision
• Febrile systemic infections

Presentation

• Red eye, usually unilateral
• May have mild irritation
• Usually asymptomatic

Signs

• Most common appearance is a bright red patch with relatively normal surrounding.
• The haemorrhage may spread and become green or yellow, like a bruise. Usually this disappears within 2 weeks.
• Examination of the eye, including pupil responses and visual acuity, is otherwise normal.

It is worth noting that a haemorrhage without a posterior margin (i.e extends posteriorly so that the whole extent of the haemorrhage cannot be seen) may be associated with an intracranial bleed³ or an orbital roof fracture (associated with a black eye) - the history should guide you as to whether to consider this or not.

Differential diagnosis

Other causes of acute red eye, including:

• Conjunctivitis
• Episcleritis
• Iritis (uveitis)
• Acute angle closure glaucoma)
• Keratitis

If it is a persistent haemorrhage (as opposed to the conjunctival injection seen in a red eye), consider rarer causes such as:⁴

• Kaposi's sarcoma
• Other conjunctival neoplasms

Investigations

• Usually, no laboratory studies are indicated.
• Check blood pressure.¹
• If history of trauma, may need referral to rule out more extensive eye injury.
• In recurrent cases, or if history of bleeding problems, e.g. epistaxis, easy bruising, check the INR, prothrombin time/activated partial thromboplastin time (PT/aPTT), full blood count including platelets, and protein C and S should be obtained.³

Management

• Medical care is not required, unless there is an underlying disorder.
• Artificial tears can be used 4 times per day for mild irritation.
• Discourage elective use of aspirin products or NSAIDs.
• Simultaneous bilateral haemorrhages, persistent or unexplained recurrence warrant a referral to the ophthalmologists.

Prognosis

• Subconjunctival haemorrhage is a benign, self-limiting condition when not associated to systemic illness.
• Prognosis is excellent.

Document references

1. Fukuyama J, Hayasaka S, Yamada K, et al; Causes of subconjunctival hemorrhage. Ophthalmologica. 1990;200(2):63-7. [abstract]
2. Pitts JF, Jardine AG, Murray SB, et al; Spontaneous subconjunctival haemorrhage--a sign of hypertension? Br J Ophthalmol. 1992 May;76(5):297-9. [abstract]
3. Jackson TL. Moorfields Manual of Ophthalmology, Mosby (2008)
4. Kunimoto DY, Kanitkar KD, Makar MS; The Wills Eye Manual (4th Ed), Lippincott, Williams and Wilkins (2004)

Acknowledgements