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Subconjunctival Hemorrhage

ROUTINE — Signs

Symptoms

  • painless red eye: often discovered incidentally in the mirror or by a peer
  • asymptomatic: vision is normal, there is no discharge, and no photophobia
  • mild irritation: a slight foreign body sensation or "tightness" if the hemorrhage is large
  • no itching: helps distinguish it from allergic conjunctivitis

Clinical Findings

Clinical appearance

  • blood under conjunctiva: a sharply demarcated, bright-red flat patch
  • color evolution: turns yellow, green, or brown over 1–3 weeks (like a bruise)
  • posterior margin: if you can see the back edge of the blood, it’s likely local; if not, consider an orbital source

Warning signs

  • 360° bullous hemorrhage: an elevated "bag of blood" after trauma suggests a ruptured globe until proven otherwise
  • chemosis: swelling of the conjunctiva over the blood suggests a higher-pressure event or trauma
  • recurrent same-site: look for underlying vascular lesions like lymphangiectasia or Kaposi Sarcoma

Etiology

Valsalva & mechanical

  • sudden pressure: coughing, sneezing, vomiting, or straining (lifting/constipation)
  • eye rubbing: common in patients with dry eyes or allergies

Systemic factors

  • hypertension: a frequent "silent" trigger for spontaneous vessel rupture
  • medications: aspirin, clopidogrel, or anticoagulants (warfarin, apixaban)
  • bleeding disorders: thrombocytopenia or clotting factor deficiencies (rare)

Red Flags

  • 360° bullous hemorrhage + trauma: treat as an open globe; rigid shield and NPO immediately
  • bilateral/spontaneous in a child: must rule out non-accidental trauma or leukemia
  • recurrent episodes: warrants checking blood pressure and basic coagulation (PT/PTT)
  • trauma + restricted motility: rule out orbital fracture or retrobulbar hemorrhage

Investigations

Primary checks

  • blood pressure: the most important systemic vital to check in the office
  • slit lamp: confirm the hemorrhage is flat and check for associated trauma (abrasions, hyphema)

Laboratory (for recurrent/bilateral)

  • cbc with smear: to rule out low platelets or leukemia
  • coag panel: PT, PTT, and INR (especially if the patient is on Warfarin)

Imaging

  • orbital ct: only if trauma is present or if there is no visible posterior margin of the blood

Treatment

Observation

  • spontaneous resolution: no treatment is required; it "clears" like a bruise
  • artificial tears: for comfort if the patient feels a "lump" or dryness

Systemic management

  • do NOT stop essential blood thinners, but advise against elective aspirin/NSAIDs
  • manage blood pressure if it is found to be elevated
  • for 360° bullous trauma: emergent surgery and IV antibiotics

Clinical Pearl

A spontaneous subconjunctival hemorrhage is almost always benign — the exception is the patient on warfarin or with bilateral recurrences, where you should check BP, INR, and a platelet count.

Differential Diagnosis

  • • conjunctivitis (diffuse injection, discharge, itching)
  • • episcleritis (sectoral redness, visible vessels, blanches with phenylephrine)
  • • kaposi sarcoma (vascular tumor, usually more elevated and purple, seen in HIV/AIDS)

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