Subconjunctival Hemorrhage

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Basics

Description

  • Subconjunctival hemorrhage (SCH) is bleeding from small blood vessels underneath the conjunctiva, the thin clear skin covering the sclera (white part) of the eye.
  • SCH is diagnosed clinically:
    • Well-demarcated areas of extravasated blood can be seen just under the surface of the conjunctiva of the eye
    • Lesions can be flat, elevated, or bullous.
  • Typically, SCH self-resolves in 1–3 weeks depending on the severity.

Epidemiology

  • Male = female; no gender predilection
  • Common; 3% rate of diagnosis in ophthalmology clinics (1)

Incidence

Incidence increases

  • With increasing age
  • In contact lenses wearers (5% of cases) (2)
  • With systemic diseases such as diabetes, hypertension (HTN), and coagulation disorders
  • With trauma
  • During summer months, possibly due to trauma (1)

Etiology and Pathophysiology

  • Subconjunctival hemorrhage results from damage to conjunctival and episcleral vessels from direct or indirect injury.
  • Antithrombogenic and anticoagulated states (blood dyscrasias, thrombocytopenia, anemia, antiplatelet use, anticoagulant use) increase the risk and severity of SCH.
  • Causes include
    • Idiopathic (most common cause)
    • Direct trauma from
      • Blunt or penetrating injury to the eye
      • Contact lens placement or removal; improper contact lens wear
      • Rubbing eyes
      • Foreign body in eye
      • Ocular surgery, injection, or other procedure
    • Valsalva maneuvers causing sudden severe venous congestion such as coughing, sneezing, vomiting, straining, severe asthma or COPD exacerbation, weightlifting, or childbirth/labor
    • Damaged vessels from diabetes or atherosclerotic disease. Diabetes is a cause of recurrent SCH without trauma
  • In patients age >60 years, HTN is the most common etiology.
  • In patients age <40 years, trauma, Valsalva and contact lens use are the most common etiologies.
  • In patients age >40 years, conjunctivochalasis (redundant conjunctival folds) and presence of pinguecula are strongly associated (2).

Risk Factors

  • Trauma
  • Age
  • Contact lens wearer
  • Systemic diseases (HTN, diabetes)
  • Bleeding disorders (1)
  • Recent ocular surgery (cataract, laser-assisted in situ keratomileusis [LASIK])

General Prevention

  • Avoid rubbing eyes
  • Proper cleaning and maintenance of contact lenses
  • Protective eyewear in sports and hobbies
  • Optimizing control of systemic diseases such as HTN, diabetes, and atherosclerotic disease, thrombocytopenia
  • Control of PT/INR in patients on warfarin therapy (3)

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Basics

Description

  • Subconjunctival hemorrhage (SCH) is bleeding from small blood vessels underneath the conjunctiva, the thin clear skin covering the sclera (white part) of the eye.
  • SCH is diagnosed clinically:
    • Well-demarcated areas of extravasated blood can be seen just under the surface of the conjunctiva of the eye
    • Lesions can be flat, elevated, or bullous.
  • Typically, SCH self-resolves in 1–3 weeks depending on the severity.

Epidemiology

  • Male = female; no gender predilection
  • Common; 3% rate of diagnosis in ophthalmology clinics (1)

Incidence

Incidence increases

  • With increasing age
  • In contact lenses wearers (5% of cases) (2)
  • With systemic diseases such as diabetes, hypertension (HTN), and coagulation disorders
  • With trauma
  • During summer months, possibly due to trauma (1)

Etiology and Pathophysiology

  • Subconjunctival hemorrhage results from damage to conjunctival and episcleral vessels from direct or indirect injury.
  • Antithrombogenic and anticoagulated states (blood dyscrasias, thrombocytopenia, anemia, antiplatelet use, anticoagulant use) increase the risk and severity of SCH.
  • Causes include
    • Idiopathic (most common cause)
    • Direct trauma from
      • Blunt or penetrating injury to the eye
      • Contact lens placement or removal; improper contact lens wear
      • Rubbing eyes
      • Foreign body in eye
      • Ocular surgery, injection, or other procedure
    • Valsalva maneuvers causing sudden severe venous congestion such as coughing, sneezing, vomiting, straining, severe asthma or COPD exacerbation, weightlifting, or childbirth/labor
    • Damaged vessels from diabetes or atherosclerotic disease. Diabetes is a cause of recurrent SCH without trauma
  • In patients age >60 years, HTN is the most common etiology.
  • In patients age <40 years, trauma, Valsalva and contact lens use are the most common etiologies.
  • In patients age >40 years, conjunctivochalasis (redundant conjunctival folds) and presence of pinguecula are strongly associated (2).

Risk Factors

  • Trauma
  • Age
  • Contact lens wearer
  • Systemic diseases (HTN, diabetes)
  • Bleeding disorders (1)
  • Recent ocular surgery (cataract, laser-assisted in situ keratomileusis [LASIK])

General Prevention

  • Avoid rubbing eyes
  • Proper cleaning and maintenance of contact lenses
  • Protective eyewear in sports and hobbies
  • Optimizing control of systemic diseases such as HTN, diabetes, and atherosclerotic disease, thrombocytopenia
  • Control of PT/INR in patients on warfarin therapy (3)

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