Subconjunctival Hemorrhage

Subconjunctival Hemorrhage is a topic covered in the 5-Minute Clinical Consult.

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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 of the eye.
  • SCH is diagnosed clinically:
    • Flat, well-demarcated areas of extravasated blood can be seen just under the surface of the conjunctiva of the eye (red patch of blood sign).
    • SCH is more common in the inferior and temporal regions of the eye (1).
  • Typically, SCH resolves spontaneously within 2 weeks.

Epidemiology

  • Male = female; no gender predilection
  • Common; 3% rate of diagnosis in ophthalmology clinics (2)

Incidence

Incidence increases.

  • With increasing age
  • In contact lenses wearers (5% of cases) (3)
  • With systemic diseases such as diabetes, hypertension (HTN), and coagulation disorders
  • During summer months, possibly due to trauma (2)

Etiology and Pathophysiology

  • Direct trauma to the blood vessels of the conjunctiva from blunt or penetrating trauma to the eye
  • Direct trauma to the conjunctiva from improper contact lens placement or improper cleaning
  • Increased blood pressure (BP) in the vessels of the conjunctiva from HTN or from the temporary increase in BP from a Valsalva type maneuver (e.g., vomiting, sneezing)
  • Damaged vessels from diabetes or atherosclerotic disease
  • Increased bleeding tendencies from either thrombocytopenia or elevated prothrombin time (PT)/elevated international normalized ratio (INR) (4)
  • Valsalva maneuvers causing sudden severe venous congestion such as coughing, sneezing, vomiting, straining, severe asthma or COPD exacerbation, weightlifting, or childbirth/labor (1)
  • In patients age >60 years, HTN is the most common etiology.
  • In patients age <40 years, trauma/Valsalva and contact lenses use are the most common etiologies.
  • In patients age >40 years, conjunctivochalasis (redundant conjunctival folds) and presence of pinguecula are strongly associated (3).

Risk Factors

  • Age
  • Contact lenses wearer
  • Systemic diseases (HTN, diabetes)
  • Bleeding disorders (2)
  • Recent ocular surgery (cataract, laser-assisted in situ keratomileusis [LASIK])

General Prevention

  • Correct cleaning and maintenance of contact lenses
  • Protective eyewear in sports and hobbies
  • Optimizing control of systemic diseases such as HTN, diabetes, and atherosclerotic disease
  • Control of PT/INR in patients on warfarin therapy (5)

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