Subconjunctival Hemorrhage



  • Subconjunctival hemorrhage (SCH) is bleeding from small blood vessels underneath the conjunctiva, the thin clear skin covering the sclera (white outer layer) 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 a few days to weeks depending on the severity.


Common; 3% rate of diagnosis in ophthalmology clinics (1)

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

  • SCH results from damage to conjunctival and episcleral vessels from direct or indirect injury.
  • Antithrombogenic and anticoagulated states (blood dyscrasias, thrombocytopenia, anemia, anti-platelet use, anticoagulant use) increase the risk and severity of SCH.
  • Causes include the following:
    • Idiopathic
    • Direct trauma from
      • Blunt or penetrating injury to the eye
        • If there is a large SCH from a trauma, the patient may have underlying globe rupture and should be evaluated for this.
      • Contact lenses placement or removal; improper contact lenses wear
      • Rubbing eyes
        • Commonly when sleeping, which leads to patient waking up with eye redness
        • In patient on anticoagulation, even mild eye rubbing can induce SCH.
      • Foreign body in eye
      • Ocular surgery, injection, or other procedure
      • Related to ocular surface infection (i.e., viral conjunctivitis) or ocular surface lesion
    • Valsalva maneuvers causing sudden severe venous congestion such as coughing, sneezing, vomiting, straining, severe asthma or COPD exacerbation, weight lifting, or childbirth/labor
    • Damaged vessels from atherosclerotic disease or diabetes (which is a cause of recurrent SCH without trauma)
  • In patients aged >60 years, HTN is the most common etiology.
  • In patients aged <40 years, trauma, Valsalva maneuver, and contact lenses use are the most common etiologies.
  • In patients aged >40 years, conjunctivochalasis (redundant conjunctival folds) and presence of pinguecula are strongly associated (2).

Risk Factors

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

General Prevention

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

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