Ophthalmology – Subconjunctival Hemorrhage

What the Finding Represents

A subconjunctival hemorrhage (SCH) is extravasation of blood from small conjunctival vessels into the potential space beneath the conjunctiva.

It typically appears as a:

• Sharply demarcated bright-red patch
• Flat or mildly elevated area of blood over the sclera
• Painless red eye with otherwise preserved vision

The blood is trapped beneath the transparent conjunctiva and therefore appears striking despite usually being:

Benign and self-limited.

Why the Eye Looks So Red

Small conjunctival vessels rupture and blood accumulates between the:

• Conjunctiva
• Episcleral surface

Unlike conjunctivitis, there is usually:

• No significant discharge
• No diffuse conjunctival inflammation
• No corneal involvement

Common Clinical Patterns

SCH may be:

• Spontaneous
• Valsalva-related
• Traumatic
• Postoperative
• Recurrent

Most isolated spontaneous cases have no serious underlying disorder.

Common Triggers

Frequent precipitating events include:

• Coughing
• Sneezing
• Vomiting
• Constipation/straining
• Heavy lifting
• Vigorous exercise
• Eye rubbing
• Minor unnoticed trauma

These transiently increase venous pressure and can rupture fragile conjunctival vessels.

Systemic Factors That Increase Risk

Associated conditions include:

• Hypertension
• Diabetes mellitus
• Platelet disorders
• Coagulopathy

Medication-associated risk is increased with:

• Anticoagulants
• Antiplatelet agents

Examples include:

• Warfarin
• Direct oral anticoagulants
• Aspirin
• Clopidogrel

Other Ocular Associations

SCH may occur after:

• Contact lens trauma
• Intravitreal injection
• Cataract or glaucoma surgery
• Conjunctival surgery
• Local anesthetic injection
• Viral conjunctivitis

It can also accompany more substantial ocular trauma.

Typical Symptoms

Most patients simply notice:

A painless red patch on the eye

often discovered:

• In a mirror
• By a family member
• Incidentally

Vision should remain:

Normal.

Minor Associated Sensations

Some patients report:

• Mild foreign-body sensation
• Slight fullness
• Mild irritation

Significant:

• Pain
• Photophobia
• Visual loss

is not typical and should prompt consideration of another or additional diagnosis.

Typical Examination Appearance

The hemorrhage is usually:

• Bright red initially
• Well circumscribed
• Located beneath the conjunctiva
• Nonblanching

The underlying sclera may be completely obscured within the involved area.

How the Appearance Changes During Healing

As the hemorrhage resolves, the color may evolve from:

• Bright red
• Dark red
• Brown
• Yellow

similar to a resolving bruise.

This does not indicate infection.

How Long It Takes to Resolve

Most uncomplicated SCH clears spontaneously within approximately:

1–2 weeks

Larger hemorrhages may require:

2–3 weeks or occasionally longer.

Blood may appear to spread during the first few days because of redistribution beneath the conjunctiva, even though the total hemorrhage is not necessarily increasing.

What Should Be Checked in a Routine Case

For an isolated atraumatic SCH, assess:

• Visual acuity
• External eye
• Cornea
• Anterior chamber

It is also reasonable to check:

Blood pressure

particularly in older adults or patients with recurrent hemorrhage.

When the History Matters More

Ask about:

• Trauma
• Recent surgery
• Coughing or vomiting
• Heavy straining
• Anticoagulant use
• Antiplatelet therapy
• Easy bruising
• Epistaxis
• Gum bleeding
• Previous similar episodes

Recurrent unexplained episodes warrant more investigation than a single typical event.

When Trauma Changes the Situation

A traumatic SCH should not automatically be assumed benign.

A complete ocular examination is necessary to exclude:

• Open-globe injury
• Hyphema
• Corneal or scleral laceration
• Intraocular foreign body
• Orbital injury

A Major Trauma Red Flag

After significant trauma, a:

Bullous, extensive, or 360-degree subconjunctival hemorrhage

can be associated with occult:

Globe rupture.

Particular concern exists when accompanied by:

• Poor vision
• Irregular pupil
• Shallow or abnormally deep anterior chamber
• Low IOP
• Uveal prolapse
• Severe pain

Such cases require urgent ophthalmic assessment.

When Imaging Is Appropriate

Imaging is not needed for routine spontaneous SCH.

In significant ocular/orbital trauma, imaging may include:

CT of the orbits

when evaluating for:

• Fracture
• Intraocular foreign body
• Orbital injury

If open globe is suspected, avoid unnecessary pressure on the eye.

When Laboratory Testing Is Unnecessary

Routine blood testing is generally:

Not required for a single uncomplicated SCH

in an otherwise healthy patient.

When Blood Tests Become Appropriate

Consider investigation when hemorrhages are:

• Recurrent
• Bilateral and unexplained
• Unusually extensive
• Associated with easy bruising or systemic bleeding

Possible tests include:

• CBC with platelet count
• PT/INR
• aPTT

Additional studies should be guided by the clinical history.

Patients Taking Warfarin

For a patient on warfarin with recurrent or unexpectedly large SCH, check:

INR

to ensure anticoagulation is within the intended therapeutic range.

Do Not Stop Anticoagulation Automatically

An isolated SCH is usually not an indication to stop:

• Anticoagulants
• Antiplatelet medications

Discontinuing these agents can expose patients to serious:

• Thromboembolic
• Cardiovascular
• Cerebrovascular

risk.

Any medication adjustment should be coordinated with the prescribing clinician.

Conditions That Can Look Similar

Important alternatives include:

• Conjunctivitis
• Episcleritis
• Scleritis
• Conjunctival vascular lesion
• Traumatic conjunctival laceration

The absence of pain, discharge, photophobia, and visual loss generally favors SCH.

Distinguishing It From Episcleritis

Subconjunctival Hemorrhage

• Sharply demarcated blood
• No visible branching vascular pattern
• Painless
• Nonblanching

Episcleritis

• Dilated superficial vessels
• Mild tenderness possible
• Vessels remain individually visible
• Often partially blanch with phenylephrine

Distinguishing It From Scleritis

Scleritis generally produces:

• Severe deep pain
• Violaceous rather than bright-red color
• Globe tenderness
• Deep vascular congestion

These features are not typical of an uncomplicated SCH.

Treatment in the Usual Case

No specific therapy is required.

Management consists primarily of:

Reassurance and observation.

The blood is gradually resorbed spontaneously.

Relieving Mild Irritation

If mild foreign-body sensation occurs, use:

• Artificial tears
• Lubricating drops

These improve comfort but do not make the hemorrhage disappear faster.

Large or Elevated Hemorrhages

A large elevated or bullous SCH near the limbus can rarely disturb the adjacent tear film and produce:

Corneal dellen

from localized dehydration.

Management may include:

• Frequent lubrication
• Lubricating ointment

and closer ophthalmic observation.

What Not to Do

Routine treatment does not require:

• Antibiotics
• Topical corticosteroids
• Vasoconstrictor drops

These do not accelerate blood resorption.

Follow-Up Needs

An isolated uncomplicated SCH usually requires:

No scheduled ophthalmic follow-up

provided that:

• Vision remains normal
• There is no significant trauma
• Symptoms resolve as expected

When Reassessment Is Appropriate

Review is appropriate if:

• Hemorrhage repeatedly recurs
• It persists unusually long
• It continues enlarging substantially
• Pain develops
• Vision decreases
• Significant ocular trauma occurred

Recurrent Subconjunctival Hemorrhage

Repeated episodes should prompt reassessment for:

• Hypertension
• Anticoagulation
• Platelet disorders
• Coagulopathy
• Recurrent mechanical trauma

Rarely, persistent localized recurrent hemorrhage can be associated with:

• Conjunctival vascular lesions
• Amyloid deposition
• Other local conjunctival pathology

SCH in Newborns

Subconjunctival hemorrhage may occur in newborns after:

• Vaginal delivery
• Instrument-assisted delivery

It usually resolves spontaneously and is generally benign when isolated.

Expected Outcome

The prognosis for uncomplicated SCH is:

Excellent.

It does not usually cause:

• Permanent visual loss
• Corneal damage
• Intraocular bleeding

The main issue is its alarming appearance.

Potential Complications

Complications are rare.

Possible problems include:

• Corneal dellen adjacent to a very elevated hemorrhage
• Identification of previously unrecognized systemic bleeding disorder
• Associated ocular injury when SCH results from significant trauma

The hemorrhage itself usually leaves:

No permanent ocular damage.

High-Yield Takeaways

• Subconjunctival hemorrhage is blood trapped beneath the conjunctiva and usually presents as a painless, sharply demarcated bright-red patch with normal vision.
• Common precipitants include coughing, sneezing, vomiting, straining, eye rubbing, and minor trauma.
• Important systemic associations include hypertension, anticoagulant or antiplatelet therapy, thrombocytopenia, and coagulation disorders.
• Most isolated spontaneous cases are benign and require reassurance only.
• Resolution typically occurs within 1–2 weeks, although large hemorrhages may persist longer.
• Mild spreading or color change during healing is usually normal.
• Routine laboratory testing is not indicated for a single uncomplicated episode.
• Recurrent or unexplained SCH should prompt consideration of blood pressure measurement, CBC/platelets, PT/INR, and aPTT according to the clinical setting.
• Do not automatically discontinue anticoagulants or antiplatelet medications because of an isolated SCH.
• Significant pain, photophobia, or reduced vision is not characteristic and should prompt evaluation for another diagnosis.
• Following trauma, an extensive, bullous, or 360-degree SCH may be a warning sign of occult globe rupture.
• A large elevated hemorrhage near the limbus can rarely cause corneal dellen, for which lubrication and follow-up are appropriate.
• The long-term prognosis is excellent, and uncomplicated SCH does not normally damage vision.