- Abnormalities of the Pupil
- Atopic Keratoconjunctivitis (AKC)
- Basal cell carcinoma (BCC) (periocular)
- Blepharitis (Lid Margin Disease)
- CL-associated Papillary Conjunctivitis (CLAPC), Giant Papillary Conjunctivitis (GPC)
- Cellulitis, preseptal and orbital
- Chalazion (Meibomian cyst)
- Concretions
- Conjunctival pigmented lesions
- Conjunctival scarring
- Conjunctivitis (Acute Allergic)
- Conjunctivitis (bacterial)
- Conjunctivitis (viral, non-herpetic)
- Conjunctivitis (seasonal & perennial allergic)
- Conjunctivitis, Chlamydial (adult inclusion conjunctivitis)
- Conjunctivitis medicamentosa (also Dermatoconjunctivitis medicamentosa)
- Corneal (or other superficial ocular) foreign body
- Corneal Transplant Rejection
- Corneal abrasion
- Corneal hydrops
- Dacryocystitis (acute)
- Dacryocystitis (chronic)
- Dry Eye (Keratoconjunctivitis Sicca, KCS)
- Ectropion
- Endophthalmitis (post-operative) (Exogenous endophthalmitis)
- Entropion
- Episcleritis
- Facial palsy (Bell's Palsy)
- Fuchs Endothelial Corneal Dystrophy (FECD)
- Glaucoma (chronic open angle) (COAG)
- Herpes Simplex Keratitis (HSK)
- Herpes Zoster Ophthalmicus (HZO)
- Hordeolum
- Keratitis (marginal)
- Keratitis, CL-associated infiltrative
- Microbial keratitis (Acanthamoeba sp.)
- Microbial keratitis (bacterial, fungal)
- Molluscum contagiosum
- Nasolacrimal duct obstruction (nasolacrimal drainage dysfunction)
- Ocular hypertension (OHT)
- Ocular rosacea
- Ophthalmia neonatorum
- Photokeratitis (Ultraviolet [UV] burn, Arc eye, Snow Blindness)
- Phthiriasis (pediculosis ciliaris)
- Pigmented fundus lesions
- Pinguecula
- Post-operative suture breakage
- Primary Angle Closure / Primary Angle Closure Glaucoma (PAC / PACG)
- Pterygium
- Recurrent corneal epithelial erosion syndrome
- Retinal Vein Occlusion
- Scleritis
- Steroid-related Ocular Hypertension and Glaucoma
- Sub-conjunctival haemorrhage
- Sub-tarsal foreign body (STFB)
- Trauma (blunt)
- Trauma (chemical)
- Trauma (penetrating)
- Trichiasis
- Uveitis (anterior)
- Vernal Keratoconjunctivitis
- Vitreomacular Traction and Macular Hole
- How to use the Clinical Management Guidelines
Sub-conjunctival haemorrhage
Contents
Aetiology
Spontaneous in 50-87% of cases; may be recurrent
Known causes include:
• Valsalva manoeuvre (e.g. coughing, straining, vomiting) producing rise in central venous pressure
• traumatic (may be isolated or associated with ruptured globe or retrobulbar haemorrhage – see Clinical Management Guideline on Blunt Trauma)
• recent eye surgery
History is important. Ask about hypertension, medications, acute or chronic cough, eye rubbing, heavy lifting, recent ocular or head trauma, bleeding or clotting abnormalities and recurrent subconjunctival haemorrhage
Predisposing factors
Older age (highest incidence at 60-80 years)
Trauma (including contact lens-related injury)
Systemic hypertension
Anticoagulant medication (e.g. aspirin, warfarin)
Diabetes and other systemic vascular disorders
Bleeding abnormality (leukaemia, clotting disorders)
Long-term topical steroid treatment
Conjunctival vascular lesion
Symptoms of sub-conjunctival haemorrhage
Mild ache or irritation (no pain)
May be asymptomatic
Signs of sub-conjunctival haemorrhage
Red area on eye, location usually inferior, caused by blood beneath the conjunctiva of which the posterior border can be seen (if cannot be seen, may originate from intra-cranial haemorrhage, in which case immediate emergency referral may save a life)
Usually unilateral
No discharge
Differential diagnosis
Haemorrhagic conjunctivitis (EHC)
- viral conjunctivitis (usually small multiple haemorrhages; rare)
- usually bilateral
Conjunctival neoplasms (e.g. lymphoma) with secondary haemorrhage
Kaposi’s sarcoma (red or purple lesions under conjunctiva)
Management by optometrist
Practitioners should recognise their limitations and where necessary seek further advice or refer the patient elsewhere
Non pharmacological
- Reassure patient
- Condition usually clears within 5-10 days
- Cold compress may reduce discomfort
- Advise patient to return/seek further help if problem does not resolve or if it recurs
(GRADE*: Level of evidence=low, Strength of recommendation=strong)
Spontaneous sub-conjunctival haemorrhage
- measure blood pressure, or arrange for this to be done (see NICE guidance Hypertension in adults: diagnosis and management)
- if patient has history of recurrent subconjunctival haemorrhages or a history of bleeding or clotting abnormalities, refer to GP. Also refer for checking of international normalized ratio (INR) if patient is on warfarin (particularly if associated with unexplained bruising on the skin)
(GRADE*: Level of evidence=low, Strength of recommendation=strong)
Traumatic sub-conjunctival haemorrhage
- refer to Clinical Management Guideline on Blunt Trauma
- ensure that posterior border of haemorrhage can be seen, to exclude intra-cranial source e.g. following skull base fracture
(GRADE*: Level of evidence=low, Strength of recommendation=strong)
Pharmacological
Tear supplement / ocular lubricant if mild ocular irritation is present
(GRADE*: Level of evidence=low, Strength of recommendation=strong)
Management category
B3: management to resolution
Refer to GP if suspicion of hypertension or bleeding disorder, or if condition is recurrent
A1: if intracranial source of haemorrhage suspected, emergency (same day) referral
to A&E
Possible management by ophthalmologist
(Not normally referred)
Investigate for underlying cause of subconjunctival haemorrhage
Cauterise bleeding vessel if found
Evidence base
*GRADE: Grading of Recommendations Assessment, Development and Evaluation (www.gradeworkinggroup.org)
Sources of evidence
Cagini C, Iannone A, Bartolini A, Fiore T, Fierro T, Gresele P. Reasons for visits to an emergency center and hemostatic alterations in patients with recurrent spontaneous subconjunctival hemorrhage. Eur J Ophthalmol. 2016;26(2):188-92
Leiker LL, Mehta BH, Pruchnicki MC, Rodis JL. Risk factors and complications of subconjunctival hemorrhages in patients taking warfarin. Optometry. 2009;80(5):227-31
Mercieca K, Sanghvi C, Jones NP. Spontaneous sub-conjunctival haemorrhage in patients using long-term topical corticosteroids. Eye (Lond). 2010;24(12):1770-1
Pitts JF, Jardine AG, Murray SB, Barker NH. Spontaneous subconjunctival haemorrhage-a sign of hypertension? Br J Ophthalmol. 1992;76(5):297-9
Tarlan B, Kiratli H. Subconjunctival hemorrhage: risk factors and potential indicators. Clin Ophthalmol. 2013;7:1163-70
Plain language summary
Sub-conjunctival haemorrhage (S-CH) is a common condition which is not serious but very occasionally indicates a significant medical condition. It occurs when a small amount of bleeding takes place beneath the conjunctiva (the membrane overlying the white of the eye) and is similar to a bruise elsewhere. It appears bright red because the conjunctiva is transparent. This may happen spontaneously (that is, with no apparent cause) or as the result of minor injury, for example when a contact lens is mishandled. It can also indicate raised blood pressure or a bleeding abnormality. S-CH occurs more often in people taking blood thinning medications or aspirin, and in diabetics. The condition is often alarming because of its dramatic appearance but there is usually only mild discomfort and the haemorrhage usually disappears in 5-10 days without treatment. It is usual to check the blood pressure of people with S-CH and to investigate the problem if it recurs.
Sub-conjunctival haemorrhage
Version 12
Date of search 23.01.21;
Date of revision 31.03.21;
Date of publication 20.08.21;
Date for review 22.01.23
© College of Optometrists
- Abnormalities of the Pupil
- Atopic Keratoconjunctivitis (AKC)
- Basal cell carcinoma (BCC) (periocular)
- Blepharitis (Lid Margin Disease)
- CL-associated Papillary Conjunctivitis (CLAPC), Giant Papillary Conjunctivitis (GPC)
- Cellulitis, preseptal and orbital
- Chalazion (Meibomian cyst)
- Concretions
- Conjunctival pigmented lesions
- Conjunctival scarring
- Conjunctivitis (Acute Allergic)
- Conjunctivitis (bacterial)
- Conjunctivitis (viral, non-herpetic)
- Conjunctivitis (seasonal & perennial allergic)
- Conjunctivitis, Chlamydial (adult inclusion conjunctivitis)
- Conjunctivitis medicamentosa (also Dermatoconjunctivitis medicamentosa)
- Corneal (or other superficial ocular) foreign body
- Corneal Transplant Rejection
- Corneal abrasion
- Corneal hydrops
- Dacryocystitis (acute)
- Dacryocystitis (chronic)
- Dry Eye (Keratoconjunctivitis Sicca, KCS)
- Ectropion
- Endophthalmitis (post-operative) (Exogenous endophthalmitis)
- Entropion
- Episcleritis
- Facial palsy (Bell's Palsy)
- Fuchs Endothelial Corneal Dystrophy (FECD)
- Glaucoma (chronic open angle) (COAG)
- Herpes Simplex Keratitis (HSK)
- Herpes Zoster Ophthalmicus (HZO)
- Hordeolum
- Keratitis (marginal)
- Keratitis, CL-associated infiltrative
- Microbial keratitis (Acanthamoeba sp.)
- Microbial keratitis (bacterial, fungal)
- Molluscum contagiosum
- Nasolacrimal duct obstruction (nasolacrimal drainage dysfunction)
- Ocular hypertension (OHT)
- Ocular rosacea
- Ophthalmia neonatorum
- Photokeratitis (Ultraviolet [UV] burn, Arc eye, Snow Blindness)
- Phthiriasis (pediculosis ciliaris)
- Pigmented fundus lesions
- Pinguecula
- Post-operative suture breakage
- Primary Angle Closure / Primary Angle Closure Glaucoma (PAC / PACG)
- Pterygium
- Recurrent corneal epithelial erosion syndrome
- Retinal Vein Occlusion
- Scleritis
- Steroid-related Ocular Hypertension and Glaucoma
- Sub-conjunctival haemorrhage
- Sub-tarsal foreign body (STFB)
- Trauma (blunt)
- Trauma (chemical)
- Trauma (penetrating)
- Trichiasis
- Uveitis (anterior)
- Vernal Keratoconjunctivitis
- Vitreomacular Traction and Macular Hole
- How to use the Clinical Management Guidelines
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