Aetiology

Subconjunctival haemorrhage (S-CH) results from rupture of conjunctival or episcleral blood vessels causing bleeding into the subconjunctival space.

Two main causes:

• spontaneous (higher incidence in adults over 50 years)
• traumatic (higher incidence in younger adults)

Known spontaneous causes include:

• idiopathic (most common)
• Valsalva manoeuvre (e.g. coughing, lifting, straining, vomiting) producing increase in central venous pressure
• systemic vascular disease (e.g. hypertension, diabetes)
• medication (anticoagulants, NSAIDs)

Traumatic causes include:

• injury (may be isolated or associated with ruptured globe or retrobulbar haemorrhage – see Clinical Management Guideline on Blunt Trauma)
• eye rubbing
• ocular surgery/procedure (cataract surgery, refractive surgery, anaesthesia technique such as sub-Tenon’s anaesthetic or peribulbar block and intravitreal injection)
• contact lens handling injury

S-CH is uncommon in children. However, may arise as a result of accidental or non-accidental trauma (seriously considered in infants presenting with bilateral isolated SCHs, particularly in the presence of facial petechia)

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)

Anticoagulant medication (e.g. aspirin, warfarin, clopidogrel, rivaroxaban, apixaban)

Hypertension, 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 (if extensive haemorrhage, otherwise painless)
May be asymptomatic

Signs of sub-conjunctival haemorrhage

Red area on eye, location usually temporal or inferior, caused by blood beneath the conjunctiva of which the posterior border can be seen
Haemorrhage-localised or diffuse
Usually unilateral
No discharge

Differential diagnosis

Acute haemorrhagic conjunctivitis (AHC)

• viral conjunctivitis (typically enterovirus; usually small multiple haemorrhages; rare)
• usually bilateral

Retrobulbar haemorrhage

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

Reassure patient (self-limiting)

Condition usually clears over 1-2 weeks (depending on size, and maybe longer in patient taking anticoagulants) 

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
• following head trauma, ensure that posterior border of haemorrhage can be seen, which may otherwise indicate orbital fracture or intra-cranial source e.g. skull base fracture (In these cases, the S-CH is usually accompanied by other signs and symptoms e.g. proptosis, abnormal pupil reactions and/or reduced visual acuity)

(GRADE*: Level of evidence=low, Strength of recommendation=strong)

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 orbital fracture or 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

Sub-conjunctival haemorrhage
Version 13
Date of search 29.03.23;
Date of revision 30.05.23;
Date of publication 03.08.23;
Date for review 28.03.25
© College of Optometrists