Sub-conjunctival haemorrhage

The CMGs are guidelines on the diagnosis and management of a range of common and rare, but important, eye conditions that present with varying frequency in primary and first contact care.

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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

Mild ache or irritation (no pain)
May be asymptomatic

Signs

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

Measure blood pressure (see NICE guidance)

In traumatic cases, 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)

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)

  • 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)
 

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

Lay summary 

Sub-conjunctival haemorrhage (S-CH) is a common condition which is usually unimportant but very occasionally indicates a serious 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 11
Date of search 26.02.19;
Date of revision 24.04.19;
Date of publication 10.07.19;
Date for review 25.02.21
© College of Optometrists 

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