Subconjunctival Haemorrhage

Subconjunctival haemorrhage is bleeding from small conjunctival vessels into the potential space between the conjunctiva and sclera.

• Usually spontaneous and benign, resolving in 1 to 3 weeks (colour change red to orange, yellow).
• Causes: trivial trauma, rubbing, coughing, sneezing, straining, vomiting, Valsalva manoeuvre, contact lens wear, conjunctivitis (acute haemorrhagic conjunctivitis by enterovirus), hypertension, anticoagulants and antiplatelets, bleeding disorders, diabetes, and blunt or penetrating ocular trauma.
• Infants: consider birth trauma and non-accidental injury (with other injuries).

• Painless, sudden, bright red patch beneath the conjunctiva, sharply demarcated, sometimes involving the entire sclera. Vision normal.
• No discharge, no pain, normal pupil and anterior chamber.
• If extends posteriorly without visible posterior border, or follows head trauma, think of orbital fracture or skull base injury.
• Recurrent or bilateral bleeds suggest a systemic cause.
• Associated findings of concern: pain, reduced vision, proptosis, restricted motility, abnormal pupil, hyphaema.

• History: trauma, straining, drugs (warfarin, aspirin, clopidogrel, direct oral anticoagulants), systemic disease.
• Examination: visual acuity, slit lamp, intraocular pressure (if no trauma suspicion), eversion of lids, dilated fundus exam if trauma. Exclude open globe: Seidel test, anterior chamber depth, pupil shape.
• Blood pressure measurement.
• Recurrent or unexplained cases: full blood count, platelets, prothrombin time and INR, activated partial thromboplastin time, and screen for diabetes; consider von Willebrand disease and other bleeding disorders.
• Imaging (CT orbits and head) after significant trauma, particularly if bleeding has no posterior limit.

• Reassure: spontaneous resolution over 7 to 21 days with no treatment required.
• Lubricants for mild irritation (carboxymethylcellulose 0.5 percent four times daily); cold compress early in the first 24 hours.
• Avoid aspirin and NSAIDs unless prescribed for a clear indication; do not stop anticoagulants without advice, but check the INR is in range (2.0 to 3.0 for most warfarin indications).
• Control hypertension and treat the underlying cause; stop eye rubbing, treat cough or constipation.
• Trauma: exclude globe rupture (Seidel test, pupil shape, anterior chamber depth) and orbital fracture (CT orbits); surgical referral if suspected.
• Recurrent bleeding: haematological evaluation.
• Review in 2 weeks if persistent, in children assess for non-accidental injury and bleeding disorder.