Traumatic Subconjunctival Hemorrhage

Traumatic subconjunctival hemorrhage is bleeding under the conjunctiva after blunt or penetrating injury to the eye or orbit. It is a marker of potential serious damage and the underlying injury must be excluded.

• Causes are blows, falls, road traffic crashes, fireworks and sports injuries.
• A haemorrhage extending behind the globe without a visible posterior border suggests orbital or skull base fracture.
• Penetrating injury can be hidden beneath the haemorrhage.

Painless or mildly painful red patch on the eye after injury, often with eyelid bruising and swelling.

• Look for reduced vision, a distorted pupil, hyphaema, enophthalmos, double vision, limited eye movements, lid laceration and numbness below the eye.
• Differential diagnosis: open globe injury, hyphaema, orbital fracture, retrobulbar haemorrhage, corneal abrasion, retinal detachment, vitreous haemorrhage, skull base fracture, lens dislocation.
• Complications: occult globe rupture, traumatic optic neuropathy, orbital compartment syndrome, glaucoma, infection, vision loss.

Examine carefully to exclude associated injury.

• Visual acuity, pupil reactions, eye movements, fluorescein staining for Seidel sign, slit lamp examination and dilated fundus examination.
• CT of the orbits and brain without contrast if open globe, fracture or head injury is suspected, without applying pressure to the eye.
• Tonometry only when open globe is excluded.

Protect the eye and refer when injury is suspected.

• Supportive: rigid eye shield (not a pad) for suspected open globe, head up 30 degrees, nil by mouth if surgery likely, cold compress to the lids only without pressing on the globe, avoid nose blowing.
• Pharmacological: paracetamol 1 g every 6 hours; ondansetron 4 mg IV for vomiting; tetanus toxoid if the injury is penetrating or dirty; for open globe, ciprofloxacin 500 mg orally twice daily or moxifloxacin 400 mg daily, or ceftazidime 1 g IV with vancomycin; lubricating drops for the simple haemorrhage. Avoid NSAIDs and aspirin.
• Procedures: urgent surgical repair of open globe; lateral canthotomy for retrobulbar haemorrhage with vision loss; orbital fracture repair by specialist.
• Special groups: children, consider abuse; pregnancy, orbit CT with shielding if required; patients on anticoagulants, check coagulation and consider reversal in major bleeding.
• Red flags: loss of vision, severe pain, tense proptosis, afferent pupil defect, distorted pupil, flat anterior chamber, hyphaema, double vision, fluid leak.
• Follow-up: review at 24 to 48 hours; simple haemorrhage clears in 2 weeks.