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eMedicine Specialties > Ophthalmology > Conjunctiva

Subconjunctival Hemorrhage

Robert H Graham, MD, Senior Associate Consultant, Department of Ophthalmology, Mayo Clinic, Scottsdale, Arizona
Vivian Monsanto, MD, Consulting Staff, The Mackool Eye Institute and Laser Center; Norvin Perez, MD, Clinical Assistant Professor of Emergency Medicine, Albert Einstein College of Medicine; Consulting Staff, Department of Emergency Medicine, Montefiore Medical Center

Updated: Feb 3, 2009

Introduction

Background

Subconjunctival hemorrhage is defined as blood between the conjunctiva and the sclera, and it is involved in the differential diagnosis of a red eye.

Pathophysiology

Subconjunctival hemorrhage results from bleeding of the conjunctival or episcleral blood vessels into the subconjunctival space. The hemorrhage can be traumatic, spontaneous, or related to systemic illness.

Frequency

United States

Subconjunctival hemorrhage occurs frequently. Exact figures are unknown because it is a self-limited disorder.

Mortality/Morbidity

Subconjunctival hemorrhage is a self-limited condition when not associated with systemic illness.

Race

No racial preference for subconjunctival hemorrhage is evident.

Sex

No gender difference for subconjunctival hemorrhage is evident.

Age

Subconjunctival hemorrhage can occur at all ages, but it is more common with increasing age.

Clinical

History

  • Red eye
  • May have mild irritation
  • Usually asymptomatic

Physical

  • The most common appearance of a subconjunctival hemorrhage is a bright red patch with relatively normal surroundings. 
  • A slit lamp examination shows its precise location under the conjunctiva.
  • The view of the sclera may be obscured by blood. If thick, it may be dark red.

Causes

  • Idiopathic
  • Valsalva (eg, coughing, straining)
  • Traumatic (isolated or associated with retrobulbar hemorrhage or ruptured globe)
  • Hypertension/arteriosclerosis
  • Bleeding disorders (if recurrent or in young patients without history of trauma or infection), including hematologic or hepatic disease, diabetes, systemic lupus erythematosus, parasites, and vitamin C deficiency
  • Various antibiotics, drugs/chemicals (eg, coumadin, nonsteroidal anti-inflammatory drugs [NSAIDs], aspirin), steroids, contraceptives, and vitamins A and D have been associated with subconjunctival hemorrhage.
  • Normal sequelae of ocular surgery even if no conjunctival incision
  • Several febrile systemic infections can cause subconjunctival hemorrhage, including meningococcal septicemia, scarlet fever, typhoid fever, cholera, rickettsia, malaria, and viruses (eg, influenza, smallpox, measles, yellow fever, sandfly fever).
  • Subconjunctival hemorrhage has been reported as a result of emboli from long bone fractures, chest compression, cardiac angiography, open-heart surgery, and other remote operations.

Differential Diagnoses

Conjunctivitis, Acute Hemorrhagic
Kaposi Sarcoma
Red Eye Evaluation

Other Problems to Be Considered

Other conjunctival neoplasms with secondary hemorrhage

Workup

Laboratory Studies

  • Usually, no laboratory studies are indicated.
    • Check blood pressure.
    • If history of trauma, rule out ruptured globe or retrobulbar hemorrhage.
    • In recurrent cases or if history of bleeding problems (eg, epistaxis, easy bruising), a bleeding time, prothrombin time/activated partial thromboplastin time (PT/aPTT), CBC with platelets, and protein C and S should be obtained with consideration for consultation to an internist.

Treatment

Medical Care

Medical care is not required.

  • Artificial tears can be used 4 times per day for mild irritation.
  • Discourage elective use of aspirin products or NSAIDs.

Consultations

Referral to an internist or a family physician should be made as indicated for hypertension or bleeding diathesis.

Medication

Medications are not indicated for this condition.

Follow-up

Further Outpatient Care

  • With time and blood breakdown, the hemorrhage may become green or yellow, like a bruise, spreading around the circumference of the globe. Usually, this disappears within 2 weeks.
  • Patients are told to return if the blood does not fully resolve or if they have a recurrence.

Prognosis

  • The prognosis is excellent.

Patient Education

  • For excellent patient education resources, visit eMedicine's Eye and Vision Center. Also, see eMedicine's patient education articles Subconjunctival Hemorrhage (Bleeding in Eye) and Black Eye.

Miscellaneous

Special Concerns

  • The occurrence of subconjunctival hemorrhage in an eye after scleral buckle indicates buckle infection until proven otherwise even if the surgery was performed years before. Usually, there is focal tenderness somewhere over the buckle.

References

  1. American Academy of Ophthalmology. External disease and cornea. In: Basic and Clinical Science Course. Vol 8. American Academy of Ophthalmology; 1995:292.

  2. Bodack MI. A warfarin-induced subconjunctival hemorrhage. Optometry. Mar 2007;78(3):113-8. [Medline].

  3. Fraunfelder FT. Drug Induced Ocular Side Effects and Drug Interactions. 3rd ed. Philadelphia: Lea & Febiger; 1989.

  4. Friberg TR, Weinreb RN. Ocular manifestations of gravity inversion. JAMA. Mar 22-29 1985;253(12):1755-7. [Medline].

  5. Knopf HL, Carter K, Prokopius MJ. Recurrent subconjunctival hemorrhage. Compr Ophthalmol Update. May-Jun 2006;7(3):155-6. [Medline].

  6. Pong JC, Lam DK, Lai JS. Spontaneous subconjunctival haemorrhage secondary to carotid-cavernous fistula. Clin Experiment Ophthalmol. Jan-Feb 2008;36(1):90-1. [Medline].

  7. Quezada AA, Shields CL, Wagner RS, Demirci H, Caputo AR, Shields JA. Lymphangioma of the conjunctiva and nasal cavity in a child presenting with diffuse subconjunctival hemorrhage and nosebleeds. J Pediatr Ophthalmol Strabismus. May-Jun 2007;44(3):180-2. [Medline].

  8. Rhee DJ. Subconjunctival hemorrhage. In: Wills Eye Manual: Office & Emergency Room Diagnosis & Treatment of Eye Disease. 3rd ed. Lippincott Williams & Wilkins; 1999:130-131.

  9. Russell SR, Olsen KR, Folk JC. Predictors of scleral rupture and the role of vitrectomy in severe blunt ocular trauma. Am J Ophthalmol. Mar 15 1988;105(3):253-7. [Medline].

  10. Shields SR. Managing eye disease in primary care. Part 2. How to recognize and treat common eye problems. Postgrad Med. Oct 2000;108(5):83-6, 91-6. [Medline].

  11. Spitzer SG, Luorno J, Noël LP. Isolated subconjunctival hemorrhages in nonaccidental trauma. J AAPOS. Feb 2005;9(1):53-6. [Medline].

  12. van Heuven WAJ. Subconjunctival hemorrhage. In: Decision Making in Ophthalmology: An Algorithmic Approach. Mosby-Year Book; 2000:66-67.

  13. Wirbelauer C. Management of the red eye for the primary care physician. Am J Med. Apr 2006;119(4):302-6. [Medline].

Keywords

subconjunctival hemorrhage, red eye, bleeding in eye, blood in eye

Contributor Information and Disclosures

Author

Robert H Graham, MD, Senior Associate Consultant, Department of Ophthalmology, Mayo Clinic, Scottsdale, Arizona
Robert H Graham, MD is a member of the following medical societies: American Academy of Ophthalmology, American Medical Association, and Arizona Ophthalmological Society
Disclosure: WebMD/eMedicine Salary Employment

Coauthor(s)

Vivian Monsanto, MD, Consulting Staff, The Mackool Eye Institute and Laser Center
Vivian Monsanto, MD is a member of the following medical societies: Alpha Omega Alpha and American Academy of Ophthalmology
Disclosure: Nothing to disclose.

Norvin Perez, MD, Clinical Assistant Professor of Emergency Medicine, Albert Einstein College of Medicine; Consulting Staff, Department of Emergency Medicine, Montefiore Medical Center
Norvin Perez, MD is a member of the following medical societies: American College of Emergency Physicians and American Medical Association
Disclosure: Nothing to disclose.

Medical Editor

Kilbourn Gordon III, MD, FACEP, Urgent Care Physician
Kilbourn Gordon III, MD, FACEP is a member of the following medical societies: American Academy of Ophthalmology and Wilderness Medical Society
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

J James Rowsey, MD, Former Director of Corneal Services, St Luke's Cataract and Laser Institute, Florida
J James Rowsey, MD is a member of the following medical societies: American Academy of Ophthalmology, American Association for the Advancement of Science, American Medical Association, Association for Research in Vision and Ophthalmology, Florida Medical Association, Pan-American Association of Ophthalmology, Sigma Xi, and Southern Medical Association
Disclosure: Nothing to disclose.

CME Editor

Lance L Brown, OD, MD, Ophthalmologist, Affiliated With Freeman Hospital and St John's Hospital, Regional Eye Center, Joplin, Missouri
Disclosure: Nothing to disclose.

Chief Editor

Hampton Roy Sr, MD, Associate Clinical Professor, Department of Ophthalmology, University of Arkansas for Medical Sciences
Hampton Roy Sr, MD is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, and Pan-American Association of Ophthalmology
Disclosure: Nothing to disclose.

Further Reading

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