H11.31-33 Subconjunctival Hemorrhage

The conjunctiva is the clear tissue that covers the sclera and lines the inside of both eyelids.  A subconjunctival hemorrhage is blood that is located between the conjunctiva and the underlying sclera. 

• Coughing
• Sneezing
• Vomiting
• Vigorous eye rubbing
• Choking
• Trauma to the eye or head
• Ocular or eyelid surgery
• Viral eye infection

Subconjunctival hemorrhages are mostly considered to be idiopathic since it is impractical to define the main causes. They can develop from either ocular or systemic conditions.

Ocular Conditions

• Local trauma
• Acute inflammation of the conjunctiva
• Conjunctival tumors
• Conjunctivochalasis
• Ocular amyloidosis
• Contact lens usage
• Ocular surgery
• Ocular adnexal tumors

Systemic Conditions

• Vascular disease
• Severe venous congestion
• Hematological dyscrasias
• Systemic trauma
• Acute febrile systemic diseases
• Drugs
• Carotid cavernous fistulas

Structural Damage to the Eye

Health complications are rare.  In most cases, the underlying blood is absorbed within one to two weeks without treatment and without any structural damage to the eye.

Functional Damage to the Eye

Vision is usually not affected and any other functional damage that may occur is usually caused by some other ocular or systemic condition.

The main goal of the diagnostic evaluation in a patient with a subconjunctival hemorrhage is to accomplish the following: 

• Determine the underlying associated systemic etiology of the conjunctival hemorrhage
• Prescribe a treatment program to treat the underlying condition

Patient History

Patients usually come in because they notice the bleeding in the conjunctiva, but are otherwise asymptomatic in the early stages of the growth.

External Ocular Examination with Biomicroscopy

• Abnormal conjunctival vessel diameter
• Vessel tortuosity
• Distended vessels
• Damaged vessels
• Sacculated vessels
• Microaneurysms
• Blood sludging

DIAGNOSTIC TESTS

External Ocular Photography

• To document the progress or lack of progress of the conjunctival hemorrhage
• To document the delivery of medical treatment
• To document the response to treatment

There is no classification system in place for subconjunctival hemorrhages.  However, they may be classified under ocular or systemic conditions, respectively.

Other Conjunctival Neoplasms With Secondary Hemorrhage

Squamous Cell Carcinoma Conjunctival neoplasms (e.g., lymphoma) with secondary hemorrhage

Conjunctivitis

Swelling (inflammation) or infection of the conjunctiva.

Kaposi Sarcoma

Eyedrops may be used, such as artificial tears, to soothe any discomfort in the eye.  Beyond that, the blood in the conjunctiva will absorb within about one to two weeks and no treatment will be necessary.

If minor ocular discomfort is associated with the hemorrhage, a mild topical steroid can be prescribed for short-term treatment.

1.  Subconjunctival Hemorrhage (Broken Blood Vessel in Eye).  Mayo Clinic.  22 Jan 2014. http://www.mayoclinic.org/diseases-conditions/subconjunctival-hemorrhage/basics/definition/con-20029242.  Last accessed September 14, 2014.
2.  Tarlan B. Kiratli H.  Subconjunctival Hemorrhage: Risk Factors and Potential Indicators.  National Library of Medicine.  12 Jan 2013.  http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3702240/.  Last accessed September 14, 2014.
3.  Subconjunctival Hemorrhage.  The Wills Eye Manual (Fifth Edition).  2008.  112-113.
4.  Sub-conjunctival Haemorrhage. The College of Optometrists.  http://www.college- optometrists.org/download.cfm/docid/6267166e-8bdd-4a05-abf64b3dd4ad559a.  Last accessed January 4, 2015.