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Subconjunctival Hemorrhage

Conjunctiva is a transparent tissue that shields the white part of the eye called sclera; and also coats the inside of eyelids. Bleeding in the area between conjunctiva and sclera is called subconjunctival hemorrhage.


Presentation

There are no specific symptoms of this disease. The affected eye is slightly irritated. There should not be any problem in the vision. Eye pain is felt very rarely in subconjunctival hemorrhage. There might be a feeling of fullness under the eyelid. As the condition resolves gradually, mild irritation and a sense of eye awareness can be experienced by the patient. Occasionally, the entire white area is covered by the blood and usually, a patch of redness is observed in the eye. In a spontaneous subconjunctival hemorrhage, no blood is expressed out of the eye; therefore, no blood is blotted on to a tissue when applied on the eye. 

Flushing
  • To remove any foreign body from the eyes, it is advised to flush the eye gently with water or by using artificial tears. Wearing goggles can prevent any dust particles from entering into the eyes.[symptoma.com]
  • If you suspect there’s something in your eye, flush it out with your own tears or artificial tears rather than using your fingers. Always wear protective goggles when recommended to avoid getting particles in your eyes.[healthline.com]
Petechiae
  • Case 3 was admitted to hospital for multiple unexplained limb fractures but had been seen 2 weeks prior for poorly explained bilateral isolated subconjunctival hemorrhages and facial petechiae.[ncbi.nlm.nih.gov]
Red Eye
  • Coumadin , Dr Anna-Kay Tenn , Dr Bearden , Dr Dawn Bearden , Dr Emily McCulloh , Dr McCulloh , Dr Tenn , Eye Exam , Eye Redness , Garlic , Ginger , Ginkgo , High Blood Pressure , Hypertension , Irritated Eye , Red Eye , Red Eye Constipation , Red Eye[visionaryeyecare.wordpress.com]
  • This condition is also called red eye or hyposphagma.[eyedoctorguide.com]
  • If a small amount of blood leaks from the broken blood vessel, it usually smears the eye, causing the appearance of a severe red eye The red eye usually lasts 2-4 weeks before resolving on its own.[dovemed.com]
  • Other than a red eye, you probably won’t have any symptoms. You might feel like you have something in your eye, but this is not common. The hemorrhage shouldn’t impair your vision, and it shouldn’t cause any pain.[saintlukeshealthsystem.org]
  • This condition is one of several disorders called red eye. The white of the eye (sclera) is covered with a thin layer of clear tissue called the bulbar conjunctiva .[nlm.nih.gov]
Facial Petechiae
  • Case 3 was admitted to hospital for multiple unexplained limb fractures but had been seen 2 weeks prior for poorly explained bilateral isolated subconjunctival hemorrhages and facial petechiae.[ncbi.nlm.nih.gov]
Cesarean Section
  • Three of 19 patients delivered by cesarean section and 30 of 92 newborns delivered by the vaginal route had SCHN.[ncbi.nlm.nih.gov]

Workup

Diagnosis of subconjunctival hemorrhage is done primarily by the examination of eye and by identifying the cause of the hemorrhage such as any injury or presence of any foreign body [8].

The blood pressure of the patient is checked after inspecting the eye. Blood tests are done to detect if there are any bleeding disorders in the patient. These tests are mostly done if the patient had more than one episode of bleeding beneath the conjunctiva. If eye trauma is the cause of bleeding, then specific analysis and examination with the help of slit lamp or eye examining microscope is performed [9].

Treatment

Usually, subconjunctival hemorrhage resolves on its own and no treatment is necessary. If the eyes are irritated, artificial tears are recommended to be used more than once a day. Artificial tears will provide soothing effect to the eyes. Drugs that might increase the risk of bleeding (like warfarin and aspirin) are stopped after doctor’s consultation if the patient was already using them. If the cause of subconjunctival hemorrhage is high blood pressure or any bleeding disorder, then treatment for these conditions is also needed. In 1 to 2 weeks, the blood under the thin layer gets absorbed and the eye returns to normal [10].

Prognosis

This condition is quite harmless and the prognosis is good. Subconjunctival hemorrhage is a benign condition and is self-limiting if it is not accompanied by any other systemic ailments [7].

Etiology

Subconjunctival hemorrhage occurs as a result of a minor trauma to the eye. It might also occur due to extensive rubbing, sneezing, coughing or vomiting. Some of the potential reasons for subconjunctival hemorrhage are sudden elevation in blood pressure due to an intense activity such as heavy object lifting, eye trauma, using drugs like aspirin and warfarin, vitamin K and C deficiency or a clotting disorder. Infections such as influenza and malaria, parasitic infestations, and diseases like systemic lupus erythematosus are also considered to be causative factors for this disease [2] [3].

Epidemiology

Epidemiological data indicates that subconjunctival hemorrhages are observed in 0.8% of patients. They also seem to occur more frequently in women compared to the men. A study revealed that this condition was found unilaterally in 90 percent of total 58 patients, out of which 30 had traumatic subconjunctival hemorrhage and 28 had spontaneous subconjunctival hemorrhage [4]. In spontaneous subconjunctival hemorrhage cohort, no other disease was found to be associated with this condition in 64.3% of the cases. Hypertension was associated with this condition in 14.3% of the cases. In traumatic subconjunctival hemorrhage, 67% of injuries were found to have happened at home [5].

Sex distribution
Age distribution

Pathophysiology

Rapid rise in abdominal pressure against a closed glottis is termed as Valsalva’s manoeuvre. This rise induces a quick rise in intravenous pressure which causes the vessels inside or around the eyes to rupture because the veins above the heart do not have valves. Therefore, activities associated with strain like lifting heavy objects, passing stools during constipation, coughing etc. can lead to subconjunctival hemorrhage. Asphyxiation also causes rise in venous pressure and further rupture of subconjunctival vessels [6].

Prevention

Prevention of subconjunctival hemorrhage is not possible unless there is a specific cause is identified for the bleeding (such as bleeding disorders or the use of blood thinning drugs). These drugs can be avoided to prevent the condition. Eyes should be rubbed gently when needed to avoid any trauma that might occur by rubbing it hard. To remove any foreign body from the eyes, it is advised to flush the eye gently with water or by using artificial tears. Wearing goggles can prevent any dust particles from entering into the eyes.

Summary

It is a protective coating of the eyeball and consists of several small blood vessels and nerves. Blood vessels in conjunctiva are normally invisible and can only be seen when there is inflammation in the eye. If the blood vessel beneath the thin cover breaks, the bleeding is trapped inside the transparent membrane which is usually considered harmless. The bright red color of the eye disappears in 1 to 2 weeks [1].

Patient Information

Deposition of outflowing blood from the blood vessels existing between the thin cover on the eye (conjunctiva) and the white part of the eye is called subconjunctival hemorrhage. The eye turns red but the blood does not exude from the eye. Simple rubbing of the eyes, elevation in blood pressure, vomiting or coughing or sneezing aggressively, using aspirin and warfarin like drugs, deficiency in vitamin K and vitamin C and blood clotting disorders are some of the causes for subconjunctival hemorrhage. Slight irritation in the eye, a sense of fullness and eye awareness in the eye are some of the common symptoms of subconjunctival hemorrhage. No other specific symptoms are seen and the condition is not a harmful one. Use of drugs like aspirin and warfarin are avoided till the bleeding stops and till the eye comes back to normal. Treatment for any bleeding disorder and high blood pressure is given if they are identified as the causes for subconjunctival hemorrhage. Artificial tears are used to provide soothing effect to the eye. 

References

Article

  1. Pong JC, Lam DK, Lai JS. Spontaneous subconjunctival haemorrhage secondary to carotid-cavernous fistula. Clin Experiment Ophthalmol. Jan-Feb 2008;36(1):90-1.
  2. van Heuven WAJ. Subconjunctival hemorrhage. In: Decision Making in Ophthalmology: An Algorithmic Approach. Mosby-Year Book; 2000:66-67.
  3. Bodack MI. A warfarin-induced subconjunctival hemorrhage. Optometry. Mar 2007;78(3):113-8.
  4. Pong JC, Lam DK, Lai JS. Spontaneous subconjunctival haemorrhage secondary to carotid-cavernous fistula. Clin Experiment Ophthalmol. Jan-Feb 2008;36(1):90-1.
  5. Liesegang TJ. Contact lens-related microbial keratitis: Part I: Epidemiology. Cornea 1997; 16:125.
  6. Mimura T, Yamagami S, Usui T, Funatsu H, Noma H, Honda N, et al. Location and extent of subconjunctival hemorrhage. Ophthalmologica. 2010;224(2):90-5
  7. Dart JK. Eye disease at a community health centre. Br Med J (Clin Res Ed) 1986; 293:1477.
  8. 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.
  9. Pavan-Langston D. Manual of Ocular Diagnosis and Therapy. 5th ed. 2007.
  10. Kunimoto DY, Kanitkar KD, Makar M. The Wills Eye Manual: Office and Emergency Room Diagnosis and Treatment of Eye Disease. 2008.

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Last updated: 2018-06-21 20:58