Subconjunctival HemorrhageEdit

Subconjunctival hemorrhage is a common, usually benign eye finding characterized by a bright red patch on the white of the eye. It occurs when a tiny blood vessel beneath the conjunctiva— the clear membrane that covers the sclera and lines the inside of the eyelids—ruptures. The condition is typically painless and does not affect vision. In most cases it resolves on its own within one to two weeks, leaving no lasting damage or scarring.

Despite its alarming appearance, subconjunctival hemorrhage is rarely a sign of anything serious. It can arise after a minor bump, a vigorous sneeze or bout of coughing, heavy lifting, or intense eye rubbing. It can also occur spontaneously, particularly in people taking certain medications or with underlying bleeding tendencies. This article explains what a subconjunctival hemorrhage is, how it presents, how it is diagnosed, and how it is managed in routine practice, along with some of the practical debates that surround its care.

Definition and clinical features

Subconjunctival hemorrhage refers to bleeding under the conjunctiva, the delicate membrane that covers the visible surface of the eye. Clinically, it appears as a well-demarcated, sharply defined patch of red on the white part of the eye, with the surrounding cornea and iris typically unaffected. The eye usually looks normal otherwise; there is generally no pain, discharge, or vision change. In most cases, no treatment is required, and no permanent damage occurs.

Common triggering factors include sudden increases in venous pressure from coughing, vomiting, constipation, straining during bowel movements, or heavy lifting. Local trauma, rubbing the eye, or recent ocular surgery can also precipitate the event. Medications that affect blood clotting, such as anticoagulants and, to a lesser extent, antiplatelet therapy, can increase the likelihood or ease of a bleed. Rarely, recurrent or unusual patterns of subconjunctival hemorrhage may prompt evaluation for underlying bleeding disorders or systemic conditions, discussed in the diagnosis and management sections.

Causes and risk factors

Increased venous pressure from coughing, sneezing, vomiting, constipation, or heavy lifting.
Local trauma to the eye or eyelids.
Ocular procedures or recent eye surgery.
Use of medications that affect coagulation, such as anticoagulants or antiplatelet therapy.
Bleeding diatheses or systemic bleeding disorders in some cases.

Most people with a single episode do not require laboratory tests or imaging. If the hemorrhage recurs repeatedly, is accompanied by abnormal bruising elsewhere, or occurs in the setting of new medications or a known bleeding disorder, a clinician may pursue a targeted review of systemic health and coagulation status, often starting with a basic history and physical and, if warranted, selective testing.

Diagnosis

Diagnosis is typically clinical. An eye examination by a clinician or ophthalmologist reveals a localized subconjunctival bleed with a normal cornea, clear lens, and intact vision. Key distinguishing features include: - Absence of corneal involvement or pain. - No discharge or lash itching that would suggest conjunctivitis or keratoconjunctivitis. - Normal visual acuity, unless other eye disease is present.

In cases of recurrence, trauma history, or red flags such as eye pain, vision loss, photophobia, or a diffuse or changing redness, an exam may include slit-lamp evaluation to assess the anterior segment of the eye and to rule out other etiologies. If there is concern for a systemic condition, a clinician may consider reviewing medications and history of bleeding disorders and, in select cases, coordinating with primary care or a hematology consultation. See slit-lamp examination for more on the technique used in thorough anterior segment assessment.

Management and prognosis

Most cases require only reassurance and observation.
Symptomatic relief can be provided with artificial tears or lubricating eye drops if the eye feels dry or irritated.
Patients should avoid rubbing the eye, which can exacerbate bleeding or delay resolution.
If a patient is on anticoagulant or antiplatelet therapy, decisions about continuing or adjusting medication should be made in consultation with the prescribing clinician, rather than by self-discontinuation.

Underlying systemic issues or medication effects should be addressed when indicated. For recurrent hemorrhages or when there are additional symptoms (pain, sudden vision changes, or a history of bleeding disorders), a clinician may pursue a broader evaluation, including review of medications and, if appropriate, targeted blood tests. The prognosis for a typical episode is excellent, with the red patch gradually fading as the conjunctival vessels reabsorb the blood.

Epidemiology

Subconjunctival hemorrhage is a relatively common finding across age groups. It occurs in children and adults with similar frequency, though the circumstances of triggering events—such as a forceful sneeze or vigorous crying in children—may differ from adult risk factors. Recurrence is possible but not guaranteed, and most individuals experience only sporadic episodes in a lifetime. While it can be alarming in appearance, the vast majority of cases do not reflect a serious underlying disease and resolve without intervention.

Controversies and debates

When to pursue systemic testing after a subconjunctival hemorrhage: Proponents of a conservative, cost-conscious approach favor limiting testing to those with recurrent episodes, unusual bleeding elsewhere, known bleeding disorders, or recent changes in medications. They argue that extensive workups in a single, isolated episode add costs and anxiety without improving outcomes. Opponents contend that even rare but serious conditions can present with seemingly isolated eye findings, and a low-threshold evaluation is prudent in older adults or patients with risk factors. See bleeding disorders and anticoagulants for related considerations.
Management of anticoagulant therapy: There is ongoing discussion about whether subconjunctival hemorrhage warrants any modification of anticoagulant or antiplatelet therapy. Most clinicians emphasize that SCH is typically benign and does not mandate stopping a systemic therapy. In practice, decisions should be individualized, taking into account the patient’s cardiovascular or thrombotic risk and in consultation with the prescribing clinician. See anticoagulants and antiplatelet therapy for more.
Avoidance of overtreatment: A practical debate centers on avoiding unnecessary testing or treatment for a condition with a favorable natural history. Critics of overtesting argue that many red-eye visits are driven by anxiety and precaution rather than clinical need, and that evidence supports patient reassurance, education, and minimal intervention in typical cases. Supporters of a more proactive approach caution against missed diagnoses in atypical presentations, advocating selective investigation when clues point to systemic disease or ocular pathology.
Public and professional information: In line with broader discussions about medical information, some critics argue that overly alarmist internet content can drive demand for unneeded visits and tests. A measured, evidence-based presentation that emphasizes self-limited nature and clear red flags can help patients decide when urgent care is necessary and when reassurance is sufficient.