Subconjunctival hemorrhage is when one or more blood spots appear on the white of your eye. If they break, blood leaks between the conjunctiva and sclera. This bleeding is the bright red spot that you see on the white of your eye. These blood spots can look scary. But a subconjunctival hemorrhage is usually harmless and often heals on its own. Usually the only symptom of subconjunctival hemorrhage is a red spot in your eye.
|Published (Last):||23 August 2016|
|PDF File Size:||3.84 Mb|
|ePub File Size:||7.95 Mb|
|Price:||Free* [*Free Regsitration Required]|
Subconjunctival hemorrhage is a benign disorder that is a common cause of acute ocular redness. The major risk factors include trauma and contact lens usage in younger patients, whereas among the elderly, systemic vascular diseases such as hypertension, diabetes, and arteriosclerosis are more common. In patients in whom subconjunctival hemorrhage is recurrent or persistent, further evaluation, including workup for systemic hypertension, bleeding disorders, systemic and ocular malignancies, and drug side effects, is warranted.
Subconjunctival hemorrhage SCH is a common benign condition of the eye that has characteristic features, such as the painless acute appearance of a sharply circumscribed redness of bleeding underneath the conjunctiva in the absence of discharge, and inflammation in contagious areas.
It can vary from dot-blot hemorrhages to extensive areas of bleeding that render the underlying sclera invisible. The majority of cases are mostly considered to be idiopathic, since it is usually impossible and impractical to define the main cause of SCH.
However, the clinician must have a systematic review scheme in mind, and major causes can be classified under ocular and systemic conditions, respectively. The first study on the risk factors was reported by Fukuyama et al 5 in , who showed that local trauma, systemic hypertension, acute conjunctivitis, and diabetes mellitus were the main causes or associated conditions of SCH. On the other hand, the cause of SCH was undetermined in about half of the patients. The relationship between age, local trauma, and systemic hypertension was assessed, and it was demonstrated that hypertension was seen more often in patients older than 50 years; however, local trauma was an important cause in all age-groups.
Ocular causes include local trauma to the globe, injuries to the orbit, acute inflammation of the conjunctiva, conjunctival tumors, conjunctivochalasis, ocular amyloidosis, contact lens usage, ocular surgery, and ocular adnexal tumors. Various types of local injuries to the globe constitute the common cause of SCH, spanning from a minor trauma originating from a foreign body or eye rubbing to major traumas, such as blunt or penetrating injuries of the globe, which can cause SCH at all levels.
Therefore, all patients presenting with SCH should be thoroughly asked about any possible trauma in the last few days. SCH may develop 12—24 hours after the fracture of orbital bones and results from influent leakage of blood under the conjunctiva. Acute hemorrhagic conjunctivitis, caused by enterovirus type 70, Coxsackie virus A24 variant, and less commonly adenovirus types 8, 11, and 19, is characterized by sudden onset of follicular conjunctivitis with mucoid discharge, epiphora, photophobia, eyelid edema, and conjunctival chemosis.
SCH was seen in This massive subconjunctival hemorrhage accompanied acute intralesional bleeding of an orbital arteriovenous malformation following strenuous physical exercise. In recent years, there have been few reports evaluating the association between conjunctivochalasis and SCH. According to these results, the authors suggested that conjunctivochalasis might contribute to the pathogenesis of SCH.
In this report, they could not comment on the role of dry eyes in their patients but Liu et al 19 evaluated the tear film of spontaneous SCH patients by noninvasive interferometry. Conjunctival amyloidosis may be one of the unusual causes of spontaneous SCH. At this point, it is worth considering the simple classification of amyloidosis: 1 primary localized amyloidosis, 2 primary systemic amyloidosis, 3 secondary localized amyloidosis, and 4 secondary systemic amyloidosis.
Although the association of conjunctival amyloidosis with monoclonal gammopathies and multiple myeloma is not common, there is a case, reported by Higgins et al, 26 presenting with recurrent SCH and periorbital hemorrhage as the first sign of systemic amyloid light-chain amyloidosis.
In patients with systemic disease such as multiple myeloma, which can be associated with amyloidosis, recurrent SCHs may occur even in the absence of prominent amyloid deposits.
The possible pathogenesis of these hemorrhages can be explained as amyloid deposition within the walls of the vessels, leading to increase in the fragility of the vessels. Contact lens-induced hemorrhages have been increasingly encountered in recent years as much as the other complications of contact lens wear.
SCH in contact lens wearers can be related to contact lenses themselves or to other factors independent of contact lens usage Figure 3. Devices used for lens insertion or removal or long fingernails can promote this kind of injury in contact lens wearers. The incidence of contact lens-related SCH was reported to be 5. Also, the connective tissue under the conjunctiva is still strong in young individuals, preventing the spread of hemorrhage.
Traumatic subconjunctival hemorrhage involving the nasal half of the bulbar conjunctiva caused by soft contact lens wear. It should not be forgotten that although SCH in contact lens users can be related to the contact lenses most of the time, other ocular or systemic factors must also be considered.
The contact lens should be inspected thoroughly, and recurrent hemorrhages should be accepted as a sign for further systemic evaluation.
Patients with hematologic disorders should not wear contact lenses. Many ocular and nonocular surgical procedures may prompt SCH by different mechanisms. SCH may appear at each step of ocular surgery, especially starting with anesthesia. Although it does not have any effect on postoperative visual status of the eye, the patient may remain cosmetically unsatisfied. There have been many reports suggesting that patients on anticoagulant or antiplatelet therapy did not show an increased rate of hemorrhagic complications during cataract surgery or local anesthesia, although some studies have reported that there was an increase in minor hemorrhagic complications in patients taking warfarin.
Patients on aspirin should continue taking the drug before cataract surgery and international normalized ratio INR should be checked in all patients on warfarin medication to maintain the therapeutic level. In that case, prolonged bleeding time was identified as the possible mechanism.
A case of subconjunctival ecchymosis appearing after extraction of maxillary teeth has been reported. Recurrent SCHs have been reported as the initial sign of anaplastic carcinoma of the lacrimal gland.
Although not a common presenting sign, ocular adnexal lymphoma can be an underlying condition of recurrent SCH. Systemic factors that may lead to SCH can be classified as systemic vascular diseases, sudden severe venous congestion, hematological dyscrasias, systemic trauma, acute febrile systemic diseases, drugs, carotid cavernous fistulas CCFs , menstruation, and delivery in newborns.
The fragility of conjunctival vessels, as well as every other vessel elsewhere in the body, increases with age and as a result of arteriosclerosis, systemic hypertension, and diabetes. A study by Pitts et al 47 demonstrated that blood pressure checked at initial presentation and 1 week and 4 weeks after first presentation was higher in patients presenting with SCH than healthy controls; therefore, the incidence of hypertension was higher in patients with SCH.
It is recommended that all patients with SCH have their systemic blood pressure checked. SCH may occur after sudden severe venous congestion to the head, such as in a Valsalva maneuver, whooping cough, vomiting, sneezing, weight lifting, crush injuries, or spontaneously without any apparent cause.
The patient should be examined by a pediatrician from the perspective of high suspicion of abuse in the case of unexplained isolated bilateral SCHs.
Asthmatic patients may face severe bilateral SCH at the peak of their fulminant attacks of severe asthma. A possible mechanism could be intrathoracic airway pressure rising to overcome airway obstruction, causing sudden congestion of blood into the superior vena cava.
Pathologies of the coagulation system, including the disorders associated with thrombocytopenia and platelet dysfunction, such as thrombocytopenic purpura, anemia, leukemia, splenic disorders, anticoagulant or antiplatelet therapy, and uremia, may cause bleeding in conjunctival vessels. Parmeggiani et al 60 conducted a study to determine whether FXIII Val34Leu polymorphism, thought to be a predisposing risk factor for primary intracerebral hemorrhages in a previous study, might increase the risk of SCH, and showed that frequency of FXIII-mutated allele was higher in patients with SCH than in controls.
An unusual bilateral massive spontaneous SCH can be an initial sign of acute lymphoblastic leukemia as a result of blood dyscrasia. Anticoagulant and antiplatelet therapies, including aspirin, dipyridamole, clopidogrel, warfarin, and dabigatran direct thrombin inhibitor , may prompt recurrent SCHs. It is important to take a detailed drug history to determine the usage of these drugs, as they may increase the risk of spontaneous or perioperative SCHs. Splinter SCHs may be seen in the upper fornix, due to fat emboli originating from fractures of long bones in remote injuries.
Petechial SCHs can be seen in febrile systemic infections, such as zoonosis tsutsugamushi disease, scrub typhus, leptospirosis , enteric fever, malaria, meningococcal septicemia, subacute bacterial endocarditis, scarlet fever, diphtheria, influenza, smallpox, and measles. In addition to anticoagulant and antiplatelet medication, there are some drugs reported in the literature related to SCH. It should be kept in mind that interferon therapy in chronic viral hepatitis patients may give rise to SCH, and retinopathy and antiviral therapy, including polyethylene gycolated interferon plus ribavirin, can cause SCH in addition to vascular ophthalmological side effects.
One of them was direct CCF presenting with sudden onset and pulsatile exophthalmos, SCH, ophthalmoplegia, and increased intraocular pressure.
Newborns may show SCH after normal vaginal delivery. In a study of healthy full-term newborns who had undergone an eye examination, the number of patients who showed SCH was reported as 50 1. Spontaneous SCHs may be seen in menstruation, whereas hemorrhages from the conjunctiva occur more frequently in these cases. An ophthalmologist, a general practitioner, or a physician may face patients with SCH many times in each step of daily clinical practice.
The key point is to decide whether further investigation is necessary or not. In most cases, SCHs do not require specific treatment, but the patient should be reassured that the hemorrhage will disperse in 2—3 weeks, with blood turning from red to brown and then to yellow Figure 4.
An island of yellow discoloration on the nasal part of the bulbar conjunctiva indicating absorption of the subconjunctival hemorrhage.
There is not any approved treatment to accelerate the resolution and absorption of SCH. The first treatment reported in the literature was air therapy. The report concluded that the subconjunctival injection of liposome-bound LMWH had a significant influence on facilitating SCH absorption in rabbits in comparison to only liposome and liposome-free form of LMWH. Failure to resolve hemorrhage in persistent or recurrent cases suggests a serious underlying cause.
A careful history is the most important step in identifying whether there is a serious underlying condition that may require more detailed examination and treatment.
A detailed history may provide clues to the underlying conditions. It is important to obtain a thorough medication, medical, and ocular history from patients presenting with SCH, including any possible trauma, ocular surgery, contact lens wear, drugs, and heritable conditions. First, a careful slit-lamp examination is essential to determine if there has been any trauma to the eye, and also to rule out any local ocular condition that can lead to SCH, as mentioned previously.
After excluding ocular factors, further systemic evaluation is necessary. Blood pressure should be checked routinely in all patients with SCH, particularly in older patients. In recurrent cases, a workup for bleeding disorders and hypocoagulable states is required.
The INR should be checked if the patient is taking warfarin. In conclusion, only recurrent or persistent SCH mandates further systemic evaluation, and no treatment is required unless it is associated with certain serious conditions. The authors have no conflicts of interest and no commercial interests in any products or services used in this study. National Center for Biotechnology Information , U. Journal List Clin Ophthalmol v. Clin Ophthalmol.
Published online Jun Bercin Tarlan 1 and Hayyam Kiratli 2. Author information Copyright and License information Disclaimer. This is an Open Access article which permits unrestricted noncommercial use, provided the original work is properly cited. This article has been cited by other articles in PMC. Abstract Subconjunctival hemorrhage is a benign disorder that is a common cause of acute ocular redness. Keywords: subconjunctival hemorrhage, contact lens, hypertension, red eye.
What is a subconjunctival hemorrhage? Open in a separate window. Figure 1. This patient with diffuse subconjunctival hemorrhage had uncontrolled hypertension. What are the causes of subconjunctival hemorrhage? Local trauma Various types of local injuries to the globe constitute the common cause of SCH, spanning from a minor trauma originating from a foreign body or eye rubbing to major traumas, such as blunt or penetrating injuries of the globe, which can cause SCH at all levels.
Orbital injuries SCH may develop 12—24 hours after the fracture of orbital bones and results from influent leakage of blood under the conjunctiva.
Bleeding Under the Conjunctiva (Subconjunctival Hemorrhage)
A subconjunctival hemorrhage sub-kun-JUNK-tih-vul HEM-uh-ruj occurs when a tiny blood vessel breaks just underneath the clear surface of your eye conjunctiva. The conjunctiva can't absorb blood very quickly, so the blood gets trapped. You may not even realize you have a subconjunctival hemorrhage until you look in the mirror and notice the white part of your eye is bright red. A subconjunctival hemorrhage often occurs without any obvious harm to your eye. Even a strong sneeze or cough can cause a blood vessel to break in the eye.
Subconjunctival bleeding , also known as subconjunctival hemorrhage , is bleeding from a small blood vessel over the whites of the eye. Causes can include coughing, vomiting, heavy lifting, and direct injury including that from wearing contact lenses. Generally no specific treatment is required and the condition improves in two to three weeks. A subconjunctival bleeding usually does not result in pain, although occasionally the affected eye may feel dry, rough, or scratchy.
Subconjunctival hemorrhage is a benign disorder that is a common cause of acute ocular redness. The major risk factors include trauma and contact lens usage in younger patients, whereas among the elderly, systemic vascular diseases such as hypertension, diabetes, and arteriosclerosis are more common. In patients in whom subconjunctival hemorrhage is recurrent or persistent, further evaluation, including workup for systemic hypertension, bleeding disorders, systemic and ocular malignancies, and drug side effects, is warranted. Subconjunctival hemorrhage SCH is a common benign condition of the eye that has characteristic features, such as the painless acute appearance of a sharply circumscribed redness of bleeding underneath the conjunctiva in the absence of discharge, and inflammation in contagious areas. It can vary from dot-blot hemorrhages to extensive areas of bleeding that render the underlying sclera invisible. The majority of cases are mostly considered to be idiopathic, since it is usually impossible and impractical to define the main cause of SCH. However, the clinician must have a systematic review scheme in mind, and major causes can be classified under ocular and systemic conditions, respectively.
What is a Subconjunctival Hemorrhage?
The transparent tissue that covers your eye is called the conjunctiva. Many tiny blood vessels are located in the conjunctiva and in the space between the conjunctiva and the underlying sclera, which is the white of your eye. In addition to covering the sclera, the conjunctiva also lines the insides of your eyelids. It contains many tiny glands that secrete fluid to protect and lubricate your eye. One of the small vessels can burst occasionally. Even a tiny amount of blood can spread out a lot in the narrow space. As the conjunctiva only covers the white of each eye, the central area of the eye the cornea is unaffected.