Subconjunctival Hemorrhage

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Article initiated by:

J. Louis Pecora, MD

All contributors:

J. Louis Pecora, MD, Vatinee Y. Bunya, MD, MSCE, Maria A. Woodward, MD, Joobin Khadamy, MD, FEBO, Christina Moon, M.D., Colleen Halfpenny, M.D., Brian M. Smith D.O., Ravi Patel, MD, MBA

Assigned editor:

Ravi Patel, MD, MBA

Review:

Assigned status Update Pending

 by Christina Moon, M.D. on November 9, 2023.

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Contributing Editors:	add

Subconjunctival hemorrhage or Hyposphagma that caused corneal dellen in a patient on warfarin. (Courtesy of J. Khadamy)

Disease

Subconjunctival hemorrhage (SCH) is a common cause of red eye that does not impact visual acuity. This benign, generally painless, condition refers to the rupture of a blood vessel in the subconjunctival space located between the superficial conjunctiva and the tenon’s capsule. This appears as an often-flat area of bleeding under the conjunctiva. If severe, it can appear bullous.

Key words

1. Subconjunctival hemorrhage
2. Red Eye
3. Trauma
4. Spontaneous
5. Anticoagulants

Epidemiology

Subconjunctival hemorrhage is a fairly common cause of red eye. This disease entity accounts for 3% of all patients who visit outpatient departments or emergency rooms for ophthalmic concerns and 10.1% of the elderly over 65 years of age. A study of 8726 patients in Japan presenting with the complaint of red eye were evaluated and found 225 or 2.9% of patients had subconjunctival hemorrhage. Fukuyama et al, in a 1990 overview of SCH causation, noted no significant predilection regarding age or gender to SC susceptibility.

Pathophysiology

There are a few mechanisms that have been reported regarding the development of SCH. There is damage of the conjunctival vessels which leads to hemorrhage in the space between Tenon's capsule and the conjunctiva. In younger individuals, the bleeding rarely extends under the entire conjunctiva, however in older adults, the elastic and connective tissues between the Tenon's capsule and conjunctival is more fragile allowing for easier spread of SCH.

The cause of the vascular damage may differ depending on the associated risk factors of the patient which will be described further below. The most common cause in younger patients would be local ocular trauma causing the vascular disruption versus older patients are more likely to be associated with systemic vascular diseases like hypertension and diabetes, iatrogenic after ocular surgery, or idiopathic. In patients with local or systemic amyloidosis, amyloid deposition in the blood vessel walls makes the subconjunctival blood vessels more fragile. Damage to the conjunctival vessels may occur from the bulging of bullous conjunctiva in conjunctivochalasis and the degeneration of fibrous connections between the conunctiva and Tenon's capsule.

Traumatic SCH has been shown to be smaller in extent when compared to SCH related to hypertension, diabetes, or idiopathic SCH. Its location is more common in the inferior conjunctiva than superior conjunctiva. In patients with SCH due to trauma or diabetes, the temporal areas were affected more often than the nasal areas.

Risk Factors

The first study on risk factors for SCH in a large series of consecutive patients was reported by Fukuyama et al, who demonstrated that the most common causes of SCH from 1987 to 1988 were minor local trauma, systemic hypertension, and acute conjunctivitis. A later study by Mimura et al showed that the number of patients with contact-lens-induced SCH has increased, while the patients with acute hemorrhagic conjunctivitis has decreased when compared to the prior study by Fukuyama et al in 1987-1988. Younger patients were more likely to develop SCH due to the risk of trauma. Mimura et al concluded SCH of unknown etiology may be a predictor of the future development of hypertension in older patients.

Idiopathic

The cause of SCH often remains unknown in up to 40% of cases . Fukuyama et al showed many cases of SCH had no identifiable risk factors by history and no identifiable trauma.

Ocular or Orbital Trauma

Minor local trauma is the most common cause of SCH among young patients. Traumatic causes of SCH can blunt injury, corneal burns, foreign bodies, episodes of eye rubbing, and non-accidental traumatic asphyxia syndrome.When surgery is excluded, 83% of SCH in children was due to trauma. Orbital trauma can cause either direct damage to subconjunctival blood vessels or blood can to extravasate from the orbit into the subconjunctival space.

Iatrogenic

Ocular surgery is a common cause of subconjunctival hemorrhage. Iatrogenic damage to conjunctival vasculature has been reported after many types of ocular surgery. It has been seen following intravitreal injections of anti-VEGF agents.

Age

Fukuyama et al did not find an age predilection for SCH. Other studies have found the number of patients with SCH increased over the age of 50. The increased prevalence of hypertension over the age of 50, which is also a risk factor for SCH, is considered a reason for this finding. Other systemic diseases like hyperlipidemia, diabetes mellitus, and complications of anticoagulant therapy increase in age.

Systemic Hypertension

Systemic hypertension was a predominant cause of SCH in patients older than 50 years old. A study measuring hemodynamic status at the time of intravitreal injection of ranizumab demonstrated patients with elevated systolic blood pressure, MAP, and pulse rate form baseline at the time of injection were significantly related to the development of SCH.

Diabetes Mellitus

Diabetes mellitus is a systemic vascular disease which causes microvascular damage leading to more fragile vessels in the conjunctiva and has been associated with subconjunctival hemorrhage in older adults.

Long term Corticosteroid Usage

Patients with chronic uveitis or long term use of topical corticosteroids have an increased prevalence of spontaneous or minimal trauma induced SCH. Steroid induced vascular fragility may lead to this finding. Prednisolone acetate 1% was the most common topical steroid seen in 71% of patients with topical corticosteroid related SCH.

Systemic Anticoagulants

The use of systemic anticoagulants has been associated with subconjunctival hemorrhage. Patients presenting with SCH on warfarin should have bloodwork performed to make sure INR is not in supra therapeutic range. A 2010 study by Kobayashi showed data demonstrating a possible relationship between post-operative SCH and the use of aspirin or warfarin. He had patients either maintain their regular dosage of aspirin or warfarin or stop their anticoagulants one week prior to cataract surgery. The group which remained on the anticoagulants had 10% more patients experience SCH after cataract surgery.

Valsalva Maneuvers

Chronic coughing, sneezing, constipation, weight lifting, and other activities that result in a valsalva maneuver has been reported as a risk factor for developing SCH. The sudden increase in venous pressure can damage the fragile conjunctival vessels and lead to SCH. In children, 1% of SCH not related to trauma was reported to be due to coughing or choking.

Acute Inflammation of Conjunctiva

SCH can be seen in relation to conjunctivitis. Acute hemorrhage conjunctivitis, primarily caused by enterovirus 70 was a common cause of SCH during the summertime. This was a more common cause of SCH decades ago as a more recent study in 2010 demonstrated only 1 patient with SCH caused by acute hemorrhagic conjunctivitis. In children, Kawasaki disease is associated with severe conjunctivitis that may lead to subconjunctival hemorrhage and has other important systemic implications.

Conjunctivochalasis

Redundant, hypermobile conjunctival tissue has been associated with the occurrence and extent of SCH, especially after cataract surgery. The extent of clock hour involvement of SCH was larger in patients who have undergone cataract surgery than those who have cataracts. The hypermobile conjunctival tissue may lead to mechanical damage to the conjunctival vessels. The elevation of conjunctiva and impairment of ocular surface wetting by SCH is demonstrated by lower Schirmer's test I values in patients with spontaneous SCH when compared to controls without SCH.

Ocular Amyloidosis

Recurrent SCH has been reported as a presenting symptom in ocular amyloidosis which was proven histologically on conjunctival biopsy. The deposition of amyloid in the blood vessel walls is thought to make the conjunctival vessels more fragile and susceptible to rupture leasing to SCH.

Conjunctival and Adnexal Tumors

Subconjunctival hemorrhage has been described as a presenting symptoms for conjunctival and adnexal tumors. Recurrent subconjunctival hemorrhage has been shown to be associated with various conjunctival tumors such as cavernous hemangioma of the conjunctiva, Kaposi's sarcoma, and lymphangioma. Hicks et al. reported a case of persistent and recurrent SCH being the presenting symptom of ocular adnexal low grade B-Cell Lymphoma. Tumors cause neovascularization and may invade local vasculature leading to SCH.

Blood Dyscrasia /Bleeding Disorders

Blood disorders and dyscrasia such as Von Willebrand disease, immune thrombocytopenia purpura, leukemia, and severe hepatic disease have been associated with SCH due to either increased clotting and occlusion of small blood vessels like the conjunctival vessels or loss of coagulation factors.

Ocular Vicarious Menstruation

A rare cause of SCH when patients develop recurrent SCH consistently every month in association with menstruation.

Child Abuse

In infants and children, bilateral SCH may be isolated ocular findings of non-accidental trauma. SCH has been reported as a sentinel sign of abusive injury. SCH associated with facial petechiae is often associated with other lid, skin, or retinal findings which may be a part of traumatic asphyxia syndrome due to severe, prolonged compression of the child's chest and upper abdomen. Deridder et al. reported 14 cases of children with SCH who were later diagnosed with child abuse.

Post Vaccination

A case of bilateral SCH has been reported following H1n1 vaccination with a negative laboratory workup for bleeding disorder and negative history of trauma, valsalva maneuvers, and contact lens usage. The authors proposed a subclinical disseminated intravascular coagulation related to thrombocytopenia caused by influenza vaccines.

Contact Lens Usage

Contact lens usage has been recognized as a risk factor for developing SCH. The presence of conjunctivochalasis and pinguecula were shown to be further risk factors for contact lens associated SCH.

Management

Subconjunctival hemorrhage is a self-limiting condition that will resolve over the course of 1-4 weeks depending on its severity and extent. The area may become pink, orange, yellow, or black if the blood remains long enough before clearing. Permanent blood staining of the conjunctiva and sclera can occur rarely. Supportive treatment with frequent topical lubrication may help patients symptoms of discomfort due to disruption in tear film.

In patients with recurrent SCH, a thorough history and assessment is important because SCH can be a presenting sign of more serious medical diseases and malignancy including and not limited to what was referenced above. Consider a laboratory and hematologic workup when medically necessary and when patients are on anticoagulants with recurrent SCH.

There is no approved treatment to accelerate the resolution and absorption of SCH. Studies have been done in rabbit models of SCH where liposome-bound LMWH appears to enhance the SCH absorption rate. Some studies had looked at preventing SCH have found that both dilute brimonidine and oxymetazoline preoperatively may decrease SCH following ocular procedures likely due to their vasoconstrictive effect, however more data is needed on this.

There is no indication for the surgical treatment of subconjunctival hemorrhage. In the setting of ocular trauma, a 360-degree subconjunctival hemorrhage may be a suggestive sign of occult globe rupture in which Zone II and III injuries cannot be ruled out due to decreased visualization of the sclera from the SCH. A CT scan of the orbits may aid in diagnosis of occult globe rupture. Consider a globe exploration if there is concern and findings are unequivocal.