para>In older adults, the area of SCH will be more widespread across the sclera (3). Elastic and connective tissues are more fragile with age, and underlying conditions such as HTN and diabetes may contribute.
DIFFERENTIAL DIAGNOSIS
- Viral, bacterial, allergic, or chemical conjunctivitis (enterovirus and coxsackie virus most common) (1)[B]
- Foreign body to conjunctiva
- Penetrating trauma
- Acute angle glaucoma
- Iritis
- Recent ocular surgery
- Contact lens induced
- Child abuse (particularly if bilateral in an infant or toddler) (1)
- May occur in newborns after vaginal delivery
DIAGNOSTIC TESTS & INTERPRETATION
- Typically no testing is indicated; SCH is a clinical diagnosis. If a foreign body is suspected, perform a fluorescein exam.
- Fluorescein exam of a patient with a SCH should show no uptake of staining (5)[C].
- If an orbital fracture is suspected, may obtain plain facial bone films or CT scan (4)[C]
Follow-Up Tests & Special Considerations
If history and physical exam suggest a bleeding etiology (5)[C]
ALERT
If a penetrating injury is suspected, may obtain a CT scan of the orbits but not an MRI (if object may be metal) (4)[C]
TREATMENT
GENERAL MEASURES
- Control BP.
- Control blood glucose.
- Control INR.
- Wear protective eyewear.
MEDICATION
No prescription medications are useful in treatment of SCH.
ISSUES FOR REFERRAL
- If a penetrating eye injury is suspected, send the patient to the emergency room for emergent ophthalmology consultation.
- If the patient complains of any decreased visual acuity or visual disturbances, refer to an ophthalmologist as soon as possible.
- If there is no resolution of SCH within 2 weeks, patient may need referral to an ophthalmologist.
ADDITIONAL THERAPIES
- Warm compresses
- Eye lubricants (5)[C]
ONGOING CARE
FOLLOW-UP RECOMMENDATIONS
- Follow up only if the area does not resolve within 2 weeks.
- If SCH recurs, then work up patient for systemic sources such as bleeding disorders (5)[C].
PATIENT EDUCATION
- Reassurance of the self-limited nature of the problem and typical time frame for resolution
- Education to return to clinic if the area does not heal or recurs.
- Correct cleaning and maintenance of contact lenses.
- Instructions on causes, self-care, and warning signs are available at PubMed Health: Subconjunctival Hemorrhage at www.ncbi.nlm.nih.gov/pubmedhealth/PMH0002583/.
PROGNOSIS
Excellent
COMPLICATIONS
Rare
REFERENCES
11 Tarlan B, Kiratli H. Subconjunctival hemorrhage: risk factors and potential indicators. Clin Ophthalmol. 2013;7:1163 " 1170.22 Mimura T, Usui T, Yamagami S, et al. Recent causes of subconjunctival hemorrhage. Ophthalmologica. 2010;224(3):133 " 137.33 Mimura T, Yamagami S, Mori M, et al. Contact lens-induced subconjunctival hemorrhage. Am J Ophthalmol. 2010;150(5):656 " 665.e1.44 Wirbelauer C. Management of the red eye for the primary care physician. Am J Med. 2006;119(4):302 " 306.55 Cronau H, Kankanala RR, Mauger T. Diagnosis and management of red eye in primary care. Am Fam Physician. 2010;81(2):137 " 144.
ADDITIONAL READING
- Mimura T, Usui T, Yamagami S, et al. Subconjunctival hemorrhage and conjunctivochalasis. Ophthalmology. 2009;116(10):1880 " 1886.
- Mimura T, Yamagami S, Usui T, et al. Location and extent of subconjunctival hemorrhage. Ophthalmologica. 2010;224(2):90 " 95.
CODES
ICD10
- H11.30 Conjunctival hemorrhage, unspecified eye
- H11.31 Conjunctival hemorrhage, right eye
- H11.32 Conjunctival hemorrhage, left eye
- H11.33 Conjunctival hemorrhage, bilateral
ICD9
372.72 Conjunctival hemorrhage
SNOMED
- 78768009 Subconjunctival hemorrhage (disorder)
- 206249007 Subconjunctival hemorrhage due to birth trauma
CLINICAL PEARLS
- SCH is a clinical diagnosis. The condition is typically asymptomatic and will resolve spontaneously in 1 to 2 weeks.
- Always check BP in a patient with SCH, as HTN is a risk factor.
- Indications for immediate referral to an ophthalmologist are eye pain, change in vision, lack of pupil reactivity, and/or penetrating eye trauma.
- Reassurance and comfort measures are key.
- Contact lens wearers should not wear contacts until the SCH resolves completely.