Subconjunctival hemorrhage (SCH) is bleeding underneath the conjunctiva caused by breaking of small blood vessels. It typically appears as a sharply defined red area in one eye and is usually painless. SCH is common in older individuals with conditions like hypertension and after eye surgeries or injuries. While most cases resolve on their own within 1-2 weeks, persistent or recurrent SCH may indicate a serious underlying cause and require further investigation. Management involves treating any underlying medical issues, using ice packs, and artificial tears for comfort.

1. SUBCONJUNCTIVAL
HAEMORRHAGE
Brian Mwaura Njoroge.

2. Definition.
• 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.
• Histologically, SCH can be defined as hemorrhage between the
conjunctiva and episclera, and the blood elements are found in the
substantia propria of the conjunctiva when a sub conjunctival vessel
breaks.

3. Etiology.
• Typically seen in older individuals, over 50 years due to hypertension,
diabetes mellitus, hyperlipidemia and anticoagulant use.
• More prevalent in young males most likely related to performing
heavy work and tendency to do more aggressive activities.
• Differentiated into two categories: traumatic vs spontaneous.
• Traumatic SCH is more likely to remain localized around the site of
impact compared to diffuse SCH-associated systemic vascular
disorders.

4. • Traumatic causes include:
• Foreign body penetration.
• Eye rubbing.
• Orbital fracture- typically occur in 12-24hours after fracture.
• Base of skull fractures such as basilar fracture present with SCH after 24 hrs. or more after
injury.
• Contact lenses use.
• Ocular surgery- cataract surgery refractive and local anaesthesia like sub Tenon injections
can potentiate SCH especially in patients on anticoagulant therapy.
• Conjunctival tumors.
• Ocular amyloidosis.
• Ocular adnexal tumors-Recurrent SCHs have been reported as the initial sign of anaplastic
carcinoma of the lacrimal gland.

5. • Spontaneous causes include:
• Traumatic asphyxia syndrome which is caused by prolonged compression
of a child's upper abdomen and chest can cause sudden severe venous
congestion.
• Arteriosclerosis.
• Systemic hypertension.
• Diabetes.
• Hematological dyscrasias such as thrombocytopenia and TTP.
• Anticoagulant and antiplatelet therapy aspirin and warfarin use.
• Emboli such as fat emboli from long bone fracture may lead to splinter
hemorrhage in upper fornix

6. Pathophysiology.
• Sub conjunctival hemorrhage results from bleeding of the conjunctival or episclera
blood vessels and subsequently leaks into the sub conjunctival space.
• Blood vessels can wear and tear over time. The elastic and connective tissues become
fragile with age and underlying comorbidities which can result in the ease of spread of
the hemorrhage in the elderly.
• Traumatic SCH is more localized to the site of impact compared to spontaneous.
• There is a predilection for SCH to develop on the temporal aspect of the eye since the
bulbar conjunctiva of the temporal aspect is larger than the nasal aspect.
• Other reasons include increased incidence of conjunctivochalasis, protection of the
nose on the nasal aspect, and more difficulty detecting projectiles on the temporal
aspect.
• The inferior aspect was noted to have increased incidence of SCH compared to superior
likely to blood gravitating downwards after insult.

7. Clinical presentation.
• Typically present with red eye and patient may not be aware.
• No visual disturbances.
• No discharge.
• Usually asymptomatic but a momentary sharp pain or a snapping or popping
sensation is sometimes felt precipitated by cough, sneeze or vomiting.

10. Investigations.
• Slit lump to check for local causes.
• Others will be guided by history.
• Full blood count
• Clotting studies.- INR, PT APPT
• Biopsy.
• Hba1c.

11. Management.
• Manage the underlying cause.
• Typically resolve within 1- 2 weeks. Thus reassure patient.
• Ice packs and artificial tears can be utilized to minimize tissue swelling and
provide some relief of discomfort respectively.
• Dilute brimonidine and oxymetazoline has been indicated to improve patient
comfort and decrease the incidence of SCH after intravitreal injections.
• Usage for tissue plasminogen activator alongside its use in vitreous, anterior
chamber, and glaucoma filter bleb to induce the clearance of fibrin clots.
• Failure to resolve hemorrhage in persistent or recurrent cases suggests a serious
underlying cause.

12. References.
• https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3702240/
• https://www.ncbi.nlm.nih.gov/books/NBK551666/
• John F. Salmon (2020). Kanski’s clinical ophthalmology (9th ed.).
Elsevier Limited.