Subconjunctival Hemorrhage (Bleeding in the Eye)

Coughing, straining, sneezing, and vomiting can cause a subconjunctival hemorrhage.

A subconjunctival hemorrhage appears as a bright red eye or a red patch overlying the white part of the eye (sclera).

• The conjunctiva is the thin transparent membrane that covers both the white part of the eye ( sclera) and the back side of the eyelids.
• When blood from a leaking broken blood vessel is trapped between the conjunctiva and the sclera, it is called a subconjunctival hemorrhage.
• The conjunctiva contains many small blood vessels. The source of the bleeding is usually from one of these conjunctival vessels.

Most subconjunctival hemorrhages are spontaneous without an obvious cause. They're typically painless. Often, you discover a subconjunctival hemorrhage on awakening and looking in the mirror, or another person might be the first to notice a red spot on your eye.

In approximately half of the subconjunctival hemorrhages, the cause is never found. These cases tend to be painless, and they clear on their own within a couple of weeks.

A subconjunctival hemorrhage can be associated with a sudden increase in back pressure from the veins, which can occur with

• sneezing,
• coughing,
• straining (for example, Valsalva maneuver when lifting heavy objects or forcing bowel movement), and
• vomiting.

Direct trauma to the eye can also result in a broken blood vessel:

• Vigorous eye rubbing
• Inadvertent trauma to a vessel during contact lens placement or removal
• Injury from a foreign object striking or rubbing against the eye
• Postoperative bleeding following eye surgery (for example, cataract surgery or glaucoma surgery) or following administration of ocular anesthesia (for example, a retrobulbar injection of anesthetic)
• In any trauma, the subconjunctival hemorrhage may be associated with more serious problems such as intraocular bleeding or a ruptured globe (puncture or laceration of the wall of the eye). Even fractured bones of the orbit and base of the skull can result in bleeding that eventually spreads into the subconjunctival space.

Sometimes a systemic medical condition can cause a subconjunctival hemorrhage, such as

• high blood pressure, which can cause vessels to burst or leak;
• diabetes;
• arteriosclerosis, which is believed to make vessels more fragile;
• bleeding disorders (for example, clotting disorders or vitamin K deficiency); and
• medications such as blood thinners (for example, warfarin).

Less commonly, subconjunctival hemorrhage can result from a severe eye infection (for example, acute hemorrhagic conjunctivitis or measles). Growths in or on the eye (such as benign tumors or cancers), as well as head and orbital conditions (like compression from internal bleeding or masses) can also result in enough back pressure on the eyes' circulation to result in a subconjunctival hemorrhage.

Most of the time, no pain is associated with a subconjunctival hemorrhage, although some people say the eye feels full or heavy. Depending on the cause, it may be tender to the touch.

• As the hemorrhage resolves, some people may experience mild irritation or a sense of awareness of the eye.

• The bright red eye is often dramatic in appearance and can be scary. Usually, it appears as a bright red patch, but on occasion, the entire white part of the eye is covered by the blood. The blood stops short of the corneal limbus (the rim around the clear cornea).
• Rarely, blood may ooze through the conjunctiva, resulting in the appearance of pink or red tears. Although this may seem alarming, the oozing itself is not a concern. The underlying cause of the hemorrhage, on the other hand, may be of serious concern if it is associated with a vision- or life-threatening condition.
• The hemorrhage may appear to enlarge within the first day or two as the blood spreads initially, but then it will typically decrease in size as the blood is reabsorbed, just as a bruise eventually goes away. You may notice the effect of gravity as the blood typically clears from the top first. The last remnants of blood may appear yellowish-orange before completely resolving.
• Episcleritis can also appear as an isolated patch of redness; however, upon closer inspection, this condition is a patch of dilated inflamed vessels under the conjunctiva rather than blood.

Seek care from an ophthalmologist or emergency medicine doctor immediately if you have a subconjunctival hemorrhage associated with

• eye injury,
• pain,
• changes in vision (blurry vision or double vision),
• history of a bleeding disorder, or
• history of high blood pressure.

If a subconjunctival hemorrhage does not show signs of clearing within a few days, if you have had multiple subconjunctival hemorrhages, or if you have other symptoms of bleeding (including easy bruising, bleeding gums, or blood in the stools or urine), you should seek medical attention to look for an underlying bleeding or clotting disorder.

• Is there any sign of damage to the eye?
• Are there signs pointing to the underlying cause of this subconjunctival hemorrhage, and is there the risk of vision loss from the underlying cause?
• How can I prevent future subconjunctival hemorrhages?

Your eye doctor or health care provider takes a concise history of the events prior to the subconjunctival hemorrhage, along with your past ocular and medical health history. An eye examination with a slit lamp (a microscope used in ophthalmology for examining the eye) is used to assess the extent of the bleeding and to find signs of a possible underlying cause. Your blood pressure may also be checked if hypertension is a suspected cause.

If trauma was the cause, additional testing will include a careful examination to look for signs of ocular trauma (such as corneal injury or hyphema), possible dilated eye exam, and possible imaging such as a CT scan to rule out a ruptured globe.

Usually, no treatment is needed. Over-the-counter artificial tears can be applied to the eye if mild irritation is present.

Do not try using redness reliever (decongestant) eyedrops. They are designed to temporarily constrict blood vessels in red eyes due to dilated vessels (for example, in allergic conjunctivitis). However, they do not clear away blood in the subconjunctival space. Furthermore, many redness reliever drops have side effects, including dry eye, medicamentosa keratitis, and a rebound dilation of vessels when they wear off.

Usually, no treatment is required for an isolated subconjunctival hemorrhage. Treatment is directed at the underlying cause (for example, clotting disorders, high blood pressure, or injury) when present.

A spontaneous subconjunctival hemorrhage that is not associated with disease or injury typically clears by itself within one to two weeks. Usually, recovery is complete and without any long-term problems, similar to a mild bruise under the skin. Like a bruise, a subconjunctival hemorrhage changes colors (often red to orange to yellow) as it heals.