Definition
A.Subconjunctival hemorrhage presents as blood patches in the bulbar conjunctiva.
Incidence
A.Subconjunctival hemorrhage may be seen in adults after forceful exertion (coughing, sneezing, childbirth, strenuous lifting). The incidence is unknown secondary to many cases not being reported.
Pathogenesis
A.Subconjunctival hemorrhage occurs when the small blood vessels in the conjuncitva rupture from force or injury. When this occurs the blood leaks out from the vessel causing a red staining of the sclera. This may appear as a dark red spot on the white part of the eye. This disorder is believed to be secondary to increased intrathoracic pressure that may occur from forces such as pushing during labor and delivery, vomiting, excessive coughing, or with physical exertion.
Predisposing Factors
A.Local trauma.
B.Systemic hypertension (HTN).
C.Acute conjunctivitis.
D.Vaginal delivery.
E.Severe coughing.
F.Severe vomiting.
Common Complaints
A.Red-eyed appearance without pain.
Other Signs and Symptoms
A.Bright red blood in plane between the conjunctiva and sclera.
B.Usually unilateral.
C.Normal vision.
Subjective Data
A.Identify onset and duration of symptoms.
B.Elicit information about trauma to the eye; is it due to severe coughing or vomiting?
C.Identify history of conjunctivitis or HTN.
D.Review medications for anticoagulant or antiplatelet use, including over-the-counter (OTC) herbal products.
Physical Examination
A.Check temperature, pulse, respirations, and blood pressure (rule out HTN).
B.Inspect:
1.Observe eyes.
2.Inspect ears, nose, and mouth.
3.Inspect skin for bruises, petechiae, or other trauma.
4.Assess for signs of trauma or abuse. Blood in the anterior chamber (hyphema) can result from injury or abuse.
C.Percuss abdomen for hepatosplenomegaly.
D.Other physical examination components are dependent on etiology.
Diagnostic Tests
A.Perform visual screening.
B.Test extraocular movements (EOMs) and peripheral vision.
Differential Diagnoses
A.Subconjunctival hemorrhage.
B.Systemic HTN.
C.Blood dyscrasia.
D.Trauma to eye.
E.Conjunctivitis.
F.Hyphema.
G.Abuse.
Plan
A.General interventions:
1.Reassure the patient that the hemorrhage is not damaging to the eye or vision, and that the blood reabsorbs on its own over several weeks.
B.Patient teaching:
1.Educate the patient regarding safety to prevent trauma to the eye.
C.Pharmaceutical therapy:
1.None.
Follow-Up
A.If subconjunctival hemorrhage recurs, evaluate the patient further for systemic HTN or blood dyscrasia.
Consultation/Referral
A.Consult or refer the patient to a physician if hyphema is noted, if glaucoma is suspected, or if the patient has additional eye injuries.
Individual Considerations
A.Adults:
1.Always measure blood pressure to rule out systemic HTN.
B.Geriatrics:
1.Research indicated that the common causes for elderly subconjunctival hemorrhage were HTN and use of aspirin. It occurred most often with geriatric males and was primarily observed in the nasal region of the eye.
2.Always measure blood pressure to rule out systemic HTN.
3.Consider evaluation for blood dyscrasia.
4.Assess clotting times if patient is taking warfarin (Coumadin) or other products interfering with coagulation.