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CLINICAL
Exploring the different causes of this condition
Subconjunctival haemorrhages
Not all of them are benign
Leonid Skorin Jr, OD, DO, FAAO, FAOCO
Patients presenting with a subconjunctival haemorrhage are a common
occurrence in every ophthalmic practice. In one study, 2.9% of patients
who presented to the outpatient eye clinics and hospitals of a large
medical university system over one year were diagnosed with this
condition . This study also found that there may be different causes for
subconjunctival haemorrhages, with minor local trauma being the most
frequent cause in all age groups . Systemic hypertension was noted
predominantly in those over 50 years .
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1
1
Patients with subconjunctival haemorrhages often present with focal or diffuse
areas of blood under the conjunctiva and
without frank pain but possible irritation
and usually no vision loss2,3. The haemorrhage may obscure only a small sector of
the underlying sclera or involve the entire
visible conjunctiva3. If the haemorrhage is
located superiorly on the conjunctiva, it is
not uncommon that with gravitational
forces, the blood will migrate downward
and make it appear as if the haemorrhage is
enlarging3. Initially, the haemorrhage is
bright red, but the colour changes to a
yellowish green, like a bruise, as it
resolves2,4. In those cases when the haemorrhage involves the perilimbal conjunctiva,
blood breakdown products can be seen in
the anterior peripheral corneal stroma as a
greenish discoloration4. The borders of
the haemorrhage may be distinct or
feathered4. In severe cases, when there is a
larger accumulation of blood in the subconjunctival space, the conjunctiva may
become elevated and redundant, and
protrude or prolapse through the palpebral
fissure4.
Trauma
Trauma, even relatively minor trauma to the
globe, such as rubbing one’s eye too hard,
may cause a subconjunctival haemorrhage1.
Often, detailed questioning by the clinician
will make the patient remember the
incident of such minor trauma to the eye.
The frequency of haemorrhage from local
trauma is increased in the Summer months
when people tend to be more active1.
Close inspection of the globe and the
area in question with biomicroscopy is
recommended to rule out a deeper or more
extensive injury, which may be concealed by
the blood4. In cases of more extensive injury,
consider the possibility of blow-out fracture
when
subconjunctival
and
eyelid
hematomas develop after a blunt injury to
the orbit5.
Case 1, Figure 1
A 60-year old man was struck by a fist in his
left eye during an altercation. He had an
extensive subconjunctival haemorrhage,
periorbital oedema and ecchymosis.
Extraocular motility was restricted in all
fields of gaze. A CT-scan of the orbits
identified an orbital floor fracture.
Various surgeries can cause post-surgical
traumatic subconjunctival haemorrhages.
These would include any surgery of the eye
or its adnexa. Even LASIK surgery has been
found to result in such haemorrhages2. Birth
trauma often causes a subconjunctival
haemorrhage in newborns2.
Case 2, Figure 2
A child with eyelid ecchymosis and subconjunctival haemorrhage after surgical
excision of chalazion.
Differential diagnosis
Most subconjunctival haemorrhages are
benign and are the result of innocuous
causes. A thorough patient history needs
to be taken to help guide the clinician, if
a more ominous entity for the subconjunctival haemorrhage is suspected.
Figure 2
Case 3, Figure 3
About the author
Dr Leonid Skorin Jr is in
group practice at the
Albert Lea Eye Clinic,
Mayo Health System,
Minnesota, USA
32 | January 27 | 2006 OT
Figure 1
An 80-year old woman underwent
unremarkable phacoemulsification cataract
extraction. One day post-operatively, she
presented with a subconjunctival haemorrhage involving the lower two-thirds of
the globe. Her vision was slightly
diminished, but this was attributed to postoperative corneal oedema and not to the
haemorrhage. No hyphaema was present.
In older children, such haemorrhages,
especially if they are present bilaterally, may
be a sign of child abuse6.
CLINICAL
Exploring different causes of this condition
Figure 3
Figure 5
Case 4, Figure 4
Case 5, Figure 5
Bleeding disorders
A young boy was seen in the emergency
department of a hospital for a fractured
humerus. Bilateral subconjunctival haemorrhages were also identified during the
examination. No retinal haemorrhages were
present. The child was referred to Children’s
Services for suspected child abuse.
A 39-year old woman tried to asphyxiate
herself by wrapping a cord tightly
around her neck. The suicide attempt
was unsuccessful. She was examined in a
psychiatric facility. Although she had
prominent subconjunctival haemorrhages,
there were no corresponding retinal
haemorrhages. Her visual acuity was
unaffected.
Other physical activity such as dancing,
weight lifting and even inverted positioning
have been known to cause subconjunctival
haemorrhages9,10.
Blood clotting disorders are associated with
multiple conditions, such as liver disease,
cancer and genetic problems11. Severe
hepatic diseases are associated with
subconjunctival haemorrhage, as are retinal
haemorrhages12.
Pancytopenia, which is the pronounced
reduction in the number of erythrocytes, all
types of white blood cells and the blood
platelets in the circulating blood, can cause
subconjunctival haemorrhage1. This type of
bleeding can also be found in patients with
thrombocytopenia, which is a condition
where there is an abnormally small number
of platelets in the circulating blood13.
Around 1-2% of the population (US) has
von Willebrand’s disease – an autosomal
dominant trait expressing a deficiency in
the coagulation cascade and possibly a
morphologic defect of platelets14. Patients
affected by this condition have a tendency
to bleed primarily from mucous
membranes, such as the conjunctiva and
the lining of the nose, which can cause
epistaxis (nosebleeds). They also have
increased bleeding after trauma or surgery2.
Disseminated intravascular coagulation
(DIC) is a complex acquired syndrome
where intravascular thrombi form and large
numbers of platelets are consumed, resulting in thrombocytopenia15. Choroidal
changes are seen most frequently with the
syndrome but subretinal, retinal, preretinal
and vitreous haemorrhage, haemorrhages
into the iris and anterior chamber and
conjunctival haemorrhages can all be
observed. If these are seen in a patient with
DIC, they are usually associated with
terminal uraemia and septicaemia15.
Valsalva’s manoeuvre
Valsalva’s manoeuvre is a rapid rise in
intrathoracic
(abdominal)
pressure,
especially against a closed glottis. The
pathophysiology of this process occurs
because the veins above the heart have no
valves. A rapid rise in the abdominal
pressure induces a rapid rise in the
intravenous pressure, and various vessels
inside or around the eye may rupture7.
Various straining activities such as heavy
lifting, coughing, vomiting, blowing
balloons and straining on a stool if constipated frequently lead to subconjunctival
haemorrhages1,7,8.
Asphyxiation also causes the neck vessels
to be compressed, with a sudden increase in
venous pressure and subsequent rupture of
the delicate subconjunctival vessels5. Severe
traumatic asphyxia may produce ocular
proptosis and blue discolouration of the
eyelids, face and neck, in addition to
extensive subconjunctival haemorrhages.
Systemic diseases
Systemic hypertension is a very common
cause of subconjunctival haemorrhages,
especially in those over 50 years1. This type
of spontaneous haemorrhaging may be the
first sign of hypertension1,4. Patients with
raised subconjunctival haemorrhages have
been shown to have an overall higher
systolic blood pressure2. Therefore, it
is recommended that the blood pressure
should be checked in all patients
with spontaneous subconjunctival haemorrhage2,4.
Other systemic diseases associated with
subconjunctival haemorrhage include
diabetes mellitus and hyperthyroidism1.
Conjunctival conditions
Figure 4
Tumours such as hemangioma or
melanoma can cause a secondary subconjunctival haemorrhage that may obscure
the tumour. Consider this possibility if the
haemorrhage does not resolve within two
weeks, or if it recurs in the same location2.
Primary
conjunctival
amyloidosis,
Kawasaki disease, which is a childhood
disease characterised by an exanthemous
33 | January 27 | 2006 OT
CLINICAL
Exploring different causes of this condition
eruption and multisystem involvement, and
any of the acute conjunctivides can all result
in subconjunctival haemorrhages1,13,16,17. Both
viral and bacterial infections may cause
small patches of haemorrhage known as
‘petechial haemorrhages’.
Case 6, Figure 6
A 47-year old man with a follicular conjunctivtis and preauricular adenopathy
developed a subconjunctival haemorrhage.
He had a watery discharge from both eyes.
He was suspected to have an adenoviral
infection, which is the leading cause of viral
conjunctivitis and is responsible for 5-20%
of all cases of acute conjunctivitis18.
Medication
Any medication that can inhibit coagulation
can cause subconjunctival haemorrhage.
This includes the non-steroidal anti-inflammatory drugs, along with aspirin and the
anticoagulants such as heparin or warfarin2.
A direct metabolic relationship has been
established between ingestion of a large
amount of aspirin and presentation of
bilateral subconjunctival haemorrhages19.
vitamins, such as vitamin E (tocopherol) can
also cause bleeding, especially in individuals
on anticoagulant medications.
Clinical evaluation
For all patients presenting with a subconjunctival haemorrhage, conduct a thorough
review of their history. In many instances,
this history will disclose the underlying
cause of the haemorrhage.
A blood pressure measurement should be
performed on all these patients1,2. In patients
with recurrent haemorrhages, laboratory
tests such as Prothrombin Time (PT),
Activated Partial Thromboplastin Time
(APTT) and Complete Blood Count (CBC)
with platelets should be ordered to rule out
serious systemic diseases2.
When ordering a CBC, the laboratory will
include values of the patients’ white blood
cells (WBCs), red blood cells (RBCs)
haemoglobin (Hgb) and haematocrit (HCT).
Platelets may or may not be included and,
therefore, depending on the laboratory the
clinician uses, may have to be ordered
separately. The normal value for platelets at
the Mayo Clinic for both men and women is
150,000 to 450,000/mm3,20. Haemorrhages
may be the first sign of thrombocytopenia,
a condition in which a patient’s number of
platelets is decreased21.
The coagulation activity of a patient can
be measured with additional laboratory
tests. These include Prothrombin Time
(PT; Protime) and Activated Partial
Thromboplastin Time (APTT). These are the
laboratory tests that are obtained for
patients who are using anti-coagulating
drugs such as heparin and warfarin.
The APTT measures the activity of the
intrinsic clotting mechanism (includes
Factors I, II, V, VIII, IX, X, XI, and XII). Any
deficiency in the intrinsic clotting system will
adversely affect fibrin clot formation.
A prolonged or elevated test value can result
Figure 6
Case 7, Figure 7
A 77-year old man presented for evaluation
of a ‘bleeding eye’. A large, elevated,
diffuse subconjunctival haemorrhage was
involving his left eye. A thorough medical
history revealed that the patient was taking
warfarin for a cardiac arrhythmia, but also
started taking aspirin for his arthritic
condition. It was suspected that this
combination of medications was inhibiting
his normal coagulation. He was advised to
stop the aspirin and see his cardiologist for
re-evaluation of his warfarin dosage.
Certain herbal supplements may increase
the risk of bleeding. These include garlic,
ginger, gingko biloba and feverfew. They
should not be taken in conjunction with
other anti-clotting medication. Some
34 | January 27 | 2006 OT
Figure 7
from excessive heparin dosing, von
Willebrand’s disease, haemophilia and
vitamin K deficiency2.
A PT laboratory test measures for
prothrombin, which is a protein produced
by the liver and whose production is
dependent on vitamin K. A PT evaluates the
extrinsic clotting mechanism (includes
Factors I, II, V, VII and X). Patients taking the
anti-coagulant warfarin are routinely
monitored with the PT laboratory test.
Warfarin slows clotting, thereby increasing
the PT by interfering with vitamin K
dependent
clotting
factors.
Other
conditions that can prolong or increase a PT
value include liver disease such as hepatitis,
vitamin K deficiency and poor fat absorption2.
Management
If the subconjunctival haemorrhage is mild,
monocular or is a first occurrence, often
measuring the patient’s blood pressure and
patient reassurance is usually all that is
necessary2. The patient can also be
instructed to apply cool compresses four
times a day for four minutes for each
application. This should be done during the
first 48 hours of the haemorrhages presenting. After 48 hours, the patient can
alternate between cool compresses and
warm compresses3. Artificial tear drops can
also be used if there is any accompanying
ocular irritation3.
During the time the subconjunctival
haemorrhage is resolving, the patient
should avoid rubbing their eye, not blow
their nose and reduce any activity that
would involve significant straining.
References
Download references from
www.optometry.co.uk/references.