Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
CLINICAL MANAGEMENT GUIDELINES Sub-conjunctival haemorrhage Aetiology Usually idiopathic Valsalva manoeuvre (e.g. coughing, straining, vomiting) producing rise in central venous pressure Traumatic (may be isolated or associated with ruptured globe or retrobulbar haemorrhage – see Clinical Management Guideline on Blunt Trauma) Recent eye surgery History is important. Ask about hypertension, medications, acute or chronic cough, eye rubbing, heavy lifting, recent ocular or head trauma, bleeding or clotting abnormalities and recurrent subconjunctival haemorrhage Predisposing factors Systemic hypertension Bleeding abnormality (leukaemia, clotting disorders) Anticoagulant medication (e.g. aspirin, warfarin) Conjunctival vascular lesion Trauma (including contact lens-related injury) Diabetes Symptoms Mild ache or irritation (no pain) May be asymptomatic Signs Red area on eye, location usually inferior, caused by blood beneath the conjunctiva of which the posterior border can be seen (if cannot be seen, may originate from intra-cranial haemorrhage, in which case immediate emergency referral may save a life) Usually unilateral No discharge Differential diagnosis Haemorrhagic conjunctivitis (EHC) viral conjunctivitis (usually small multiple haemorrhages; rare) usually bilateral Conjunctival neoplasms (e.g. lymphoma) with secondary haemorrhage Kaposi’s sarcoma (red or purple lesions under conjunctiva) Management by Optometrist Practitioners should recognise their limitations and where necessary seek further advice or refer the patient elsewhere Non pharmacological measure blood pressure (see NICE guidance at: http://www.nice.org.uk/guidance/cg127/chapter/1guidance#measuring-blood-pressure) in traumatic cases, refer to Clinical Management Guideline on Blunt Trauma ensure that posterior border of haemorrhage can be seen, to exclude intra-cranial source e.g. following skull base fracture If patient has history of recurrent subconjunctival haemorrhages or a history of bleeding or clotting abnormalities, refer to GP. Also refer for checking of international normalized ratio (INR) if patient is on warfarin (particularly if associated with unexplained bruising on the skin) reassure patient condition usually clears within 5-10 days cold compress may reduce discomfort Advise patient to return/seek further help if problem does not resolve or if it recurs (GRADE*: Level of evidence=low, Strength of recommendation=strong) Pharmacological Tear supplement / ocular lubricant if mild ocular irritation is present (GRADE*: Level of evidence=low, Strength of recommendation=strong) Sub-conjunctival haemorrhage Version 9, Page 1 of 2 Date of search 07.12.14; Date of revision 20.02.15; Date of publication 28.05.15; Date for review 06.12.16 © College of Optometrists CLINICAL MANAGEMENT GUIDELINES Sub-conjunctival haemorrhage B3: management to resolution Refer to GP if suspicion of hypertension or bleeding disorder, or if condition is recurrent Possible management by Ophthalmologist (Not normally referred) Investigate for underlying cause of subconjunctival haemorrhage Cauterise bleeding vessel if found Evidence base *GRADE: Grading of Recommendations Assessment, Development and Evaluation (see http://gradeworkinggroup.org/toolbox/index.htm) Management Category Sources of evidence Leiker LL, Mehta BH, Pruchnicki MC, Rodis JL. Risk factors and complications of subconjunctival hemorrhages in patients taking warfarin. Optometry. 2009;80(5):227-31 Pitts JF, Jardine AG, Murray SB, Barker NH. Spontaneous subconjunctival haemorrhage-a sign of hypertension? Br J Ophthalmol. 1992;76(5):297-9 Tarlan B, Kiratli H. Subconjunctival hemorrhage: risk factors and potential indicators. Clin Ophthalmol. 2013;7:1163-70 LAY SUMMARY Sub-conjunctival haemorrhage (S-CH) is a common condition which is usually unimportant but which only very occasionally indicates a serious medical condition. It occurs when a small amount of bleeding takes place beneath the conjunctiva (the membrane overlying the white of the eye) and is similar to a bruise elsewhere. It appears bright red because the conjunctiva is transparent. This may happen spontaneously (that is, with no discernable cause) or as the result of minor trauma, for example when a contact lens is mishandled. It can also indicate raised blood pressure or a bleeding abnormality. S-CH occurs more often in people taking blood thinning medications or aspirin, and in diabetics. The condition is often alarming because of its dramatic appearance but there is usually only mild discomfort and the haemorrhage usually disappears in 5-10 days without treatment. It is usual to check the blood pressure of people with S-CH and to investigate the problem if it recurs. Sub-conjunctival haemorrhage Version 9, Page 2 of 2 Date of search 07.12.14; Date of revision 20.02.15; Date of publication 28.05.15; Date for review 06.12.16 © College of Optometrists