Coordinated by Bobby Christensen, O.D., F.A.A.O.

therapeutic insights
Meet a Familiar Foe
Know how to treat a subconjunctival hemorrhage -- and what to do when you find one that's not benign.
by JOHN C. SMAY, O.D., Midwest City, Okla.

Non-traumatic subconjunctival hemorrhages are a common disorder that result in patients seeking acute care from primary eyecare providers, general healthcare providers and emergency room physicians. Although the appearance of a subconjunctival hemorrhage may alarm some patients, we know that most cases require no treatment and pose no danger to the health of the eye.

However, a subconjunctival hemorrhage isn't always a benign clinical finding -- it can often be a sign of a significant systemic disorder. Optometrists must be able to correctly recognize subconjunctival hemorrhages that require further evaluation -- and then order the correct diagnostic tests or make an appropriate referral. Following are some guidelines.

Here's what you'll see

Subconjunctival hemorrhages usually present as a bright red accumulation of blood in the space beneath the bulbar conjunctiva. These bleeds are typically sectorial, but may expand to encompass the entire subconjunctival space. The color can vary from bright red, to pink, to deep purple, depending on the density of the blood.

With spontaneous subcon-junctival hemorrhages, the patient is often unaware of the condition until he glances in a mirror or someone points it out to him. Pain isn't a symptom; however, if the mass of the blood is sufficient, the patient may experience some mild discomfort. If significant pain is part of the complaint, then look for problems besides the hemorrhage.

The patient's visual acuity shouldn't be affected and his IOP should be normal. Slit lamp examination should be normal except where the sclera is obscured by the hemorrhage.

Find the culprit

Spontaneous subconjunctival hemorrhages are probably most commonly idiopathic in nature. The patient is apparently healthy and there's no apparent reason for the hemorrhage. However, the hemorrhages can be secondary to a variety of other conditions, including:

Valsalva maneuvers involve a forcible exhalation effort against a closed glottis that results in an increase of venous pressure. Examples of this include coughing, sneezing or straining. The increased venous pressure can rupture the fragile subconjunctival vessels and a subconjunctival hemorrhage will result. When taking the case history, ask the patient about any acute or chronic coughing or sneezing, or heavy lifting, constipation or vomiting.

Hypertension is probably the most common finding when a systemic disease is associated with a subconjunctival hemorrhage, and more rarely, increased IOP can cause a subconjunctival bleed. Therefore, you should routinely check blood pressure and IOP for any patient who presents with a subconjunctival hemorrhage. Also, other microvascular diseases such as diabetes may be the culprit.

Subconjunctival hemorrhages may be secondary to impaired blood clotting because of medical therapy with coagulation inhibitors such as aspirin or coumadin, or bleeding disorders caused by a variety of systemic diseases. "Bleeding disorders" is a general term for a wide range of medical problems that lead to poor blood clotting and continuous bleeding. Some of these disorders include von Willebrand's disease, which is an inherited blood disorder thought to affect between 1% and 2% of the population, severe hepatic disease, cancers such as leukemia, or bone marrow problems.

Because Vitamin K is involved in the clotting process, a vitamin K deficiency can also cause bleeding. AIDS patients can develop a subconjunctival hemorrhage due to a reduction of platelets in the blood, or because of associated orbital disease. In a young, seemingly healthy person who presents with recurrent subconjunctival hemorrhage, be suspicious of a systemic bleeding disorder as the cause and order the appropriate tests. With just a few tests (that we'll cover later), you can easily screen for most bleeding disorders caused by disease or medication.

Look closely for a conjunctival tumor when subconjunctival hemorrhages don't resolve within one to two weeks, or if they continue to recur in the same area. Remember that many neoplasms such as melanomas or hemangiomas can bleed and can cause a secondary subconjunctival hemorrhage. Kaposi's sarcoma is a type of growth that you might mistake for a subconjunctival hemorrhage. It was previously considered rare, but has become more commonplace in patients suffering from AIDS. It's a highly vascular malignant tumor that appears as a bright red or purplish mass and appears commonly on other areas of the body. About 20% of patients have conjunctival involvement.

Child abuse. Consider this a possibility in a young child who has a subconjunctival hemorrhage. Although these are traumatic in nature, the caregiver/abuser may give a non-traumatic cause. Physical child abuse may present itself in a number of ways, but the most common signs are bruises and contusions; burns; broken bones; abdominal injuries; and central nervous system injuries.

In addition to the subconjunctival hemorrhage, you may also find retinal hemorrhages during a dilated exam. Perform a complete evaluation to rule out any other damage to the eye. If you believe that a child has been abused or neglected, then it's mandatory in all states that you notify the proper authorities. Child abuse and neglect laws vary among jurisdictions, however all include designation of an agency to investigate reports (usually social services or law enforcement); and grants of immunity from liability for mandatory reporters who make reports in good faith. You can usually make initial reports orally, but you must do so immediately or as soon as possible to protect the child quickly.

	The color of a subconjunctival hemorrhage can vary from bright red, to pink, to deep purple.

Getting a plan

As with any patient encounter, the management step begins with a thorough patient ocular and medical history. Often, a good history will point to the cause of the hemorrhage. Ask if the patient has any known bleeding or clotting problems, or areas of spontaneous bruising on hands or forearms. Bruising in the absence of known injuries can signify poor blood clotting.

Ask about the patient's medications with special attention to those that inhibit clotting such as: aspirin, warfarin (Coumadin), clopidogrel bisulfate (Plavix), aspirin/ di-pyridamole (Aggrenox), anagrelide HCl (Agrylin), dipyridamole USP (Persantine), cilostazol (Pletal) and ticlopidine HCl (Ticlid). Ask if the patient is a known hypertensive. Ask about valsalva maneuvers such as coughing, sneezing or heavy lifting.

Don't forget to ask about any other ocular symptoms such as itchy eyes or irritation that may have caused eye rubbing. Inquire about any ocular symptoms that would not commonly be associated with a subconjunctival hemorrhage such as decreased vision, diplopia or severe pain. Finally, find out if this is a recurrent problem. Recurrent hemorrhages suggest a systemic pathology and not an idiopathic cause.

Check best corrected visual acuity, which should be normal, and IOP, which should also be unaffected. If there is decreased acuity or an abnormal IOP, look for other ocular problems. An increased IOP and proptosis could indicate a retrobulbar hemorrhage. Measure blood pressure in every case and make an appropriate referral if it's elevated. Perform a complete slit lamp exam to rule out any conjunctival lesions such as Kaposi's sarcoma or lymphoma.

If it's the first occurrence of a subconjunctival hemorrhage and the patient has no known risk factors and an otherwise normal evaluation, then patient education and reassurance are the only treatment needed. Let the patient know that the hemorrhage will typically resolve in one to two weeks without any long-term consequences. Have him return if the blood doesn't fully resolve, if the hemorrhage recurs or if other symptoms develop. You can give him artificial tears to alleviate any mild discomfort.

Time for a test

If the patient develops recurrent subconjunctival hemorrhages or has a history that might indicate a bleeding disorder, then you should investigation further as to the cause and consider a medical consult. Order the following lab tests: prothrombin time, partial thromboplastin time and a complete blood count (CBC) with platelets.

Prothrombin time is a broad-screening test for several types of bleeding disorders. It's often referred to as Pro-time, or simply PT. It's a measurement of the extrinsic clotting time of plasma. The normal range is 11 to 13.5 seconds, but "normal" may vary in different labs.

Partial thromboplastin time is another broad-screening test also known as PTT, APTT or activated partial thromboplastin time. It measures the clotting time in plasma, focusing on the intrinsic thromboplastin system. (The normal time is 25 to 35 seconds.)

CBC with platelets measures the number of red blood cells, the number of white blood cells, total hemoglobin, the fraction of the blood composed of red blood cells (hematocrit), mean corpuscular volume (the size of the red blood cells), mean corpuscular hemoglobin, mean corpuscular hemoglobin concentration and the number of platelets present. The CBC is a screening test used to diagnose a large number of diseases. The results can reflect problems with fluid volume, abnormalities in the production, life span and rate of destruction of blood cells. It can also detect acute or chronic infection, allergies and problems with clotting.

Low numbers of red blood cells can indicate disease such as leukemia, anemia or multiple myeloma, as well as a variety of other conditions. High numbers of white blood cells are often present in infectious or inflammatory diseases or leukemia. A diminished number of platelets is called thrombocytopenia and an elevated number is called thrombocytosis. Typically in bleeding disorders that cause subconjuctival hemorrhages, the platelet count decreases.

If a patient has a known clotting disorder or is on anticoagulant therapy, then the primary care physician may do the lab testing regularly. Contact the physician to determine if the patient has been recently evaluated or if further testing is indicated.

Practice makes perfect

Over the course of an optometric career, a primary care O.D. will encounter a countless number of subconjunctival hemorrhages. The vast majority of these will present no ocular or systemic danger to the patient, and the optometrist can manage them with reassurance and possibly artificial tears. However, routine tests such as tonometry and blood pressure measurement, and a complete patient history in every occurrence, can help to differentiate the cases that do pose a danger and require further testing or referral.