Subconjunctival Hemorrhage: Symptoms, Types, Causes and Treatment

Subconjunctival hemorrhage is a common eye condition that can look alarming but is usually harmless. It appears as a bright red patch on the white of the eye, often catching people by surprise when they look in the mirror. Although it is frequently benign and self-limiting, understanding its symptoms, types, causes, and treatment options is essential for recognizing when it might be a sign of something more serious. In this article, we'll explore all aspects of subconjunctival hemorrhage, drawing on the latest research and clinical insights.

Symptoms of Subconjunctival Hemorrhage

The symptoms of subconjunctival hemorrhage are usually unmistakable. While the appearance can look dramatic, most people are surprised to find that they experience little to no discomfort. However, some may notice mild symptoms, depending on the cause or extent of the hemorrhage.

Appearance	Sensation	Associated Signs	Source
Bright red patch	Usually painless	Mild irritation, rare swelling	1, 4, 5
Localized redness	Mild itchiness	No vision change	1, 5
No discharge	Possible mild discomfort	No photophobia	1, 4, 5

Table 1: Key Symptoms of Subconjunctival Hemorrhage

Visual Changes

The hallmark symptom is a vivid red or dark patch on the sclera (the white part of the eye). This is caused by blood leaking under the conjunctiva, the thin, clear tissue covering the sclera. The blood is usually sharply demarcated and does not cross onto the iris or cornea 1, 5.

Sensation and Discomfort

Most people do not feel any pain or discomfort. The eye may feel slightly irritated or itchy, and some report a sensation of fullness or mild pressure, especially if the hemorrhage is large. Rarely, there may be mild swelling or tenderness if the cause is traumatic or if there’s associated inflammation 1.

Vision and Other Symptoms

Vision is almost always unaffected. There is typically no discharge, no photophobia (sensitivity to light), and no change in visual acuity. The main concern for patients is the cosmetic appearance. However, if there is pain, vision loss, or other concerning symptoms, an underlying issue may be present and should be promptly evaluated 1, 4, 5.

Types of Subconjunctival Hemorrhage

Not all subconjunctival hemorrhages are the same. Understanding the various types can help differentiate benign causes from those that need further medical attention.

Category	Description	Typical Patient	Source
Traumatic	Caused by injury	Children, young adults	3, 4, 6
Spontaneous	No obvious trauma	Elderly, hypertensive	2, 3, 4
Recurrent	Multiple episodes	Underlying disorders	4, 5

Table 2: Types of Subconjunctival Hemorrhage

Traumatic Subconjunctival Hemorrhage

This type results from direct injury to the eye or periocular area. Common scenarios include accidental bumps, rubbing the eye too vigorously, sports injuries, or even surgical interventions. In children, trauma is by far the leading cause, accounting for over 80% of cases 3, 6. Contact lens-related injuries also fall into this category and are more frequent among young adults 3, 4.

Spontaneous Subconjunctival Hemorrhage

Spontaneous hemorrhages occur without any obvious external cause. They are most commonly seen in older adults and often related to underlying medical conditions such as hypertension, diabetes, or blood vessel fragility 2, 3, 4. Sometimes, even minor events like sneezing, coughing, heavy lifting, or straining during bowel movements can trigger a spontaneous bleed.

Recurrent Subconjunctival Hemorrhage

When subconjunctival hemorrhages occur repeatedly, it's a signal to investigate for underlying systemic problems such as hypertension, bleeding disorders, medication effects (like blood thinners), or even rarely, ocular or systemic malignancies 4, 5. Recurrent hemorrhages warrant a more thorough medical evaluation.

Causes of Subconjunctival Hemorrhage

The causes of subconjunctival hemorrhage are diverse. While many cases are harmless and easily explained, others may indicate more serious health issues.

Cause	Typical Population	Notes	Source
Trauma	Children, young adults	Most common in youth	3, 4, 6
Hypertension	Older adults	Main cause in elderly	2, 3, 4
Contact lens injury	Young adults	Increasingly common	3, 4
Inflammation	All ages	Conjunctivitis	2, 6
Medications	All ages	Anticoagulants, antiplatelets	10, 5
Systemic disease	All ages	Diabetes, bleeding disorders	3, 4, 6
Idiopathic	All ages	No identifiable cause	3, 4

Table 3: Common Causes of Subconjunctival Hemorrhage

Trauma and Injury

• Accidental trauma: Blunt injury, eye rubbing, or foreign bodies can rupture small conjunctival vessels 3, 4, 6.
• Surgical trauma: Eye surgeries, including injections, can cause subconjunctival bleeding 7, 9.

Systemic Hypertension

High blood pressure is a leading cause in older adults. The fragile blood vessels in the conjunctiva can rupture with even minor pressure spikes 2, 3, 4.

Contact Lens Use

Improper handling, poor hygiene, or ill-fitting lenses can injure the conjunctiva, especially in younger patients 3, 4.

Inflammation and Infection

Acute conjunctivitis can inflame and weaken blood vessels, making them more prone to rupture 2, 6.

Medications and Medical Conditions

• Blood thinners (e.g., warfarin), antiplatelet drugs (e.g., abciximab), and even some herbal supplements can increase bleeding risk 10, 5.
• Systemic disorders: Diabetes, bleeding/clotting disorders, and vascular diseases can predispose people to spontaneous hemorrhages 3, 4, 6.

Rare and Unusual Causes

• Severe coughing, sneezing, vomiting, or straining: These can abruptly increase venous pressure and rupture conjunctival vessels 6.
• Vaccine reactions: Rare cases have been reported after mRNA COVID-19 vaccines, especially in those with underlying health issues 1.
• Unknown (Idiopathic): In many cases, no definitive cause can be found—even after thorough evaluation 3, 4.

Treatment of Subconjunctival Hemorrhage

While the appearance of a subconjunctival hemorrhage can be unsettling, treatment is often straightforward. However, management can vary depending on the underlying cause and associated risk factors.

Approach	Purpose	Details	Source
Observation	Natural resolution	Most cases resolve in 1–2 weeks	4, 5
Artificial tears	Symptom relief	Soothes irritation, improves comfort	1, 10
Treat cause	Address underlying issue	Control hypertension, stop offending drugs	2, 3, 4, 10
Medical evaluation	Rule out serious causes	Needed for recurrent/persistent cases	4, 5
Vasoconstrictor drops	Reduce severity	Brimonidine before/in eye surgery	7, 9

Table 4: Treatment Options for Subconjunctival Hemorrhage

Observation and Reassurance

• Most subconjunctival hemorrhages require no treatment and resolve on their own within 1–2 weeks as the blood is gradually reabsorbed 4, 5.
• Patients should be reassured about the benign nature of the condition in most cases.

Symptomatic Relief

• Artificial tears can be used to alleviate minor irritation or dryness while healing occurs 1, 10.
• Oral analgesics may be recommended if mild discomfort is present 1.

Treating Underlying Causes

• If an underlying cause such as hypertension or a bleeding disorder is identified, appropriate management is essential 2, 3, 4.
• For medication-induced cases, the offending agent (e.g., anticoagulant or antiplatelet drug) may be stopped or adjusted under medical supervision 10.

When to Investigate Further

• Recurrent or persistent subconjunctival hemorrhage warrants a comprehensive medical evaluation. This may include blood pressure measurement, blood tests, and, in rare cases, imaging to rule out bleeding disorders or malignancies 4, 5.
• Children with subconjunctival hemorrhage, especially those under 2 years old, should be examined carefully to exclude trauma or abuse 6.

Special Treatments

• Vasoconstrictor drops: Brimonidine drops, used before certain eye surgeries (e.g., intravitreal injections, microincisional vitrectomy), have been shown to significantly reduce the risk and severity of subconjunctival hemorrhage post-procedure 7, 9.
• Management of exceptional cases: In rare instances, such as those related to vaccine reactions or medications like abciximab, stopping the offending agent and providing supportive care leads to resolution 1, 10.

Conclusion

Subconjunctival hemorrhage is a common, mostly benign eye condition that can appear alarming but usually requires minimal intervention. Understanding its symptoms, types, causes, and treatment can help patients and healthcare professionals distinguish harmless cases from those needing further investigation.

Key takeaways:

• Symptoms: Bright red patch on the sclera, usually painless, with no vision changes 1, 4, 5.
• Types: Traumatic, spontaneous, and recurrent—each with distinct risk factors 3, 4, 6.
• Causes: Range from trauma and hypertension to medications and rare systemic diseases 2, 3, 4, 6, 10.
• Treatment: Most cases resolve without intervention; treat underlying causes if present; use artificial tears for comfort; vasoconstrictor drops can prevent surgical cases 1, 4, 5, 7, 9, 10.
• When to seek help: Recurrent, persistent, or symptomatic hemorrhages, or those in children, require further evaluation 4, 5, 6.

Knowing when to seek medical attention and when reassurance is appropriate can make all the difference in managing this eye condition with confidence.