Eyes & Vision

Subconjunctival haemorrhage

Subconjunctival haemorrhage is a superficial bleed beneath the conjunctiva causing a sharply demarcated bright-red patch with normal vision; it is usually harmless, but pain, visual change or trauma means the diagnosis must be reconsidered urgently.

In a nutshell

Subconjunctival haemorrhage is a sharply demarcated bright-red patch under the conjunctiva with normal vision, pupils and eye movements. It is usually painless and clears in about one to two weeks without treatment. Check blood pressure and context; recurrent or unexplained episodes need selective systemic assessment. Pain, visual change or significant trauma means it is not safe to reassure without urgent review.

Classic presentation

A patient notices a sudden bright-red patch on the white of one eye after coughing or rubbing it, but has normal acuity, no pain and a clear cornea.

Key points

Flat superficial red patch, normal vision and little/no pain are the reassuring pattern.
Most cases resolve without treatment in about one to two weeks.
Check blood pressure and ask about Valsalva, trauma, contact lenses and antithrombotics.
Recurrent, bilateral, spontaneous bleeding or bruising elsewhere prompts targeted assessment.
Significant trauma, pain, photophobia, visual loss, abnormal pupil or proptosis requires urgent eye/trauma review.
Do not use antibiotic or steroid drops for an uncomplicated subconjunctival haemorrhage.

First-line investigation

Focused eye examination confirming a superficial bleed with normal acuity, pupils, cornea and motility, plus blood-pressure measurement.

Management

Confirm an isolated superficial bleed

Check acuity, pupils, motility, cornea and pain/photophobia; urgent assessment is needed if these are abnormal or if significant trauma occurred.^1,2

Check blood pressure and contributing context

Ask about Valsalva, rubbing, contact lenses, trauma, surgery and blood-thinning medicines; check blood pressure and manage any identified issue through the appropriate pathway.^1,3,2

Reassure and avoid unnecessary drops

No treatment is usually required; the patch clears like a bruise in about one to two weeks. Lubricants may help mild irritation, but antibiotics and topical steroids are not indicated in an uncomplicated case.^1,2,3

Refer trauma or sinister features urgently

Use an emergency eye/trauma pathway for high-velocity or penetrating injury, reduced vision, severe pain, photophobia, abnormal pupil, proptosis, ophthalmoplegia or extensive post-traumatic haemorrhage.^1,2,4

Safety-net recurrence and failure to clear

Review recurrent, bilateral or spontaneous episodes, unexplained bruising, medication concerns or a haemorrhage that has not cleared by about two weeks; arrange targeted systemic tests when indicated.^1,2

Exam traps

A dramatic red appearance does not imply intraocular bleeding if vision and examination are normal.
Pain or reduced vision is not typical; reconsider keratitis, uveitis, glaucoma, scleritis or globe injury.
After high-velocity or penetrating trauma, the red patch can mask globe rupture.
Do not routinely order clotting tests for a first isolated bleed; investigate recurrent or multisite bleeding selectively.
Do not stop prescribed anticoagulants or antiplatelets without the prescriber reviewing the indication and risk.

Illustrations

Subconjunctival haemorrhageA clinical photograph of a broad bright-red subconjunctival collection surrounding a clear cornea and normal pupil. Label it as an uncomplicated example only when normal vision and absence of trauma are stated.James Heilman, MD, Wikimedia Commons · CC-BY-SA-3.0

Key sources

This page is exam revision material, not medical advice, and must not be used for patient care. Always check drug doses against the BNF and current guidance. Full disclaimer.