Sub-conjunctival Bleed
Definition
A sub-conjunctival bleed (also known as Subconjunctival Hemorrhage) is the extravasation of blood from ruptured capillaries into the space between the conjunctiva and sclera. It presents as a bright red patch on the eye and is usually painless.
Causes
Sub-conjunctival bleeds can result from various factors, including:
- Trauma: Direct injury to the eye, rubbing the eyes too hard, or after surgery.
- Sudden Increase in Pressure: Actions like coughing, sneezing, vomiting, heavy lifting, or straining during bowel movements can cause a rupture of blood vessels.
- Hypertension: Elevated blood pressure can lead to vessel rupture.
- Blood Disorders: Conditions like clotting disorders or the use of anticoagulants (e.g., warfarin) can increase the risk.
- Eye Surgery: Procedures such as LASIK or cataract surgery may sometimes lead to this condition.
- Infections: Conjunctivitis or other infections that cause inflammation of blood vessels.
- Systemic Conditions: Diabetes, bleeding disorders, or vascular diseases.
- Idiopathic: In many cases, no identifiable cause is found.
Signs and Symptoms
- Bright red patch on the sclera (white part of the eye)
- No pain or mild discomfort
- Normal vision (no blurring or loss of vision)
- Occasional mild itchiness or foreign body sensation
Diagnosis
The diagnosis of a sub-conjunctival bleed is primarily clinical, based on history and examination.
Key Points in History
- Recent trauma or eye rubbing
- Sudden onset after sneezing, coughing, or straining
- History of hypertension or blood-thinning medication
- Any recent surgery or systemic illness
Examination
Visual inspection reveals a sharply demarcated red patch on the sclera. Vision and intraocular pressure are typically normal.
Investigations
While sub-conjunctival bleeds are often benign and self-limiting, investigations may be necessary in recurrent or severe cases to identify underlying causes:
- Blood Pressure Measurement: To check for hypertension.
- Complete Blood Count (CBC): To detect any blood disorders or infections.
- Prothrombin Time (PT)/International Normalized Ratio (INR): For patients on anticoagulants.
- Blood Sugar Levels: To rule out diabetes.
- Ocular Imaging: Rarely required unless associated trauma or deeper ocular injury is suspected.
Treatment
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In most cases, a sub-conjunctival bleed resolves on its own within 1-2 weeks. However, treatment depends on the underlying cause and associated symptoms.
General Management
- Reassurance: Explain to the patient that the condition is benign and self-limiting.
- Avoidance of Strain: Encourage avoidance of heavy lifting or actions that increase intraocular pressure.
- Artificial Tears: To alleviate any discomfort or dryness (e.g., Carboxymethylcellulose eye drops).
- Cold Compress: Can be applied initially to reduce any minor swelling.
Medicines
- Artificial Tears:
- Carboxymethylcellulose 0.5% drops.
- Hydroxypropyl methylcellulose.
- Antibiotics: Only if associated with conjunctivitis or infection.
- Moxifloxacin eye drops or Ciprofloxacin drops.
- Antihypertensive Medication: If hypertension is diagnosed, adjust or initiate treatment accordingly.
- Amlodipine, Enalapril, or Losartan based on individual needs.
Addressing Underlying Causes
- Stop Blood Thinners: Temporarily, if medically advised.
- Treat Hypertension or Diabetes: With appropriate medication.
Complications
Although rare, complications can arise if an underlying condition is not addressed:
- Recurrent Hemorrhages: May indicate systemic issues like hypertension or clotting disorders.
- Infections: If associated with conjunctivitis or trauma.
- Deeper Ocular Injuries: In case of trauma, may involve the retina or orbit.
Management of Complications
- Regular Monitoring: For recurrent cases, regular follow-up to check for systemic causes.
- Referral to Specialists:
- Ophthalmologist for deeper ocular injuries.
- Hematologist for clotting disorders.
- Advanced Investigations: MRI or CT scans for trauma-related cases.
Key Takeaways
- Sub-conjunctival bleeds are mostly harmless and resolve on their own.
- A thorough history and examination are essential to rule out systemic causes.
- Patient reassurance is crucial to reduce anxiety associated with the dramatic appearance of the bleed.
- Promptly address any underlying systemic condition to prevent recurrence.