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Summary Table

Category	Details
Risk Factors	Elderly patients, hypertension, anticoagulant/antiplatelet use, coagulopathies, trauma, Valsalva maneuvers (coughing, straining, vomiting, heavy lifting), contact lens wear
Etiology	Rupture of small conjunctival or episcleral blood vessels beneath the bulbar conjunctiva; often spontaneous and idiopathic
Patient Presentation	Painless, bright red patch on the white of the eye noticed incidentally (often by someone else or in the mirror); no visual changes, no discharge
Classic Physical Exam	Well-demarcated, flat, bright red or dark red area on the bulbar conjunctiva; the underlying sclera is not visible through the hemorrhage; conjunctiva is otherwise smooth and non-edematous; pupils are normal and reactive; visual acuity is intact
Key Diagnostic Results	Clinical diagnosis; no labs or imaging required in isolated, spontaneous cases; check blood pressure; consider coagulation studies (PT/INR, aPTT, platelet count) only if recurrent or if the patient is on anticoagulants
Management	Reassurance and observation; artificial tears for mild irritation; resolves spontaneously in 2 to 3 weeks; treat underlying cause if identified (e.g., blood pressure control, coagulopathy correction)
Keywords	"Painless red eye," "no change in vision," "bright red patch," "woke up with a red eye," "blood-tinged sclera," "on warfarin/aspirin"

1. Pathophysiology

The conjunctiva is a thin, transparent mucous membrane that lines the inner surface of the eyelids (palpebral conjunctiva) and folds back to cover the anterior sclera (bulbar conjunctiva). Beneath this membrane lies a rich network of small, fragile blood vessels. When one of these vessels ruptures, blood leaks into the subconjunctival space, the potential space between the conjunctiva and the sclera. Because the conjunctiva is transparent, the trapped blood is directly visible as a vivid red patch.

The hemorrhage is self-limiting because the subconjunctival space is confined. Blood does not enter the anterior chamber, does not affect the cornea, and does not reach the retina. This is why vision remains completely unaffected and there is no pain, as the conjunctiva itself has minimal sensory innervation on its surface and the blood accumulation does not generate enough pressure to stimulate nociceptors.

The mechanism of vessel rupture is most commonly a sudden rise in venous pressure, as seen with Valsalva maneuvers (forceful coughing, sneezing, straining during defecation, vomiting, or heavy lifting). In elderly or hypertensive patients, chronic vascular wall fragility from arteriosclerotic changes predisposes the conjunctival vessels to spontaneous rupture, even without a clear precipitant. In patients on anticoagulants (warfarin, direct oral anticoagulants) or with underlying coagulopathies, the hemorrhage may be larger and take longer to resolve, but the mechanism is the same.

The blood undergoes a predictable color change during resorption, transitioning from bright red to orange-yellow before clearing entirely, similar to the evolution of a bruise. This process takes approximately 14 to 21 days and requires no intervention.

2. Classification and Clinical Manifestation

Type	Mechanism	Clinical Features
Spontaneous (idiopathic)	No identifiable cause; presumed minor vessel fragility or subclinical Valsalva	Painless, unilateral red patch; most common presentation; benign and self-resolving
Valsalva-related	Acute rise in venous pressure from coughing, sneezing, straining, vomiting, or heavy lifting	History of a precipitating event; often noticed shortly after the episode; may be bilateral in severe bouts of coughing (pertussis, for example)
Hypertension-associated	Chronic vascular wall damage and fragility	Often recurrent; blood pressure may be elevated on presentation; warrants blood pressure check and follow-up
Traumatic	Direct blunt or penetrating trauma to the eye or orbit	Must rule out globe rupture and orbital fracture; presence of pain, decreased visual acuity, or 360-degree (circumferential) hemorrhage raises suspicion for open globe injury
Coagulopathy/medication-related	Anticoagulant or antiplatelet therapy; thrombocytopenia; liver disease; inherited bleeding disorders	May be larger or recurrent; important to review the medication list and check coagulation parameters

A critical distinction to internalize: isolated, spontaneous subconjunctival hemorrhage is benign. However, subconjunctival hemorrhage in the setting of trauma must be treated with a high index of suspicion for occult globe injury until proven otherwise.

3. Diagnostic Workup

Test	Role	When to Order
Visual acuity	Screening; must be normal in simple subconjunctival hemorrhage	Always, on every patient with a red eye
Blood pressure measurement	Screening for hypertension as an underlying cause	Always
Slit-lamp examination	To rule out associated anterior segment pathology (corneal abrasion, hyphema, iritis)	When there is a history of trauma, pain, or visual change
PT/INR, aPTT, platelet count, CBC	Evaluate for coagulopathy	Recurrent episodes, known anticoagulant use, suspected bleeding disorder, or hemorrhage disproportionate to any reported mechanism
CT orbit	Rule out orbital fracture or retrobulbar hemorrhage	Traumatic subconjunctival hemorrhage with suspicion for orbital or globe injury

Subconjunctival hemorrhage is a clinical diagnosis. In the straightforward scenario of a patient who presents with a painless, bright red patch on the eye, has normal visual acuity, and has no history of trauma, the diagnosis is made on inspection alone. No further testing is needed beyond confirming that visual acuity is intact and checking blood pressure.

The key workup decision on the exam centers on when to investigate further. If the vignette describes a patient with recurrent subconjunctival hemorrhages, the next best step is to check a complete blood count and coagulation panel to screen for an underlying bleeding disorder. If the patient is on warfarin, the question may ask you to check the INR and determine if it is supratherapeutic.

In the trauma setting, the workup shifts entirely. A slit-lamp examination becomes essential to evaluate for corneal injury, hyphema, or lens dislocation. If there is suspicion for globe rupture (e.g., 360-degree subconjunctival hemorrhage, shallow anterior chamber, irregular pupil, decreased visual acuity), the next step is not to apply pressure or perform tonometry but rather to shield the eye and obtain emergent ophthalmology consultation. CT of the orbit may be ordered to assess bony integrity.

4. Management and Treatment

Scenario	Management	Details
Spontaneous, isolated episode	Reassurance and observation	No treatment needed; resolves in 2 to 3 weeks; artificial tears (e.g., carboxymethylcellulose 0.5% drops, 4 times daily as needed) for comfort if mild foreign body sensation is present
Hypertension-associated	Blood pressure control	Optimize antihypertensive therapy; follow up to ensure adequate control
Anticoagulant-associated	Review anticoagulation status	Check INR if on warfarin; adjust dose if supratherapeutic; do NOT stop anticoagulation solely for subconjunctival hemorrhage unless INR is dangerously elevated
Recurrent episodes	Investigate for coagulopathy	Order CBC, PT/INR, aPTT; refer to hematology if results are abnormal
Traumatic with suspected globe rupture	Emergent ophthalmology referral	Place a rigid eye shield (do NOT use a pressure patch); avoid any manipulation, tonometry, or topical medications; administer tetanus prophylaxis and systemic antibiotics as indicated; CT orbit without contrast

The core management principle is that no direct treatment is required for the hemorrhage itself. The blood resorbs naturally over 2 to 3 weeks through local fibrinolysis and phagocytic clearance. Patients should be counseled that the hemorrhage may appear to spread or change color before it resolves, and this is normal.

Artificial tears can be used for symptom relief if the patient reports a mild gritty sensation, but this is not mandatory. Importantly, topical vasoconstrictors (e.g., naphazoline, tetrahydrozoline) serve no purpose and should not be recommended, as the blood is already extravascular.

The "next best step" logic on the exam typically tests whether you can identify when the hemorrhage is a marker of something more serious. If the vignette gives you an elderly patient on warfarin with a large subconjunctival hemorrhage, the tested concept is checking the INR. If the vignette describes a child with recurrent subconjunctival hemorrhages and easy bruising, the tested concept shifts to screening for a bleeding disorder (von Willebrand disease, ITP, leukemia).

In the trauma scenario, the tested concept is recognizing when subconjunctival hemorrhage is a red flag for globe rupture. The correct next step is never to examine or manipulate the eye further but to shield and refer.

5. Differential Diagnosis and Distractors

Differential Diagnosis	Why It Is Similar	Key Discriminator
Conjunctivitis (viral/bacterial/allergic)	Also presents as a "red eye"	Conjunctivitis produces discharge (watery in viral, purulent in bacterial, stringy/mucoid in allergic), itching or burning, and diffuse injection rather than a well-demarcated blood patch; subconjunctival hemorrhage has no discharge and no pain
Episcleritis	Red eye that is often mild and self-limiting	Episcleritis causes sectoral redness with mild tenderness or discomfort; the redness blanches with topical phenylephrine 2.5%; subconjunctival hemorrhage is painless and does not blanch
Scleritis	Red eye that can appear localized	Scleritis produces deep, boring pain that worsens with eye movement, may radiate to the brow or temple; often associated with systemic autoimmune disease (rheumatoid arthritis, granulomatosis with polyangiitis); visual acuity may be affected; the redness has a violaceous (bluish-red) hue
Acute angle-closure glaucoma	Acute red eye	Presents with severe pain, nausea/vomiting, mid-dilated fixed pupil, decreased visual acuity, and halos around lights; intraocular pressure is markedly elevated; none of these features are present in subconjunctival hemorrhage
Hyphema	Blood in the eye following trauma	Blood accumulates in the anterior chamber (visible as a layered blood level behind the cornea), not under the conjunctiva; associated with pain and decreased visual acuity
Globe rupture	Subconjunctival hemorrhage may be present as a sign	Globe rupture is distinguished by 360-degree subconjunctival hemorrhage, irregularly shaped pupil, decreased visual acuity, shallow anterior chamber, and positive Seidel test (fluorescein streaming from a wound site)
Child abuse (non-accidental trauma)	Subconjunctival hemorrhage in a child	Consider abuse when the hemorrhage is bilateral, there is no plausible mechanism, other signs of trauma are present (retinal hemorrhages, subdural hematoma, long bone fractures), or the history is inconsistent with the injury pattern

6. Traps and High-Yield Pearls

The most common way students get questions about subconjunctival hemorrhage wrong is by overinvestigating or overtreating a benign condition. When a vignette describes a classic painless red patch with normal vision and no trauma, the answer is reassurance. Students who select "slit-lamp examination" or "urgent ophthalmology referral" for an uncomplicated case are falling into the trap of treating every red eye as an emergency.

The second major trap is failing to investigate when the clinical context demands it. A recurrent subconjunctival hemorrhage, one that occurs in a patient on anticoagulants with a supratherapeutic INR, or one in a child with unexplained bruising requires further workup. The tested competency here is recognizing subconjunctival hemorrhage as a potential window into a systemic condition rather than an isolated ocular finding.

The third and most dangerous trap involves the trauma scenario. When a vignette pairs subconjunctival hemorrhage with decreased visual acuity, an irregular pupil, or a 360-degree hemorrhage pattern, the diagnosis shifts from benign to potentially sight-threatening. The correct answer becomes placing a rigid eye shield and obtaining emergent surgical consultation, not prescribing artificial tears. Students who anchor on "subconjunctival hemorrhage is benign" without reading the full clinical picture will miss globe rupture.

Finally, remember that subconjunctival hemorrhage is never associated with visual changes or pain. If the vignette includes either of these, the diagnosis is something else. This single discriminator is the most reliable way to confirm or exclude subconjunctival hemorrhage on any question.

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