aka Ophthalmology Befuddler 006
A 14 year-old boy is brought into the emergency department by his weary mother. He has been keeping everyone awake at night with his incessant coughing. That, however, is not why they are here today. She is worried about bleeding under the surface of his eye.
His eye looks like this:
Q1. What is shown?
Q2. What are the possible causes?
Subconjunctival hemorrhages may be related to minor injuries such as rubbing the eye or coughing. It is more common in those with a bleeding diathesis or those taking anticoagulants and antiplatelet agents.
Subconjunctival can also coexist with more serious ocular or orbital trauma — this needs to be ruled out. A subconjunctival haemorrhage with out inferior limit may be caused by a base of skull fracture.
Q3. What features on history and examined should be looked for?
- minor trauma, coughing, bleeding diathesis
- rule out major trauma (e.g. base of skull fracture).
- unilateral, localised and sharply demarcated confluent blood red discoloration with mobile overlying conjunctiva.
- No evidence of inflammation, pain or disharge.
- Normal visual acuity, red reflex and fundoscopy — rule out coexisting serious ocular or orbital trauma.
Q4. What is the appropriate management?
- Check blood pressure and assess for a bleeding diathesis (e.g. FBC and coags) as required.
- Apply lubrication if needed, e.g. artificial tears.
- Refer if pain develops or condition worsens.
Of course, there are other ways of getting a subconjunctival hemorrhage:
- Ehlers JP, Shah CP, Fenton GL, and Hoskins EN. The Wills Eye Manual: Office and Emergency Room Diagnosis and Treatment of Eye Disease (5th edition). Lippincott Williams & Wilkins, 2008.
- Marx JA, Hockberger R, Walls RM. Rosen’s Emergency Medicine: Concepts and Clinical Practice, 7th edition (2009) Mosby, Inc. [mdconsult.com]
- NSW Statewide Opthalmology Service. Eye Emergency Manual — An illustrated Guide, 2007. [link to free pdf]