Sub conjunctival haemorrhage

Sub conjunctival haemorrhage (SCH) occurs when a blood vessel ruptures underneath the conjunctiva.

Patients will often contact or arrive in practice worried about a sudden bleed in their eyes which appears out of nowhere. This may have been spotted by a relative or friend – the patient may be unaware until they look in a mirror.

It is important that the dispensing optician can identify this condition, take ownership, offer reassurance to patients, and offer advice, guidance, and where appropriate onward referral.

Signs/Symptoms:

  • Patch of blood visible on the sclera may be isolated (Image 1) or involve a wider area of the sclera (Image 3)
  • Usually flat in appearance with no raised areas
  • There is normally no pain or discomfort but occasionally may be a mild foreign body sensation.
  • Vision is not affected

Image 1

Small sub conjunctival haemorrhage (SCH). Note all the “margins” of the SCH can be seen which is critical- ie the white of the sclera is visible all the way around the SCH.

Image 2

Large SCH running up to the limbal boundary.

Image 3

Large SCH- note that the margins cannot be seen and that there is generalized conjunctival oedema (chemosis) particularly visible between 3 & 6 o’clock position.

Causes:

• Occasionally associated with minor trauma
• Very high blood pressure can be a factor
• History of coughing, straining, or heavy lifting
• Can be recurrent in the same area
• Use of non-steroid based anti-inflammatory medications
• Side effect of eye rubbing – linked to allergy?

Treatment:

• Self resolves normally without treatment however ocular lubricants can be helpful
• If recurrent, consider routine referral to GP for blood pressure check

Red Flags:

• Vision affected
• Margins not visible
• History or suspicion of very high blood pressure
• Pain

When one or more of these red flags is raised, a conversation with another registrant in practice should take place following which appropriate referral or management should be actioned and noted. If there are no other registrants in practice then contact should be made with colleagues elsewhere or contact should be made for advice to the local Hospital Eye Service (HES).