PANCE Blueprint EENT (7%)

Subconjunctival hemorrhage

Patient will present as a 45-year-old individual who noticed a bright red patch on the white of one eye upon waking up this morning. The patient reports no pain, vision changes, or recent injury to the eye but feels self-conscious about the appearance. The red patch does not extend to the iris, and there is no discharge or photophobia. The patient has no significant PMHx and is on no medications. On examination, visual acuity is 20/20 in both eyes. Intraocular pressure is within normal limits. Anterior segment examination of the right eye reveals a well-demarcated, bright red area on the nasal conjunctiva. Blood pressure is 120/80, and the left eye examination is unremarkable. Fundoscopic examination of both eyes is normal. The patient is diagnosed with a subconjunctival hemorrhage. They are advised to avoid eye rubbing and use artificial tears for irritation. They are instructed to return if there is no resolution within 2 weeks or if there are recurrent episodes.

Subconjunctival hemorrhage is a benign condition characterized by a sudden onset of a unilateral bright red patch on the sclera due to the rupture of small blood vessels under the conjunctiva

  • It can occur spontaneously or be triggered by coughing, sneezing, heavy lifting, vomiting, or even rubbing the eye too hard
  • While it may look alarming, it typically causes no pain, no vision changes, and no discharge
  • Risk factors include hypertension, diabetes, blood thinning medications, and certain blood clotting disorders
Subconjunctival hemorrhage eye

Subconjunctival hemorrhage eye. Broken blood vessel.

Diagnosis is primarily clinical, based on the characteristic appearance of a bright red or dark red patch on the sclera, with clear demarcation, and absence of other symptoms such as pain, vision loss, or discharge

  • No specific tests are usually required unless recurrent hemorrhages suggest an underlying systemic condition

Treatment is generally not required as the condition resolves on its own within two weeks. Artificial tears can help with any mild irritation

  • Patients should be reassured about the benign nature of the condition
  • Advise avoiding rubbing the eye and monitoring for recurrent episodes, which may warrant further investigation for underlying systemic conditions
  • Check blood pressure
  • If the patient is on anticoagulant therapy, consider reviewing the medication, especially if hemorrhages are recurrent

Question 1
A 42-year-old woman presents with a red patch in her eye. She is concerned but otherwise asymptomatic. Which of the following aspects of the physical examination is most important for confirming a diagnosis of subconjunctival hemorrhage?
Assessment of pupillary reaction to light
Relevant for neurological conditions, not isolated subconjunctival hemorrhage.
Checking for blood in the anterior chamber
Suggests traumatic hyphema, not subconjunctival hemorrhage.
Fluorescein staining of the cornea
Used to detect abrasions/ulcerations, not subconjunctival hemorrhage.
Funduscopic examination to visualize the retina
Important for other conditions, but the bleeding is superficial in subconjunctival hemorrhage.
Visual acuity testing
Question 1 Explanation: 
In a subconjunctival hemorrhage, vision should be completely unaffected. Visual acuity testing confirms this, helping to reassure the patient and distinguish it from other, potentially more serious eye conditions affecting vision.
Question 2
A 55-year-old man is diagnosed with a subconjunctival hemorrhage. He is anxious about the appearance of his eye. Which of the following is the most appropriate management recommendation?
Artificial tears for lubrication
Cold compresses
May offer temporary comfort but don't hasten resolution.
Patching of the affected eye
Provides no benefit in this condition
Referral for urgent ophthalmologic evaluation
Necessary only if suspicion of other eye problems, trauma, or bleeding disorders.
Topical antibiotic drops
Not indicated as subconjunctival hemorrhage is not an infection
Question 2 Explanation: 
Subconjunctival hemorrhage usually resolves spontaneously within 1-2 weeks. Reassurance and supportive measures like artificial tears are the mainstay of management.
There are 2 questions to complete.
Shaded items are complete.

References: Merck Manual · UpToDate

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