How Would You Manage This Woman’s Ocular Injury?

A 25-year-old woman presented with a flat, hemorrhagic area covering the right sclera, which had appeared 1 week prior after she had struck her upper face on a shelf.

At presentation, she had minimal periorbital swelling superiorly at the site of impact, which was mildly tender, but no overt ecchymosis or bony tenderness or step-off deformity. She admitted to having developed a headache after the initial injury, but she denied having current eye pain or pain with eye movement. She also denied having visual changes or photophobia, eye or nasal drainage, pruritus, or a sensation of irritation.

Her past medical history revealed no systemic illness or medical conditions, and she was not taking any medications regularly. She denied domestic violence per screening questions.

What's your diagnosis?

See answer on next page.

Answer: Subconjunctival Hemorrhage

A 25-year-old woman presented with a flat, hemorrhagic area covering the right sclera, which had appeared 1 week prior after she had struck her upper face on a shelf.

At presentation, she had minimal periorbital swelling superiorly at the site of impact, which was mildly tender, but no overt ecchymosis or bony tenderness or step-off deformity. She admitted to having developed a headache after the initial injury, but she denied having current eye pain or pain with eye movement. She also denied having visual changes or photophobia, eye or nasal drainage, pruritus, or a sensation of irritation.

Her past medical history revealed no systemic illness or medical conditions, and she was not taking any medications regularly. She denied domestic violence per screening questions.

Based on the clinical presentation, the patient received a diagnosis of subconjunctival hemorrhage resulting from minor trauma. Because the subconjunctival hemorrhage involved the area 360° around the cornea, the patient was referred to an ophthalmologist for evaluation. Open-globe injury and conjunctival lacerations were ruled out. She was instructed to apply cold compresses to the area, with the prognosis that the hemorrhage would be self-limiting and resolve within approximately 2 weeks.

Etiology

Clinically, subconjunctival hemorrhages present as superficial, flat, focal collections of blood between the sclera and the conjunctiva. The most common risk factors for subconjunctival hemorrhage in patients younger than 40 years of age are occupational or leisure-related trauma and injury induced by contact lenses.¹ In patients 40 and older, systemic conditions such as hypertension and diabetes are the most common etiology of spontaneous subconjunctival hemorrhages.¹ Causes that are not age-related include coagulopathy (inherited or iatrogenic) and elevated venous pressure from bearing down, coughing, or vomiting. The etiology of subconjunctival hemorrhages is unknown in as many as 39% of reported cases.¹

Differential Diagnosis

The differential diagnosis for a red eye without a patient history of injury includes hemorrhagic conjunctivitis (allergic, viral, bacterial), corneal abrasion or ulceration, and retained conjunctival foreign bodies. However, in the setting of a traumatic injury, the differential diagnosis can be more ominous and often requires referral to an ophthalmologist. Trauma histories should raise suspicion for possible corneal or scleral lacerations, retained intraocular foreign body, hyphema (blood in the anterior chamber), or open-globe injury.² Subconjunctival hemorrhage may indicate domestic violence or child abuse. When appropriate, screening questions should be asked, and other signs of bodily trauma should be investigated.

Evaluation

Evaluation of nontraumatic or minor trauma incidents generally can be done in the primary care setting, and it begins with questions about systemic causes such as allergies or respiratory infections causing forceful coughing or sneezing, and gastrointestinal symptoms including vomiting or constipation. For a contact lens wearer, determine whether proper lens care is used. For infectious etiologies, determine whether the patient has had contact with persons experiencing similar symptoms.

In nontraumatic etiologies where no reasonable concern exists for an open-globe injury, the examination can include using a penlight to assess pupillary response, and probing with a saline-soaked cotton-tipped applicator to assess blanching of vessels or detect the presence of a foreign body. Using fluorescein dye with a Wood lamp or slit lamp can help detect abrasions and ulcerations. Diagnostic tests can include cultures of the cornea or any discharge, blood pressure evaluation, hemoglobin A_1C measurement, and coagulation studies as appropriate.³

Evaluation of cases involving more than minor trauma with the possibility of occult globe penetration can be performed with the Seidel test, which consists of slit-lamp examination performed with fluorescein and a cobalt blue light. In the presence of a perforation or leak, the fluorescein becomes diluted by the aqueous humour, appearing as a dark (diluted) stream in a pool of bright green (concentrated) dye. In such cases, placing any pressure on the eye must be avoided to prevent the extrusion of intraocular tissue through the perforation; moreover, the Seidel test should not be performed in cases with evidence of a rupture or laceration.⁴

In cases where significant suspicion exists for a ruptured globe, do not place any topical agents or rinses in the eye. Place an eye shield, and refer the patient immediately to an ophthalmologist. If necessary, analgesics or anti-inflammatories only should be administered orally. Diagnostic imaging studies can be used to rule out globe rupture and intraocular or orbital foreign body, and to evaluate the extent of orbital and periocular trauma. These can include radiography (which may rule out metallic foreign bodies) and thin-slice computed tomography. Magnetic resonance imaging is contraindicated for cases in which a metallic foreign body might be present.^4-5

Management

Generally, observation is the treatment for nontraumatic cases of subconjunctival hemorrhage, which should resolve spontaneously in 2 to 3 weeks. Recognized underlying systemic conditions should be treated. Minor trauma or infectious etiologies can be treated with topical anti-inflammatories or antibiotics and sterile moistening drops or ointment. Contact lens users can be reeducated on proper lens and eye care.

Patients with any significantly traumatic mechanism of injury should have an eye shield placed to protect the affected eye and be referred to an ophthalmologist for management. To avoid corneal staining, patients with a concern for hyphema should be placed at a 45° angle until they are seen by an ophthalmologist. Tetanus vaccination should be updated if necessary.^4-5

Referral

With all causes of red eye or eye injury, one of the biggest concerns in primary care is when to refer a patient to an ophthalmologist. Common indications for ophthalmologic consultation in the setting of a bright red eye, such as cases of subconjunctival hemorrhage, include the following^4,5:

• Symptoms of severe pain, decreased vision, or pupillary irregularity
• Foreign bodies that are deeply embedded, subconjunctival, or associated with a conjunctival laceration
• Corneal abrasions that are not healing within 24 to 48 hours
• Conjunctival lacerations greater than 1 cm in length that require suturing
• Severe subconjunctival hemorrhage involving the area 360° around the cornea
• Suspicion for an open-globe injury or intraorbital penetration
• Signs of traumatic hyphema
• Any eye injury associated with high-velocity trauma.

Casey Bonaquist, DO, is a family physician at Baptist Primary Care in Ponte Vedra, Florida.

Donna Bellinger Treesh, DO, is a physician at Pacifica Care in Jacksonville, Florida.

References:

1. Mimura T, Usui T, Yamagami S, et al. Recent causes of subconjunctival hemorrhage. Ophthalmologica. 2010;224(3):133-137.
2. Shields T, Sloane PD. A comparison of eye problems in primary care and ophthalmology practices. Fam Med. 1991;23(7):544-546.
3. Cronau H, Kankanala RR, Mauger T. Diagnosis and management of red eye in primary care. Am Fam Physician. 2010;81(2):137-144.
4. Crouch ER Jr, Crouch ER, Grant TR Jr. Ophthalmology. In: Rakel RE, Rakel DP, eds. Textbook of Family Medicine. 8th ed. Philadelphia, PA: Elsevier Saunders; 2011:chap 41.
5. Pokhrel PK, Loftus SA. Ocular emergencies. Am Fam Physician. 2007;76(6):829-836.