Subconjunctival hemorrhage is a limited accumulation of blood in the space between the sclera and the conjunctiva. Pathology is characterized by an asymptomatic course, visual discomfort rarely occurs, a feeling of an extraneous body in the eye. To make a diagnosis, an external examination of the affected area, biomicroscopy of the eye, gonioscopy, ophthalmoscopy, a blood test and a coagulogram are prescribed. In most cases, no treatment is required. Medications from the angioprotector group, artificial tear preparations, vitamins P and C are used as auxiliary therapy.
H11.3 Conjunctival hemorrhage
Subconjunctival hemorrhage or hyposphagma is a widespread phenomenon in practical ophthalmology. Signs of this pathology are detected in 98% of patients with contusion of the eyeball. According to statistics, bleeding on the background of a traumatic lesion occurs 10 times less often than hemorrhages of non-traumatic genesis. Men are diagnosed with the disease more often than women, which is associated with higher physical activity. Subconjunctival hematoma can develop at any age, most rarely occurs during the newborn period. Geographical features of distribution are not noted.
Subconjunctival bleeding is a polyetiological condition, the development of which is based on local or systemic pathological processes. Rarely, hyposphagma occurs with increased physical exertion or an increase in venous pressure, which is observed with a strong cough, vomiting. Detection of subconjunctival bleeding in the neonatal period indicates traumatic asphyxia syndrome or vitamin C deficiency. The causes of the symptoms of the disease in adulthood are:
- Increased intraocular pressure. Damage to the capillaries of the microcirculatory bed often occurs against the background of ophthalmic hypertension. The risk group also includes patients with hypertension, hyperthyroidism.
- Mechanical damage to the conjunctiva. Injuries of the visual organ can provoke subconjunctival hemorrhages, less often – intensive rubbing of the eyes, ingestion of a foreign body.
- Changes in the rheological properties of blood. The decrease in blood viscosity is due to anemic syndrome, congenital or acquired coagulopathy, taking medications from the group of anticoagulants and antiplatelet agents.
- Acute hemorrhagic conjunctivitis. The occurrence of the hemorrhagic form of the disease is caused by infection with the Coxsackie virus or enterovirus.
- Head and eye injuries. Subconjunctival hematoma is a common symptom of traumatic brain injury, skull base fracture and contusion lesions of the eyeball.
- Iatrogenic effects. The development of hyposphagma often potentiates damage to blood vessels when performing retro- or parabulbar injections. Pathology may occur in the postoperative period when performing conjunctival incisions or suturing.
The conjunctival membrane contains many small blood vessels prone to increased fragility. Damage to the capillary network of the conjunctiva leads to the spontaneous development of regional hemorrhage. Blood clots accumulate between the conjunctiva and sclera, which is manifested by the formation of a bright red hematoma. According to another pathogenetic theory, subconjunctival bleeding occurs when there are disorders in the coagulation system. Hemostasis disorder is caused by the absence or low content of clotting factors, quantitative or qualitative abnormalities of platelets or pathology of the endothelial layer of the vascular wall.
There are congenital and acquired forms of nosology. Subconjunctival hemorrhage is usually classified depending on the area of the lesion. The following variants of the disease are distinguished:
- I degree. Signs of bleeding are visualized on 1/4 of the surface of the eyeball.
- II degree. No more than half of the area of the orbital conjunctiva is involved in the pathological process.
- III degree. There is a lesion of 2/3 of the space between the outer shell of the eye and the sclera until it is completely filled with blood clots.
The severity of clinical manifestations is determined by the extent of the lesion. With I-II degree of bleeding, patients do not complain. The III degree is accompanied by discomfort, which increases with blinking, a feeling of a foreign body. Pathology does not cause pain syndrome and visual dysfunction. Patients note a pronounced cosmetic defect, visible to the naked eye. On the white background of the sclera, a red area of irregular hemorrhage is visualized, the size of which is determined by the stage. Within 2-14 days, the symptoms disappear on their own. Rarely, clinical manifestations persist for 3 weeks or more. When pathology occurs against the background of hemostasis disorders, subconjunctival hemorrhages become recurrent.
Complications are extremely rare. Extensive lesion causes the addition of infectious and inflammatory complications (conjunctivitis, blepharitis, keratitis). With iatrogenic etiology, suppuration of a hematoma is possible with the subsequent development of pan- and endophthalmitis, less often – generalization of infection in the form of sepsis. Violation of the distribution of the tear film is manifested by dry eye syndrome, xerophthalmia. Bleeding may be accompanied by hemorrhage in the anterior chamber of the eye (PCG) or vitreous. The III degree leads to a slight increase in ophthalmotonus.
To make a preliminary diagnosis, it is enough to conduct an external examination. In the initial stages, the zone of the orbital conjunctiva has a bright red color, which is later replaced by a yellow-green color. The complex of instrumental and laboratory methods of examination includes:
- Biomicroscopy of the eye. The purpose of the study is to visualize the source of bleeding. Allows you to detect signs of the development of inflammatory and infectious complications.
- Gonioscopy. The technique is used to exclude concomitant bleeding in the PCG.
- Ophthalmoscopy. Examination of the fundus is necessary to identify symptoms of damage to the inner lining of the eye, the central vein of the retina and the optic nerve disc.
- Blood test. Predisposing factors include such changes in rheology as a decrease in the level of platelets, erythrocytes, hemoglobin and color index.
- Coagulogram. It is carried out to detect signs of clotting disorders. The pathology of the hemostasis system is indicated by an increase in prothrombin time, activated partial thrombin time, and a decrease in fibrinogen concentration.
Differential diagnosis is carried out with hemophthalmos and hyphema. Unlike hyposphagma, with hemophthalmos, blood clots accumulate in the vitreous body, specific manifestations include floating opacities in front of the eyes, photophobia, the appearance of “fog” in front of the eyes. The visometry method determines the decrease in visual functions. A distinctive feature of the hyphema is the presence of a blood level in the iris area, which is detected during visual examination. If changes in the UAC or coagulogram are detected, a consultation with a hematologist is indicated.
Treatment of subconjunctival hemorrhage
The use of special treatment methods is not required, since all manifestations are independently leveled within 1-3 weeks. Etiotropic therapy is reduced to the elimination of the underlying disease. According to individual indications , they are assigned:
- Angioprotectors. Oral administration is indicated in order to increase the resistance of the capillary wall. Medicines have an antispasmodic effect, improve microcirculation and blood rheology.
- Vitamin therapy. With frequent bleeding, the use of vitamins C, P (rutin), which have a capillary-protective effect, is recommended.
- Moisturizing preparations. Active ingredient of moisturizers (hydroxypropyl cellulose) promotes thickening and stabilization of the tear film, faster resorption of hyposphagma.
- Antibacterial agents. They are necessary in case of development of subconjunctival hemorrhage on the background of acute hemorrhagic conjunctivitis or in case of secondary inflammatory complications.
Prognosis and prevention
The prognosis for life and working capacity is favorable. The development of pathology does not lead to a violation of visual functions. There is no specific prevention. Non-specific preventive measures are reduced to the control of intraocular and systemic blood pressure, timely diagnosis and treatment of diseases of the blood and the organ of vision. If signs of bleeding are detected, it is necessary to cancel anticoagulants and antiplatelet agents (aspirin, clopidogrel, heparin) or reduce the dosage. Patients with recurrent subconjunctival hemorrhages should be examined by an ophthalmologist and a hematologist 2 times a year.