Idiopathic recurrent subconjunctival hemorrhage

A 54-year-old male presented to the oculoplastics service referred from his general ophthalmologist with a 6-month history of a recurrent painless subconjunctival hemorrhage in the right eye occurring in the same spot every 2-3 weeks. The patient had a past medical history of dyslipidemia and peptic ulcer disease and a past ocular history of mono-vision LASIK (near vision OD) 2 years ago. On presentation, his visual acuity without correction was 20/200 OD and 20/30⁺¹ OS, with a normal intraocular pressure and normal pupils. Slit lamp examination showed an inferior-nasal subconjunctival hemorrhage (Fig. 1) that was not chemotic or elevated. His blood pressure was approximately 124/72 taken before and after his clinic visit. Subsequent magnetic resonance imaging (MRI) of the brain and orbits was normal. Patient was also referred to a hematologist and his workup for bleeding disorders was negative.

The patient returned for follow-up 3 weeks later and the subconjunctival hemorrhage had almost completely resolved; however, a small area of residual hemorrhage remained. The patient was seen again 3 weeks afterward, and reported that the subconjunctival hemorrhage had returned approximately 2 weeks ago. Close inspection of the area revealed a boat-shaped hemorrhage of <1 mm in area within a small out-pouching of a lymphatic vessel. This appeared to be layering of red blood cells within the lymphatics. The patient declined conjunctival biopsy and has not returned for further follow-up. To our knowledge, this is the first report of an idiopathic subconjunctival hemorrhage recurring in the same location every 2-3 weeks continuously for over 6 months.

Subconjunctival hemorrhage (SCH) is characterized by the acute appearance of a flat area of blood under the conjunctiva. SCH is diagnosed clinically and typically requires no treatment, clearing within a few weeks with good visual prognosis. However, when a hemorrhage persists or recurs, a more extensive list of differential diagnoses must be considered since there is usually an underlying cause. To date, there have been no reports in the literature of an idiopathic recurrent SCH lasting over 6 months.

According to a recent study by Mimura et al., the major current risk factors for SCH are trauma and contact lens-induced injury in younger patients, whereas hypertension is the main factor in older patients. Traumatic causes of SCH can include blunt injury, corneal burns, foreign bodies, episodes of eye rubbing, and nonaccidental traumatic asphyxia syndrome.^,  Other causes include acute hemorrhagic conjunctivitis, ocular surgery, respiratory distress, anticoagulation medications, Valsalva maneuvers, malignancies, or bleeding disorders (for instance, idiopathic thrombocytopenic purpura or genetic differences in blood coagulation factor VIII).^{,  ,  ,  ,  ,  ,  ,}  Occasionally SCH can be idiopathic. Usually the SCH will resolve without complication within 2-3 weeks and the SCH may become pink, orange, yellow, or black (if the blood remains long enough) before clearing. Permanent blood staining occurs rarely.^,  In patients where SCH is recurrent or is otherwise suspicious, a thorough assessment and possible treatment is important because SCH can occasionally be suggestive of serious or even life-threatening conditions like leukemia or other complications relating to drug usage (for instance, with warfarin) where urgent medical attention is essential.^,  This patient's presentation was unusual in that his SCH reoccurred in the same spot every 2-3 weeks over 6 months. The patient declined a conjunctival biopsy of the area, which likely would have shown a plexus of venous lymphatic vessels on pathology. To our knowledge, this is the first report of an idiopathic recurrent subconjunctival hemorrhage lasting longer than 6 months.