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[Eye Reports 2011; 1:e6] [page 15]

Spontaneous ipsilateral 
subconjunctival hemorrhage
and the related risk factors
Evgenia Kanonidou,1 Vasileios Konidaris,2

Christina Kanonidou,3 Nikolas Ziakas2

1Department of Ophthalmology, General
Hospital of Veria, Veria; 2Department of
Ophthalmology, Aristotle University of
Thessaloniki, AHEPA University Hospital;
3Postgraduate Student, Aristotle
University of Thessaloniki, Thessaloniki,
Greece

Abstract 

The aim of the report is to assess the risk
factors among patients with spontaneous ipsi-
lateral subconjunctival hemorrhage (SCH)
who presented to the outpatients’ department
in General Hospital of Veria, Veria, Greece.
Thirty-five patients with SCH participated in
the study. A thorough case history was taken
and a full ophthalmic examination was per-
formed to identify the risk factors related to
the clinical finding. The common hematologi-
cal parameters associated with the coagulation
profile of each patient were evaluated. With
the exception of SCH, the ophthalmic exami-
nation was normal in all patients. Identified
risk factors include history of systemic hyper-
tension (21 patients [60%], mean systolic
value: 170 mmHg±15 mmHg), strenuous exer-
cise [19 patients (54%)] and minor ocular
trauma [5 patients (14%)]. Other risk factors
[each in 2 patients (6%)] included: diabetes
mellitus, smoking, severe cough, straining at
stool, and weight lifting. Seven patients (20%)
were under medication related to bleeding
diathesis. The values of the blood coagulation
parameters were within the normal limits in
all patients. Twenty-nine patients (83%) had
elevated blood pressure during the ophthalmo-
logical examination. Our study provides docu-
mentation regarding the potential risk factors
associated with SCH. It is interesting to
observe the high incidence of hypertension
among the patients with SCH. Therefore, it is
highly recommended that the blood pressure
be checked in all patients with SCH and that
the patients be referred to a general practition-
er for further management if indicated. 

Introduction

Subconjunctival hemorrhage (SCH) is a
commonly presenting clinical problem for an

ophthalmologist.1,2 In several studies in gener-
al ophthalmologic studies, SCHs were seen in
0.35-0.8% of patients.3,4 The clinical sign of
SCH is the presence of blood underneath the
conjunctiva, often in one sector of the eye, to
the extent in some cases that the entire view
of the sclera is obstructed.1 The purpose of this
study was to assess the risk factors among
patients with spontaneous ipsilateral SCH who
presented to the outpatient department of our
referral centre.

Materials and Methods

Participants in the study were 35 patients
(21 male and 14 female), mean age 57 years
old (SD±16), who presented to the ophthal-
mology outpatient department with sponta-
neous ipsilateral SCH. A thorough case history
was taken from each individual and a full oph-
thalmic examination (slitlamp and non-con-
tact lens fundus examination) was performed
to identify the potential risk factors related to
the clinical finding of SCH. The patients’ blood
pressure was measured at the time of presen-
tation. The common hematological parameters
associated with the coagulation profile of each
patient [i.e. platelet count (PLT) Prothrobin
time (PT), activated partial thromboplastin
time (aPTT), and international normalized
ratio (INR)] were also evaluated. The study
followed the tenets of the Declaration of
Helsinki and was approved by the local ethical
committee. Written informed consent was
obtained from all subjects prior to their partic-
ipation.

Results

The ophthalmic examination was normal in
all the patients, with the exception of SCH.
Twenty-one patients (60%) had a history of
systemic hypertension, 2 (6%) had a history of
diabetes and 2 (6%) were smokers. Nineteen
patients (54%) had a history of recent heavy
exercise; 5 patients (14%), possible minor
local trauma during sleep; 2 patients (6%),
severe coughing prior to the subconjunctival
bleeding; 2 patients (6%), straining at stool;
and, 2 patients (6%), lifting of weights. Seven
patients (20%) were under medication related
to bleeding diathesis (5 with acetylsalicylic
acid and 2 with clopidogrel bisulfate) (Figure
1). In some of the patients there was a co-exis-
tence of two or more of the risk factors under
investigation. In 19 of the patients there was
only one identified risk factor for SCH. In 8 of
the patients, there were 2 risk factors (in 5 of
the patients, the 2 were hypertension and
heavy exercise, in 1 patient, the 2 were hyper-

tension and diabetes, in 1 patient, the 2 were
smoking and minor local trauma, in 1 patient,
the 2 were smoking and medication related to
bleeding diathesis, and in 1 patient, the 2 were
severe coughing and heavy exercise). In 6 of
the patients, there were 3 risk factors (in 1 of
the patients, the 3 were hypertension, medica-
tion related to bleeding diathesis, and lift of
weight, in 1 patient, the 3 were hypertension,
severe coughing and heavy exercise, in 1
patient, the 3 were hypertension, heavy exer-
cise and minor local trauma, in patient, the 3
were hypertension, straining at stool and
heavy exercise, in 1 patient, the 3 were hyper-
tension, heavy exercise and medication relat-
ed to bleeding diathesis, and in 1 patient, the 3
were heavy exercise, lift of weight and minor
local trauma). In one patient, there were 4 risk
factors: hypertension, severe coughing, heavy
exercise and medication related to bleeding
diathesis. In another one patient, there were 5
risk factors: hypertension, diabetes, straining
at stool, medication related to bleeding diathe-
sis and lift of weight.

The values of the blood coagulation parame-
ters were between the normal limits [PLT:
256,866 (SD 51,709), PT: 11.38 (SD 0.85),
aPTT: 26.02 (SD 2.45), INR:1.02 (0.63)]. It was
interesting to observe that 29 patients (83%)
had elevated blood pressure during the oph-
thalmological examination (mean systolic
value: 170 mmHg±15 mmHg) while 30
patients (87%) mentioned that they consid-
ered that their condition should be medically
treated despite the doctor’s reassurance that
SCH is a self-limiting condition. It is also wor-
thy to mention that 2 patients (6%) visited
again the outpatients’ department in a week’s

Eye Reports 2011; volume 1:e6

Correspondence: Kanonidou, Evgenia,
Department of Ophthalmology, General Hospital
of Veria/ 97 Vlasi Gavriilidi Street, GR 55131,
Thessaloniki, Greece. Tel: +30.6974416953.
E-mail: evkanon@hotmail.com

Key words: subconjunctival, hemorrhage, risk
factors, hypertension, bleeding diathesis.

Conflict of interest: the authors report no con-
flicts of interest. 

Contributions: all the authors contributed equally.

Received for publication: 7 April 2011. 
Accepted for publication: 8 August 2011.

This work is licensed under a Creative Commons
Attribution NonCommercial 3.0 License (CC BY-
NC 3.0).

©Copyright E. Kanonidou et al., 2011
Licensee PAGEPress, Italy
Eye Reports 2011; 1:e6
doi:10.4081/eye.2011.e6

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[page 16] [Eye Reports 2011; 1:e6]

time, even though the SCH was partially
absorbed, as they were still anxious regarding
their condition.

Discussion

Though it is a non-vision threatening condi-
tion in most of the cases, SCH may reflect
blood coagulation or underlying systemic dis-
orders. A study by Pitts, et al. confirms that
blood pressure is higher in SCH than in a con-
trol group. According to this study, there is also
a high incidence of hypertension in patients
with SCH referring themselves to the ophthal-
mologists, which persists on subsequent
assessment. This finding was found true even
when the patient attributed the SCH to eye
rubbing or to a straining manoeuvre and
whether or not the fundus shows early hyper-
tensive changes.5 The high incidence of hyper-
tension by established criteria suggests that
hypertension may be an important aetiological
factor in SCH and it is recommended that all
patients with this condition have their blood
pressure checked and be referred to the gener-
al practitioner.5 A further study by Mimura, et
al. suggested that the cause of SCH in hyper-
tensive patients is microvascular damage,
which is more common in hypertensive
patients than in otherwise healthy patients.2 In
our investigation, it was interesting to observe
that blood pressure was elevated in the vast
majority of the patients with spontaneous ipsi-
lateral SCH, a fact that might possibly be relat-
ed to their concerns about their condition.
SCH develops in patients with local trauma, or
a trauma associated with retrobulbar hemor-
rhage or ruptured globe.6 SCH is also recog-
nized in whooping cough, sneezing, constipa-
tion or other forms of straining (Valsalva) and
even strangulation, where the mechanism is
thought to be raised venous pressure.2,3,6

Recurrent, bilateral and severe subconjuncti-
val hemorrhages mandate the search for an
underlying etiology, such as a blood dyscrasia,
blood clotting disorder, or recurrent increased
intrathoracic pressure caused by repetitive
vomiting or coughing spells.7 These risk fac-
tors were also assessed in our investigation. It
has also been reported that SCH can be a fea-
ture of diabetes.8 Patients with a bleeding dis-
order, such as haemophilia, or others under
anti-platelet or anticoagulant medication may
be more prone to having a SCH. In our study,
the coagulation blood tests were normal in all
the patients. SCH presents more commonly as
a spontaneous event without these etiological
factors, especially in the elderly or arterioscle-
rotic patients.9 A recent study by Mimura, et al.
reported that the peak age of occurrence of
SCH was between 61 and 70 years. Fourteen

patients (77.7%) in that study had trauma or
contact-lens-induced injury, and 4 patients
(22.3%) among the younger patients aged 0-40
years had an unknown etiology. Among the
older patients aged 61-94 years, the chief risk
factor for SCH was hypertension (47.5%), fol-
lowed by unknown etiology (39.4%) and then
diabetes (13.1%).2 SCH is self-limiting and typ-
ically resolves in two to three weeks, without
any treatment required. Artificial teardrops
can be given if a mild ocular irritation related
to corneal dryness or dellen formation from an
elevation of conjunctiva adjacent to the cornea
is present. Some authors recommend further
investigation of patients having SCH while
others suggest that reassurance alone is
required.10 In our investigation it was interest-
ing to observe the high percentage of patients
requesting prescribed medication for the treat-
ment of their condition as well as the fact that
a proportion of patients visited again the out-
patient department for further consultation
despite the doctor’s reassurance at their initial
visit. The reason for the patients' anxiety can
be contributed to the fact that SCH can be a
source of worry and an embarrassment to the
patients, mainly due to its impressive appear-
ance, but also to the mistaken belief that SCH
is related to elevated intraocular pressure,
strokes, or other serious circulatory system
disorders. Our study provides documentation
regarding the potential risk factors associated
with SCH. It is interesting to observe the high
incidence of hypertension among the patients
with SCH. It is possible that the high incidence
of hypertension is related to patients’ concerns
about their condition. Nevertheless, it is high-
ly recommended that the blood pressure be
checked in all patients with SCH at the oph-
thalmic exam visit and that the patients should
be referred to a general practitioner for further
management if indicated. 

References

1. Kanski JJ. Clinical Ophthalmology. A sys-
tematic approach. 2nd ed. Boston,
Massachusetts: Butterworth-Heinemann;
2007. p. 629.

2. Mimura T, Usui T, Yamagami S, et al.
Recent causes of subconjunctival hemor-
rhage. Ophthalmologica 2010;224:133-7.

3. Kaimbo Wa Kaimbo D. Epidemiology of
traumatic and spontaneous subconjunctival
haemorrhages in Congo. Bull Soc Belge
Ophtalmol 2009;311:31-6.

4. Leiker LL, Mehta BH, Pruchnicki MC, Rodis
JL. Risk factors and complications of sub-
conjunctival hemorrhages in patients tak-
ing warfarin. Optometry 2009; 80:227-31.

5. Pitts JF, Jardine AG, Murray SB, Barker NH.
Spontaneous subconjunctival haemor-
rhage-a sign of hypertension? Br J
Ophthalmol 1992;76:297-9.

6. op de Coul ME, Budde JH. Diagnostic image
(136). A boy with coughing fits and subcon-
junctival hemorrhage. Subconjunctival
hemorrhage secondary to whooping cough.
Ned Tijdschr Geneeskd 2003;147:805.

7. Trevor-Roper PD, Curran PV. The eye and
its disorders. 2nd ed. Oxford: Blackwell
Scientific; 1984. pp. 341-367.

8. Fukuyama J, Hayasaka S, Yamada K,
Setogawa T. Causes of subconjunctival
hemorrhage.Ophthalmologica 1990;200:63-
7.

9. Groomer AE, Terry JE, Westblom TU.
Subconjunctival and external hemorrhage
secondary to oral anticoagulation. J Am
Optom Assoc 1990;61:770-5.

10. Alder FH. Gifford’s textbook of ophthalmolo-
gy. 4th ed. Philadelphia: Saunders; 1949. pp.
196-219.

Article

Figure 1. Risk factors related to spontaneous ipsilateral subconjunctival hemorrhage in
the participants in our investigation (% percentage).

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