Treatment Plan

Allaying Patient Concerns Over Subconjunctival Hemorrhages

BY LEO SEMES, OD, FAAO

We've all encountered patients who have varying degrees of anxiety over subconjunctival hemorrhage (SCH). Typically, this presentation is an incidental, nonrecurring event, and we can reassure patients that a one-time occurrence is often related to a specific incident. However, in rare instances it may signal a more significant situation.

Causes of SCH

Recently, a review article considered what etiologies and risk factors are associated with SCH (Tarlan and Kiratli, 2013). The authors delineate nicely the well-known causes such as trauma, conjunctivochalasis, and ocular surgery.

They note that among contact lens wearers (frequency of 5.6 percent), generally the SCHs are located temporally when related to the trauma of improper application or removal of a lens or to a damaged lens. Importantly, when the hemorrhage is inconsistently located in a contact lens wearer, other considerations then come into play.

Management Strategies

When SCHs are incidental, generally patient reassurance, tear supplements for "cushioning," and "tincture of time" are appropriate for a single incident. However, make sure to advise patients that recurrent episodes warrant further investigation.

However, what about alternative management options? Another recent report suggested that among post-op LASIK patients, 0.025% brimonidine mitigates patient discomfort as well as hastens the resolution of SCH. Patients were administered the dilute brimonidine at the one-hour and one-day postoperative time points (Pasquali et al, 2013). For incidental, non-recurring SCHs, this may be a positive, immediate (although off-label) adjunctive treatment strategy. Note that this is a dilute brimonidine concentration compared to commercial preparations and would have to be prepared extemporaneously, ideally by a compounding pharmacy.

We also need to address cases in which the SCH is recurrent or related to systemic disorders, the most likely being systemic hypertension. A close second is the vasculopathy associated with diabetes, which may be undiagnosed (Tarlan and Kiratli, 2013). We can play a significant role in managing SCH from the systemic side as well. Communicating with a patient's primary care physician or internist provides this opportunity to participate in the patient's health care.

Among patients over 50, other systemic considerations are anticoagulant use (including over-the-counter preparations such as Ginkgo and certain vitamin supplements) that may be more likely in a setting of acute venous congestion. This umbrella covers the Valsalva maneuver, coughing episodes, or heavy lifting, for example. Additional considerations among those over 50 may include other hematological dyscrasias, which would be identified and characterized by blood testing, as well as carotid cavernous fistula (Tarlan and Kiratli, 2013).

Turning our attention to younger, non-lens wearers, infants presenting with bilateral SCH should be investigated for suspected abuse. The mechanism here as well as in younger patients who have asthma appears to be related to acute venous congestion (Tarlan and Kiratli, 2013).

Keep Anxiety in Check

The next time patients present with the easily diagnosed SCH, relieve any anxiety (theirs and yours) with proper triage and consider something beyond the traditional. CLS

For references, please visit www. clspectrum.com/references.asp and click on document #217.

Dr. Semes is a professor of optometry at the UAB School of Optometry. He serves on the advisory board or speakers bureau of Alcon, Allergen, Optovue, Med Op, Merck, and B+L.