Painless flat bright-red blood under conjunctiva — self-limited; investigate trauma, anticoagulation, or recurrence.
Also known as: subconjunctival hemorrhage, subconjunctival hematoma, SCH
Overview
Extravasation of blood from small conjunctival or episcleral vessels into the potential space between the conjunctiva and the underlying sclera. Appears as a flat, sharply demarcated, bright-red patch with normal vision and no pain. The condition is benign and resolves spontaneously over 1-2 weeks.
Epidemiology
Very common in all age groups. Two peaks: young adults (trauma, contact lens use) and older adults (hypertension, anticoagulants, fragile vessels). Slight female predominance.
🔒 Free preview limit reached
Keep reading — start your free trial
You've read your 2 free diagnosis previews. Create your free account to unlock the full Subconjunctival Hemorrhage outline — plus all 514 diagnoses, 3,500+ board-style questions, flashcards, and an AI tutor. Your 7-day free trial includes everything, and there's no credit card required.
Acute hemorrhagic conjunctivitis (enterovirus 70 — bilateral hemorrhages with conjunctivitis)
Recent eye or eyelid surgery
Pathophysiology
Rupture of small conjunctival or episcleral capillaries deposits blood into the subconjunctival potential space. Because conjunctiva is loosely attached and translucent, blood becomes immediately visible as a discrete bright-red patch. Resorption proceeds through the standard hemoglobin breakdown, with the patch fading through red → orange → yellow → resolution.
Clinical presentation
Symptoms
Bright red patch noticed by patient or pointed out by family — often on awakening
PAINLESS — mild scratchy or pressure sensation at most
Normal vision
No discharge
May report preceding cough, sneeze, vomiting, lifting, straining, or trauma; sometimes no inciting event
Signs / physical exam
Sharply demarcated, FLAT, bright red patch of blood under conjunctiva
Sclera underneath is opaque (blood is in conjunctival/subconjunctival plane, not intraocular)
Pupil round and reactive; visual acuity normal; cornea clear
No injection of remainder of conjunctiva
Check blood pressure; check anticoagulation status
If trauma: examine for hyphema, ruptured globe, orbital injury, foreign body — do NOT rely on subconjunctival blood to obscure these
Classic findings
Painless, flat, well-demarcated bright-red patch under the conjunctiva with normal vision and pupil.
Differential diagnosis
Hyphema — Blood in anterior chamber (between cornea and iris), often after blunt trauma; vision affected; sickle screening; bed rest with head elevation; consider IOP control
Conjunctivitis (viral, bacterial, allergic) — Diffuse injection rather than well-demarcated red patch; discharge, itching, or follicles
Acute hemorrhagic conjunctivitis (enterovirus 70) — Bilateral subconjunctival hemorrhages plus follicular conjunctivitis in outbreak; supportive care
Kaposi sarcoma of conjunctiva — Reddish-purple plaque or nodule that persists; HIV; biopsy
If recurrent or atypical: CBC, PT/INR, PTT, platelets, liver function; consider von Willebrand workup if suggestive bleeding history
Blood pressure measurement is essential
Imaging
No imaging required for typical isolated SCH
If trauma — examine for hyphema, ruptured globe; CT orbits if orbital fracture or intraocular foreign body suspected
Diagnostic algorithm
Feature
Subconjunctival Hemorrhage
Hyphema
Conjunctivitis
Location of blood/red
Under conjunctiva; flat patch
Anterior chamber (between cornea and iris)
Diffuse conjunctival injection
Pain
None
Often present, may be severe
Mild to moderate; itching in allergic
Vision
Normal
Often decreased
Usually preserved (unless keratitis)
Trauma history
Sometimes
Almost always
Rare
Workup
BP; consider anticoagulation review
Sickle screen, IOP, exclude ruptured globe
Clinical; based on type
Treatment
Reassurance, lubrication
Bed rest, head elevation, IOP control, ophthalmology
Per etiology (viral/bacterial/allergic)
Subconjunctival hemorrhage vs hyphema vs conjunctivitis — quick differentiator.
Treatment
First-line
Reassurance — SCH is benign and self-resolves over 1-2 weeks; color fades through red → yellow before disappearing
Artificial tears for any mild irritation
Cold compresses initially (24-48 h) followed by warm compresses can speed perceived resolution
Avoid aspirin/NSAIDs and vigorous activity if recent or extensive (clinical judgment)
Address blood pressure if elevated; review anticoagulation but generally do not interrupt unless indicated
Second-line / adjunct
Recurrent (>2-3 episodes) or bilateral: evaluate for bleeding disorder, hypertension, anticoagulation adjustment, or systemic disease
Refer to ophthalmology for: associated trauma with possible globe injury, vision change, pain, persistent (>3 weeks) or atypical lesion suspicious for malignancy, or coexisting hyphema
Manage hypertension and any underlying contributors
Complications
Cosmetic only — no visual or anatomic sequelae from isolated SCH
Recurrence flags a workup for hypertension or bleeding diathesis
If associated with trauma — risk lies with concomitant injuries (hyphema, globe rupture, orbital fracture) that must not be missed
PANCE pearls
Painless, flat, bright-red patch with normal vision and pupil = subconjunctival hemorrhage, not conjunctivitis or hyphema.
Always check BP, anticoagulation, and trauma history — and examine carefully for hyphema or ruptured globe in the setting of trauma.
Reassurance is the treatment; expect resolution in 1-2 weeks with color fading through orange-yellow.
Bilateral SCH with conjunctivitis in an outbreak — think enterovirus 70 (acute hemorrhagic conjunctivitis).
Recurrent SCH should prompt workup for hypertension, bleeding disorder, or systemic anticoagulant effect; isolated, infrequent SCH does not require labs.
A persistent vascular or pigmented lesion that does not resolve is not SCH — biopsy to exclude malignancy.
References
AAO EyeWiki — American Academy of Ophthalmology. Subconjunctival Hemorrhage (EyeWiki, accessed 2026)
Mimura 2013 — Mimura T et al. Subconjunctival hemorrhage and conjunctivochalasis. Ophthalmology 2009;116(10):1880-1886
Tarlan 2013 — Tarlan B, Kiratli H. Subconjunctival hemorrhage: risk factors and potential indicators. Clin Ophthalmol 2013;7:1163-1170
Practice EENT questions on FirstPassPA
Turn this outline into retention. 3,500+ board-style questions with an AI tutor that explains every answer — free to start, no card required.
Educational use only. This outline is a study aid for PA students and is not medical advice or a substitute for clinical judgment. FirstPassPA is an independent study tool and is not affiliated with, endorsed by, or sponsored by NCCPA. PANCE® and PANRE® are registered trademarks of the National Commission on Certification of Physician Assistants.