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ophtho.subconjunctival-hemorrhage.core.v1PRODUCTION
ophtho.subconjunctival-hemorrhage.core.v1

Subconjunctival haemorrhage

general_internal_medicineacutesubacuteadultpediatricgeriatric
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12/12 authored

Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

Frame SCH as the BENIGN PIVOT of the acute red eye: a self-limited extravasation of blood between conjunctiva and sclera with intact vision, no pain, no discharge — but a presentation that must be CONFIRMED isolated and screened for the situations where it is a flag (significant trauma → open globe; spontaneous on anticoagulant; recurrent/bilateral → bleeding diathesis / HTN / occult trauma-NAI / neoplasm). This engine OWNS confirmation + reassurance + the danger screen; definitive management of trauma/globe-rupture and of the systemic drivers is routed OUT by engine_id (Tarlan & Kiratli Clin Ophthalmol 2013 PMID 23843690; Wills Eye Manual).

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SCH framed as benign-pivot; danger-screen + route-out targets flagged by engine_id

Patient inputs (15)

Discharge, true photophobia or itch are ABSENT in isolated SCH; their presence pivots to conjunctivitis / episcleritis-scleritis / uveitis rather than SCH (Wills Eye Manual; AAO PPP Conjunctivitis 2024)

Warfarin / DOAC / aspirin / P2Y12 / GP-IIb-IIIa use is the dominant spontaneous-SCH drug association; presence triggers an INR / indication review (do NOT reflexively stop) (Leiker Optometry 2009 PMID 19410227; Kul Sao Paulo Med J 2017 PMID 29267537)

Recurrence or bilaterality is the key escalation pivot — raises bleeding-diathesis, HTN, occult-trauma/NAI and (elderly unilateral recurrent) conjunctival-neoplasm priors (Tarlan & Kiratli 2013 PMID 23843690; Fierro/Gresele 2016 PMID 26087065)

Markedly elevated BP is a recognised SCH association and an opportunistic catch; severe/symptomatic hypertension routes to BP management (Tarlan & Kiratli 2013 PMID 23843690)

True benign SCH is PAINLESS (mild gritty awareness at most); genuine ocular pain means it is NOT isolated SCH — reassess for trauma/keratitis/scleritis/uveitis and return to red-eye triage (Wills Eye Manual; Tarlan & Kiratli 2013 PMID 23843690)

Visual acuity is NORMAL in isolated SCH; any reduction (especially post-trauma) is a danger sign mandating open-globe / hyphema / posterior-segment work-up — not benign SCH (Wills Eye Manual red-eye triage)

Significant blunt/penetrating trauma requires open-globe / ruptured-globe exclusion BEFORE attributing redness to benign SCH; high-velocity / sharp / hammering mechanism raises occult-rupture prior (Wills Eye Manual; Mimura Am J Ophthalmol 2010 PMID 20709310)

Bullous / circumferential 360° SCH, SCH with no visible posterior limit, or marked haemorrhagic chemosis after trauma is a globe-rupture red flag — route OUT to ophtho.ocular-trauma.core.v1 (Philip Am J Ophthalmol Case Rep 2021 PMID 33732947; Wills Eye Manual)

Normal round reactive pupil, clear cornea, formed anterior chamber with no layered blood and normal IOP confirm isolated SCH; peaked/irregular pupil, hyphema, shallow AC or hypotony reframe as open-globe / hyphema (Wills Eye Manual; Tarlan & Kiratli 2013 PMID 23843690)

Elderly, recurrent, unilateral SCH or any fleshy/atypical conjunctival lesion behind the blood mandates lesion inspection to exclude conjunctival neoplasm / Kaposi rather than presumed simple SCH (Redzuwan Cureus 2023 PMID 37846262; Tarlan & Kiratli 2013 PMID 23843690)

Mucocutaneous bleeding elsewhere (epistaxis, gum bleeding, menorrhagia, easy bruising) alongside recurrent SCH is what raises true bleeding-disorder yield — isolated recurrent SCH alone does not (Fierro/Gresele Clin Chem Lab Med 2016 PMID 26087065)

Severe Valsalva (vomiting, paroxysmal/whooping cough, labour, weightlifting), birth, or a paediatric presentation contextualises a benign mechanical SCH and flags the NAI question when the history does not fit (Karademir North Clin Istanb 2023 PMID 36910442)

Contact-lens-associated SCH is a recognised benign entity (conjunctivochalasis/pinguecula substrate); confirms a benign mechanical cause but warrants lens-hygiene review (Mimura Am J Ophthalmol 2010 PMID 20709310; Mimura Ophthalmology 2009 PMID 19596440)

Pregnancy/labour Valsalva is a benign SCH context; also drug-safety gating for any (rare) systemic agent and a prompt to review pre-eclampsia if BP elevated (Tarlan & Kiratli 2013 PMID 23843690)

In an anticoagulated patient with spontaneous SCH, a supratherapeutic INR is an actionable cause warranting dose review; a therapeutic INR still permits benign SCH and reassurance (Leiker Optometry 2009 PMID 19410227 — 77% in-range; Philip 2021 PMID 33732947 — rare severe even at therapeutic INR)

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Severity triggers (7)

7 need judgement
  • informationallife_threateningtraumatic_sch_must_exclude_open_globe_route_out
    SCH after significant blunt/penetrating trauma, OR bullous / 360° circumferential SCH, OR SCH with no visible posterior limit, reduced visual acuity, peaked/irregular pupil, hyphema, shallow AC, hypotony or Seidel-positive (Philip Am J Ophthalmol Case Rep 2021 PMID 33732947; Wills Eye Manual)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverepain_or_vision_change_NOT_sch_reassess
    True ocular pain, reduced/blurred visual acuity, discharge, or true photophobia accompanying the redness — incompatible with isolated benign SCH (Wills Eye Manual; AAO PPP Conjunctivitis 2024)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverepediatric_inconsistent_history_NAI_screen
    Paediatric SCH with an inconsistent, absent or implausible mechanism (no birth/Valsalva/trauma context), or bilateral paediatric SCH with no explanation (Karademir North Clin Istanb 2023 PMID 36910442)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatespontaneous_sch_on_anticoagulant_check_inr
    Spontaneous SCH in a patient on warfarin / DOAC / antiplatelet / GP-IIb-IIIa — check INR; supratherapeutic anticoagulation is a real, actionable cause (Leiker Optometry 2009 PMID 19410227; Kul Sao Paulo Med J 2017 PMID 29267537)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderaterecurrent_or_bilateral_sch_bleeding_workup
    Recurrent or bilateral SCH, especially WITH other mucocutaneous bleeding (epistaxis, gum bleeding, menorrhagia, easy bruising) (Tarlan & Kiratli Clin Ophthalmol 2013 PMID 23843690; Fierro/Gresele Clin Chem Lab Med 2016 PMID 26087065)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderateelderly_unilateral_recurrent_neoplasm_exclusion
    Elderly (or immunocompromised) patient with recurrent unilateral SCH, persistence beyond 3 weeks, or any fleshy / feeder-vessel / atypical conjunctival lesion behind the blood (Redzuwan Cureus 2023 PMID 37846262; Tarlan & Kiratli 2013 PMID 23843690)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatesevere_or_symptomatic_hypertension
    SCH with markedly elevated blood pressure (e.g., severe/Stage-2 or symptomatic), or resistant / young-onset hypertension (Tarlan & Kiratli Clin Ophthalmol 2013 PMID 23843690)
    Trigger could not be auto-evaluated — needs clinician judgement.

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Recommended regimen

Subconjunctival haemorrhage — reassurance / observation (no specific treatment) + conditional routed axes
axis: sch_reassurance_observation_and_conditional_routingstep 1 - Step 1 — Confirm isolated benign SCH, then reassure (NO specific treatment)
Selected step "Step 1 — Confirm isolated benign SCH, then reassure (NO specific treatment)" — Painless, flat, sharply demarcated bright-red patch with normal visual acuity, normal pupil/cornea/IOP, no discharge/photophobia, no significant trauma, not recurrent/bilateral
  • reassurance_self_limited_resolves_1_to_2_weeks_no_specific_treatment
    first line
    observation
    triggers: isolated_benign_sch_confirmed
    Tarlan & Kiratli Clin Ophthalmol 2013 (PMID 23843690) + Jeon Ophthalmic Epidemiol 2021 (PMID 34793286 — SCH itself is not a stroke/AMI risk factor) — isolated SCH is self-limited and needs NO specific treatment; resolves over 1-2 weeks (up to ~3 wk for large bleeds), colour evolves like a bruise. The therapeutic action is reassurance + return precautions.
  • cold_compress_first_24_to_48h_then_warm_compress
    add on
    supportive
    triggers: symptomatic_or_extensive_sch
    Wills Eye Manual — cold compress in the first 24-48 h to limit extension, then warm compress to speed clearance; mechanical/symptomatic adjunct only (no drug).
  • preservative_free_artificial_tears_if_surface_irritation
    add on
    ocular_lubricant
    triggers: ocular_surface_irritation_or_foreign_body_sensation
    AAO PPP Conjunctivitis 2024 / Wills Eye Manual — lubrication only if the raised blood causes mild surface irritation; NOT a treatment for the haemorrhage itself; no topical antibiotic (no infection).

outpatient playbook — drug actions (0)

No drug actions defined for this setting.

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: Bright-red, painless, flat, sharply demarcated patch under the conjunctiva with NORMAL vision — the classic benign SCH and the most reassuring red eye (Tarlan & Kiratli Clin Ophthalmol 2013 PMID 23843690; Wills Eye Manual red-eye triage); Spontaneous SCH in a patient on warfarin / DOAC / antiplatelet — check INR; supratherapeutic anticoagulation is a real actionable cause; do NOT reflexively stop the agent (Leiker Optometry 2009 PMID 19410227; Philip Am J Ophthalmol Case Rep 2021 PMID 33732947); Recurrent or bilateral SCH — pivot to bleeding diathesis / HTN / occult trauma or NAI (paediatric) / severe Valsalva / conjunctival neoplasm in the elderly (Tarlan & Kiratli 2013 PMID 23843690; Fierro/Gresele Clin Chem Lab Med 2016 PMID 26087065).

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Subconjunctival haemorrhage** (ophtho.subconjunctival-hemorrhage.core.v1).
Phenotype framing: Terminal differential with explicit pivot findings — ISOLATED BENIGN SCH: painless + normal acuity + flat + sharply demarcated + bright-red + no discharge + normal pupil/cornea/IOP + posterior limit visible pivot. DANGEROUS / NOT-SCH look-alikes: open / ruptured globe (significant trauma + bullous/360° SCH + reduced acuity + peaked pupil + hypotony + Seidel pivot — route to ophtho.ocular-trauma.core.v1); hyphema (layered red blood in the anterior chamber, not under conjunctiva, after trauma pivot); conjunctivitis (discharge + itch + bilateral + diffuse injection NOT a discrete blood patch pivot); episcleritis / scleritis (sectoral/violaceous injected vessels that blanch (epi) or boring pain (scleritis), not extravasated blood pivot); conjunctival laceration (focal trauma + Seidel/fluorescein + foreign-body pivot); conjunctival neoplasm / Kaposi sarcoma (fleshy/feeder-vessel/recurrent in elderly or immunocompromised + persistent beyond expected resolution pivot — biopsy). Co-existence flagged (e.g., SCH overlying an occult rupture; SCH plus a small hidden conjunctival mass) — the blood must not hide the lesion (Redzuwan Cureus 2023 PMID 37846262; Wills Eye Manual).
Scope: Frame SCH as the BENIGN PIVOT of the acute red eye: a self-limited extravasation of blood between conjunctiva and sclera with intact vision, no pain, no discharge — but a presentation that must be CONFIRMED isolated and screened for the situations where it is a flag (significant trauma → open globe; spontaneous on anticoagulant; recurrent/bilateral → bleeding diathesis / HTN / occult trauma-NAI / neoplasm). This engine OWNS confirmation + reassurance + the danger screen; definitive management of trauma/globe-rupture and of the systemic drivers is routed OUT by engine_id (Tarlan & Kiratli Clin Ophthalmol 2013 PMID 23843690; Wills Eye Manual).

No severity triggers fired against current inputs.

Plan

Regimen axis: **Subconjunctival haemorrhage — reassurance / observation (no specific treatment) + conditional routed axes** — step "Step 1 — Confirm isolated benign SCH, then reassure (NO specific treatment)".
1. reassurance_self_limited_resolves_1_to_2_weeks_no_specific_treatment (observation, first line) — Tarlan & Kiratli Clin Ophthalmol 2013 (PMID 23843690) + Jeon Ophthalmic Epidemiol 2021 (PMID 34793286 — SCH itself is not a stroke/AMI risk factor) — isolated SCH is self-limited and needs NO specific treatment; resolves over 1-2 weeks (up to ~3 wk for large bleeds), colour evolves like a bruise. The therapeutic action is reassurance + return precautions.
2. cold_compress_first_24_to_48h_then_warm_compress (supportive, add on) — Wills Eye Manual — cold compress in the first 24-48 h to limit extension, then warm compress to speed clearance; mechanical/symptomatic adjunct only (no drug).
3. preservative_free_artificial_tears_if_surface_irritation (ocular_lubricant, add on) — AAO PPP Conjunctivitis 2024 / Wills Eye Manual — lubrication only if the raised blood causes mild surface irritation; NOT a treatment for the haemorrhage itself; no topical antibiotic (no infection).

Non-pharmacologic actions:
- Reassure: self-limited, resolves 1-2 weeks (up to ~3 wk if large); colour evolves red → orange/yellow (Tarlan & Kiratli 2013 PMID 23843690)
- Cold compress first 24-48 h then warm compress; preservative-free artificial tears only if surface irritation; NO antibiotic, NO patch (Wills Eye Manual)
- If anticoagulated + spontaneous: check INR; review indication/dose with the prescriber — do NOT reflexively stop (Leiker Optometry 2009 PMID 19410227)
- If markedly elevated BP: route to BP management / secondary-HTN screen (Tarlan & Kiratli 2013 PMID 23843690)
- If recurrent/bilateral WITH other bleeding: route to bleeding-disorder / heme work-up (Fierro/Gresele 2016 PMID 26087065)
- Paediatric SCH with inconsistent/absent mechanism: NAI safeguarding pathway (Karademir North Clin Istanb 2023 PMID 36910442)

AVOID / contraindication checks:
- No topical antibiotic for isolated sch (Tarlan & Kiratli Clin Ophthalmol 2013 PMID 23843690 — SCH is not an infection; antibiotics add cost/harm with no benefit)
- Do not reflexively stop anticoagulation for isolated benign sch (Leiker Optometry 2009 PMID 19410227 — review indication/INR with the prescriber; thrombotic risk of stopping usually outweighs a benign self limited bleed)
- Do not attribute redness to benign sch before excluding open globe in significant trauma (Wills Eye Manual; Philip Am J Ophthalmol Case Rep 2021 PMID 33732947)
- Do not over investigate isolated single sch (Jeon Ophthalmic Epidemiol 2021 PMID 34793286; Fierro/Gresele Clin Chem Lab Med 2016 PMID 26087065 — routine bloods low yield for an isolated event)
- Inspect conjunctiva behind the blood for an occult lesion if recurrent or elderly or immunocompromised (Redzuwan Cureus 2023 PMID 37846262)

Monitoring

Regimen monitoring:
- counsel expected worsening then clearance 24-48h to 1-3 weeks (Tarlan & Kiratli Clin Ophthalmol 2013 PMID 23843690)
- return if new pain vision change discharge photophobia or non resolution by 3 weeks (Wills Eye Manual)
- INR recheck if anticoagulated and supratherapeutic (Leiker Optometry 2009 PMID 19410227)
- BP review if elevated (Tarlan & Kiratli 2013 PMID 23843690)
- re examine conjunctiva if not resolved by 3 weeks to exclude a lesion (Redzuwan Cureus 2023 PMID 37846262)

Setting (outpatient) monitoring:
- Counsel expected transient worsening 24-48 h then clearance over 1-3 weeks (Tarlan & Kiratli 2013 PMID 23843690)
- Return precautions: any new pain, vision change, discharge, photophobia, recurrence, or non-resolution by 3 weeks (Wills Eye Manual)

Follow-up plan: Education + return precautions are the core deliverable for benign SCH — explicit RED-FLAG return: new true ocular pain, any vision drop, discharge, severe photophobia, recurrence, bilateral involvement, or non-resolution by 3 weeks → re-present. Modifiable-driver follow-up where flagged: optimise BP, review/optimise (do not reflexively stop) anticoagulation with the prescribing clinician, contact-lens hygiene, treat the Valsalva source (e.g., antitussive / pertussis management). Recurrent/bilateral or persistent → ensure the bleeding-disorder / conjunctival-neoplasm / paediatric-safeguarding pathway is closed. For routed dangerous cases, ownership transfers to the receiving engine (Tarlan & Kiratli 2013 PMID 23843690; Fierro/Gresele Clin Chem Lab Med 2016 PMID 26087065).
- Close-out criterion: return-precaution + modifiable-driver counselling documented; recurrent/persistent work-up routed if applicable

Monitoring phase: Isolated benign SCH needs no active monitoring beyond expected colour evolution; counsel that the patch often looks WORSE / spreads over the first 24-48 h before clearing — this is expected and prevents needless re-presentation. Re-evaluate only if NEW pain, vision change, discharge or photophobia emerge (re-triggers RED_FLAGS / re-triage to ophtho.acute-red-eye.core.v1) or if it has not resolved by ~3 weeks (prompts re-examination for an underlying lesion). For routed cases, confirm the receiving engine has carryover state (Jeon Ophthalmic Epidemiol 2021 PMID 34793286; Tarlan & Kiratli 2013 PMID 23843690).

Disposition

Current setting: outpatient — Confirm isolated benign SCH, reassure with explicit return precautions, and selectively catch the flag situations (anticoagulant/INR, recurrent/bilateral, HTN, neoplasm, paediatric NAI) without over-investigating a single benign event (Tarlan & Kiratli Clin Ophthalmol 2013 PMID 23843690; Jeon Ophthalmic Epidemiol 2021 PMID 34793286)

Disposition criteria:
- Isolated benign SCH → discharge to primary care with return precautions; no routine bloods, no follow-up (Jeon Ophthalmic Epidemiol 2021 PMID 34793286)
- Flag present → arrange the targeted routed work-up and document why bloods were/were not sent (Tarlan & Kiratli 2013 PMID 23843690)

Escalation triggers (move to higher acuity):
- Significant trauma / open-globe sign / reduced acuity / hyphema → shield, no pressure, NPO, route to ophtho.ocular-trauma.core.v1 same-hour (Philip Am J Ophthalmol Case Rep 2021 PMID 33732947)
- New pain / discharge / photophobia / vision change → it is NOT SCH → re-triage to ophtho.acute-red-eye.core.v1 (Wills Eye Manual)
- Persistent (>3 wk) / elderly recurrent unilateral / fleshy lesion → conjunctival-neoplasm referral (Redzuwan Cureus 2023 PMID 37846262)

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] SCH after significant blunt/penetrating trauma, OR bullous / 360° circumferential SCH, OR SCH with no visible posterior limit, reduced visual acuity, peaked/irregular pupil, hyphema, shallow AC, hypotony or Seidel-positive (Philip Am J Ophthalmol Case Rep 2021 PMID 33732947; Wills Eye Manual)
- [SEVERE] True ocular pain, reduced/blurred visual acuity, discharge, or true photophobia accompanying the redness — incompatible with isolated benign SCH (Wills Eye Manual; AAO PPP Conjunctivitis 2024)
- [SEVERE] Paediatric SCH with an inconsistent, absent or implausible mechanism (no birth/Valsalva/trauma context), or bilateral paediatric SCH with no explanation (Karademir North Clin Istanb 2023 PMID 36910442)

Citations

- Tarlan & Kiratli — Subconjunctival hemorrhage: risk factors and potential indicators (Clin Ophthalmol 2013) as the canonical SCH risk-factor / work-up authority + Wills Eye Manual red-eye triage algorithm + AAO Preferred Practice Pattern Conjunctivitis (2024) for the SCH-vs-dangerous-red-eye danger-sign set + nationwide reassurance cohorts (Jeon Ophthalmic Epidemiol 2021 — SCH not a stroke/AMI risk factor; Hong Sci Rep 2023 — not associated with increased ICH/GI bleed) + recurrent-SCH haemostatic-yield evidence (Fierro/Gresele Clin Chem Lab Med 2016) + anticoagulant-associated SCH literature (Leiker Optometry 2009; Philip Am J Ophthalmol Case Rep 2021) [PMID:23843690](https://pubmed.ncbi.nlm.nih.gov/23843690/)
- Cited evidence (PMID 34793286) [PMID:34793286](https://pubmed.ncbi.nlm.nih.gov/34793286/)
- Cited evidence (PMID 38097669) [PMID:38097669](https://pubmed.ncbi.nlm.nih.gov/38097669/)
- Cited evidence (PMID 26087065) [PMID:26087065](https://pubmed.ncbi.nlm.nih.gov/26087065/)
- Cited evidence (PMID 19410227) [PMID:19410227](https://pubmed.ncbi.nlm.nih.gov/19410227/)

Last reconciled with current guidelines: 2026-05-17.
References
  • Tarlan & Kiratli — Subconjunctival hemorrhage: risk factors and potential indicators (Clin Ophthalmol 2013) as the canonical SCH risk-factor / work-up authority + Wills Eye Manual red-eye triage algorithm + AAO Preferred Practice Pattern Conjunctivitis (2024) for the SCH-vs-dangerous-red-eye danger-sign set + nationwide reassurance cohorts (Jeon Ophthalmic Epidemiol 2021 — SCH not a stroke/AMI risk factor; Hong Sci Rep 2023 — not associated with increased ICH/GI bleed) + recurrent-SCH haemostatic-yield evidence (Fierro/Gresele Clin Chem Lab Med 2016) + anticoagulant-associated SCH literature (Leiker Optometry 2009; Philip Am J Ophthalmol Case Rep 2021) — PMID:23843690
  • Cited evidence (PMID 34793286) — PMID:34793286
  • Cited evidence (PMID 38097669) — PMID:38097669
  • Cited evidence (PMID 26087065) — PMID:26087065
  • Cited evidence (PMID 19410227) — PMID:19410227