Case In Point: Subconjunctival Hemorrhages in a Teenage Boy

Consultant for PediatriciansConsultant for Pediatricians Vol 5 No 11
Volume 5
Issue 11

A 13-year-old Hispanic boy presented to emergency department with a 1-day history of red eyes. The eye changes were not associated with vision changes, increased tearing, discharge, pain, fever, or trauma.

A 13-year-old Hispanic boy presented to emergency department with a 1-day history of red eyes. The eye changes were not associated with vision changes, increased tearing, discharge, pain, fever, or trauma.

The boy's parents reported that the patient had multiple episodes of vomiting and diarrhea for 4 days when he and his family returned home after a few weeks in Mexico.

On examination, we found a well-developed alert boy in no distress. Results of the systemic examination were completely normal except for extensive "redness" of his eyes (Figures). Eye examination revealed extensive bilateral subconjunctival hemorrhage without eye discharge, photophobia, or limitation of eye movement. Fundus findings and visual acuity were normal.

Causes of Subconjunctival Hemorrhage

A number of conditions can cause subconjunctival hemorrhage (SCH) in children. These include:

• Trauma. Blunt or any penetrating injury can directly cause SCH. Asphyxiating trauma can also cause petechial hemorrhages in the head and neck along with SCH.1

When SCH is detected in infants and young children, a thorough clinical examination is warranted. Evidence of non-accidental trauma or child abuse may be revealed.2 A funduscopic examination is indicated to check for retinal hemorrhages.

• Infection. Eye infections, especially conjunctivitis, can lead to SCH. Symptoms in conjunctivitis may include itching, watering, photophobia, and eye discharge (purulent or non-purulent). Chemosis may also be present.

Conjunctivitis associated with symptoms of cough, cold, and upper respiratory tract infection usually has a viral cause. Otitis media with concurrent conjunctivitis (otitis-conjunctivitis syndrome) is often caused by Haemophilus influenzae.3 Community-wide epidemics of viral conjunctivitis with consequent SCH have been reported.4

Enterovirus,4 human herpes virus,5 and respiratory tract viral infections are the chief viral causes of conjunctivitis that may lead to SCH.5Staphylococcus, Pseudomonas, and Leptospirosis are the leading causes of bacterial conjunctivitis.6

• Bleeding diathesis. Anticoagulant therapy and thrombocytopenia can lead to SCH.7-9

• Mechanical causes. Straining during sneezing, coughing (pertussis, pertussis coughing),10 chronic coughing, retching,11 and recurrent forceful vomiting11 can all cause SCH. SCH can develop in the newborn after normal vaginal delivery: the hemorrhages resolve spontaneously.12

Treatment and Management of SCH

Therapy involves the identification and treatment of the underlying condition (eg, bacterial conjunctivitis, herpetic infection, or bleeding diathesis). SCH secondary to elevated intraocular pressure usually resolves spontaneously within a few days to a week once the underlying cause is addressed. Symptoms such as vomiting, coughing, and retching should be appropriately managed whenever identified.

Outcome of the Case

As noted, our patient had no other eye symptoms (ie, lacrimation, photophobia, or vision changes) and clinical examination findings were normal. The SCH was thought to be the result of excessive vomiting and retching, which led to an intraocular pressure rise and subsequent rupture of the small vessels in the conjunctiva. The patient was hospitalized for acute gastroenteritis; as the vomiting and diarrhea resolved, the hemorrhages spontaneously resolved within a few days.




Yeong EK, Chen MT, Chu SH. Traumatic asphyxia.

Plast Reconstr Surg.



Kleemann WJ, Wiechern V, Schuck M, Troger HD. Intrathoracic and subconjunctival petechiae in sudden infant death syndrome (SIDS).

Forensic Sci Int.



Buznach N, Dagan R, Greenberg D. Clinical and bacterial characteristics of acute bacterial conjunctivitis in children in the antibiotic resistance era.

Pediatr Infect Dis J.



Kosrirukvongs P, Kanyok R, Sitritantikorn S, Wasi C. Acute hemorrhagic conjunctivitis outbreak in Thailand, 1992.

Southeast Asian J Trop Med Public Health.



Aoki K, Kawana R, Matsumoto I, et al. Viral con-junctivitis with special reference to adenovirus type 37 and enterovirus 70 infection.

Jpn J Ophthalmol.



Martins MG, Matos KT, da Silva MV, de Abreu MT. Ocular manifestations in the acute phase of leptospirosis.

Ocul Immunol Inflamm.



Sodhi PK, Jose R. Subconjunctival hemorrhage: the first presenting clinical feature of idiopathic thrombocytopenic purpura.

Jpn J Ophthalmol.

2003; 47:316-318.


Superstein R, Gomolin JE, Hammouda W, et al. Prevalence of ocular hemorrhage in patients receiving warfarin therapy.

Can J Ophthalmol.

2000; 35:385-389.


Groomer AE, Terry JE, Westblom TU. Subconjunctival and external hemorrhage secondary to oral anticoagulation.

J Am Optom Assoc.



Reisli I, Keles S, Kamis U, et al. Picture of the month: coughing paroxysms associated with subconjunctival hemorrhage and dellen.

Arch Pediatr Adolesc Med.



Weinstein HD, Halabis JA. Subconjunctival hemorrhage in bulimia.

J Am Optom Assoc.

1986;57: 366-367.

12.Katzman GH. Pathophysiology of neonatal subconjunctival hemorrhage. Clin Pediatr (Phila). 1992;31:149-152.

Related Videos
Courtney Nelson, MD
Tina Tan, MD, FAAP, FIDSA, FPIDS, editor in chief, Contemporary Pediatrics, professor of pediatrics, Feinberg School of Medicine, Northwestern University, pediatric infectious diseases attending, Ann & Robert H. Lurie Children's Hospital of Chicago
Related Content
© 2024 MJH Life Sciences

All rights reserved.