Case In Point: Subconjunctival Hemorrhages in a Teenage Boy

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.⁵ Staphylococcus, 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.

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.