Pictorial case study

Contributed by Dr Gwen Lewis, a GP in Windsor, Berkshire.

The case
A 58-year-old man presented urgently in the surgery one morning. He had been alarmed by the appearance of his left eye that morning.

His left eye was bright red but painless. There was no history of trauma and no discharge from his eye. He was otherwise well. He attended the surgery infrequently, having no past history of medical problems and he was taking no medication.

On examination, his left eye was obviously bright red but there was no evidence of discharge. His fundi appeared normal and his vision with glasses was normal.

What is the diagnosis, management and differential diagnosis?

Blood from a ruptured vessel escapes below the conjunctiva (SPL)

Diagnosis and management
The diagnosis is subconjunctival haemorrhage. This occurs due to rupture of one of the blood vessels lying between the conjunctiva and the sclera. It is more common with increasing age.

Usually there are no symptoms associated with the haemorrhage, although there may be a slight ache in the eye. In particular the vision is unaffected, as the haemorrhage does not extend over the pupil.

In the majority there is no apparent cause for the haemorrhage, although it may occur after trauma or after a severe bout of vomiting or coughing. In rare cases it may be due to raised BP, so this should be checked. Rarely, it may be due to a bleeding disorder or warfarin therapy.

No treatment is necessary and the patient should be advised that this is a harmless condition with no sequelae. The haemorrhage fades over several days becoming more bruise-like and disappears in 10-14 days.

Possible different diagnoses

  • Bacterial conjunctivitis.
  • Allergic conjunctivitis.
  • Iritis.

Differential diagnosis
Iritis:

  • A more serious condition.
  • Associated with ocular or periorbital pain, photophobia and cloudy vision.
  • Patients should be referred to an ophthalmologist.

 

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