3.19 Sub-Conjunctival Haemorrhage

eyes.nhs.scot/
Eyecare Guidelines/
Section 3 - Conjunctiva/
3.19 Sub-Conjunctival Haemorrhage

Date of revision:

10/04/2026

Date of next review:

10/04/2028

Date of publication:

20/04/2026

Differential diagnosis ⁽¹⁾

Acute haemorrhagic conjunctivitis (AHC)
Viral conjunctivitis (often enterovirus; typically bilateral with small, multiple haemorrhages)
Retrobulbar haemorrhage
Conjunctival neoplasms (e.g. lymphoma) with secondary haemorrhage
Kaposi’s sarcoma, presenting as red or purple vascular lesions under conjunctiva

Possible management by optometrist

Advice

Reassure the patient: Sub-conjunctival haemorrhage (S-CH) is benign and self-limiting, typically clearing within 1–2 weeks, though resolution may take longer in patients on anticoagulants ⁽¹⁾
A cold compress may help ease mild discomfort ⁽¹⁾
Advise review if symptoms fail to resolve or if haemorrhages recur ⁽¹⁾

Spontaneous S-CH

Advise patient that blood pressure (BP) is a risk factor; direct patient to have BP checked if deemed appropriate based on age and presentation ⁽⁷⁾:
- Scenario: Management of red eye | Management | Red eye | CKS | NICE
- NICE guidance Hypertension in adults: diagnosis and management
Refer the patient to their GP if ⁽¹⁾:
- S-CH is recurrent, or
- There is a history of bleeding/clotting abnormalities

Traumatic S-CH

If possible, establish cause of trauma and examine eye(s) thoroughly for other signs of injury ⁽⁷⁾
After head trauma, ensure that the posterior border of the haemorrhage is visible; inability to see it may indicate ⁽¹⁾:
- Orbital fracture
- Skull base fracture or intracranial bleeding
  Typically accompanied by additional signs such as proptosis, pupil abnormalities, or reduced vision

Treatment

Ocular lubricants for symptomatic relief if mild ocular irritation present ⁽¹⁾(drops/gel for use during the day ± unmedicated ointment for use at bedtime)⁽⁷⁾ Refer to local formularies for suitable options⁽⁶⁾
Recommend simple over the counter pain relief with advice from pharmacist if needed ^(1,7)

Typical adult dosage/duration

(Blue text = IP, black text = non-IP)

As required (see ‘Treatment’ above)

Regimens should be adjusted according to severity and patient factors (e.g. age, weight, pregnancy, renal function). Prescribing should follow local formulary and national guidance where available ⁽⁷⁾.

In cases of known sensitivities, please consult local formularies for alternative options ⁽⁷⁾.

Further management options ⁽¹⁾

Management to resolution
Refer to GP if suspicion of hypertension or bleeding disorder, or if condition is recurrent
If orbital fracture or intracranial source of haemorrhage suspected, emergency (same day) referral to A&E

Possible management in secondary care or local/community pathways where available ⁽¹⁾

See Further management options
Not normally required unless further guidance is indicated locally

College of Optometrists Clinical Management Guideline⁽¹⁾

Sub-conjunctival haemorrhage - College of Optometrists

* With special thanks to The College of Optometrists for providing the evidence framework for diagnosis and management from the Clinical Management Guidelines (CMGs) for this condition. All references to the College/CMGs are included where appropriate and form the basis of the Community Eyecare Guidelines.

Guidance is informed by the following sources

College of Optometrists Clinical Management Guidelines Clinical Management Guidelines - College of Optometrists
Advisory alignment with the College of Optometrists Formulary Optometrists' Formulary - College of Optometrists
Advisory alignment with the BNF BNF (British National Formulary) | NICE
Advisory alignment with the Summary Product Characteristics taken from the EMC Home - electronic medicines compendium (emc)
Advisory alignment with Scottish Health Board formularies (where a clear majority is present) *
Advisory alignment with expert consensus (CEGG), informed by sources 2-5 above
Advisory alignment with expert consensus (CEGG)
“Annex C of the Statement” https://www.eyes.nhs.scot/for-professionals/legislation/

* Scottish formularies should be available within the Prescribing section of your Health Board pages on the eyes.nhs.scot website. If unavailable, contact your local Health Board for further information; Health Boards landing page

If you have a query relating to this page, please email NSS.ComEyecareGuidelineGroup@nhs.scot

Disclaimers

CEG disclaimer for guidelines awaiting update:

The Eyecare Guidelines area of the eyes.nhs.scot website (“Website”) is intended as a reference source for education and clinical decision support and is intended for use by ophthalmic healthcare professionals working in Scotland.

As such, the Eyecare Guidelines are not intended for use by the general public and do not replace the advice of a healthcare professional. Members of the public should seek advice directly from their optometrist.

Before reading the Eyecare Guidelines or making any management decisions based upon them, all users should read the ‘supporting information’ page which gives more detail around the content of the Guidelines and useful website links [link to Supporting Information page].

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Users should note that that the Eyecare Guidelines guidance is not mandatory. The guidelines will not be suitable for every situation and they are not intended to be a substitute for specialist expertise and clinical judgement. Users assume all responsibility for using/interpreting the information within the Eyecare Guidelines section of the website. Users should also note that the Eyecare Guidelines should not be adhered to in isolation and should be considered in conjunction with other national and locally available guidance/pathways. 

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