Original Paper
Ophthalmologica 2010;224:90–95
DOI: 10.1159/000235798
Location and Extent of Subconjunctival
Hemorrhage
Tatsuya Mimura a Satoru Yamagami a Tomohiko Usui a Hideharu Funatsu b
Hidetaka Noma b Norihiko Honda a Shima Fukuoka a Hiroshi Hotta a
Shiro Amano a
a
Department of Ophthalmology, University of Tokyo Graduate School of Medicine, Tokyo, and
b
Department of Ophthalmology, Yachiyo Medical Center, Tokyo Women’s Medical University, Chiba, Japan
Key Words
Subconjunctival hemorrhage ⴢ Location ⴢ Hypertension ⴢ
Trauma
Abstract
Purpose: Subconjunctival hemorrhage (SCH) is a relatively
frequent disease; however, there have been no reports about
its location and extent. We examined its location and extent.
Methods: A total of 151 patients with SCH aged 2–94 years
were studied. The conjunctiva was divided into 8 equal ar-
eas. The age, gender, medical history, ocular history and site
of hemorrhage were determined for all subjects. Results:
The number of areas involved by SCH showed an age-related
increase. Traumatic SCH had a smaller extent compared with
SCH related to hypertension, diabetes and hyperlipidemia,
or idiopathic SCH. Overall, SCH was significantly more com-
mon in the inferior areas than the superior areas (55.3% vs.
25.0%, p ! 0.000001). In patients with SCH secondary to trau-
ma or diabetes, however, the temporal areas were affected
more often than the nasal areas (61.5% vs. 30.8% and 73.3%
vs. 20.0%, respectively). Conclusion: SCH showed an age-re-
lated increase in extent and was predominant in the inferior
areas. However, traumatic SCH was usually detected as local-
ized hemorrhage in the temporal areas.
Copyright © 2009 S. Karger AG, Basel
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Received: December 12, 2008
Accepted after revision: January 29, 2009
Published online: August 28, 2009
Introduction
Subconjunctival hemorrhage (SCH) is a common eye
condition that is characterized by the acute appearance
of a flat area of bleeding under the conjunctiva. Gener-
ally, it is a benign disorder with a good visual prognosis.
An association between SCH and hypertension [1–3],
trauma [1, 3], acute hemorrhagic conjunctivitis [1, 3, 4]
and anticoagulant therapy [5, 6] has been reported previ-
ously. Among older patients, it is well known that SCH is
associated with common systemic vascular disorders
such as hypertension, arteriosclerosis and diabetes [1, 7].
SCH has some well-known clinical features, but there
have been no reports about its location and extent. Ac-
cordingly, this study was performed (1) to examine risk
factors for SCH, (2) to determine the incidence of SCH at
each conjunctival location and (3) to find out the extent
of SCH.
Materials and Methods
Subjects
This study was performed in accordance with the Helsinki
Declaration of 1975 and its 1983 revision. Institutional Review
Board approval was obtained and each subject gave informed
consent. Consecutive patients attending our outpatient clinic
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Tatsuya Mimura, MD, PhD
Department of Ophthalmology
University of Tokyo Graduate School of Medicine, 7-3-1 Hongo
Bunkyo-ku, Tokyo 113-8655 (Japan)
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 Superior 80
S
S /N 60
S /T

Temporal
40

Nasal
T C o rn e a N
20

I/T I/N
I 0
1 2 3 4 5 6 7 8
a Inferior b Number of areas involved

Fig. 1. Location and extent of SCH. a Location of SCH. The conjunctiva was divided into 8 equal areas as fol-
lows: superior (S), superior/nasal (S/N), nasal (N), inferior/nasal (I/N), inferior (I), inferior/temporal (I/T), tem-
poral (T) and superior/temporal (S/T). b Extent of SCH in all patients. The size of each hemorrhage is expressed
as the number of areas involved (1–8), which was determined as shown in a.

Table 1. Profile of the patients with SCH ing with fluorescein or rose bengal, and Schirmer 1 test results of
less than 5 mm or tear BUT of less than 5 s were diagnosed to have
Number Age, years dry eye.
of patients
Location of SCH
Total 151 (100) 63.7818.1 The anterior segment was examined with a slit lamp and color
Ocular history photographs were taken using a digital camera (Nikon Coolpix
Cataract surgery 18 (11.8) 73.486.7 4500; Nikon, Tokyo, Japan) mounted on a slit lamp. To examine
Current cataract 28 (18.4) 68.887.1 the extent of SCH, we divided the conjunctiva into 8 equal areas
Glaucoma 11 (7.2) 64.9810.2 as follows: superior, superior/nasal, nasal, inferior/nasal, inferior,
Allergic conjunctivitis 13 (8.6) 66.2811.5 inferior/temporal, temporal and superior/temporal (fig. 1a).
Dry eye 9 (5.9) 54.5818.5 Then, location of small SCH was determined by examining the
Diabetic retinopathy 3 (1.9) 67.086.4 anterior segment photograph. As for large SCH, the presence (de-
Associated factors fined as SCH occupying more than half of the area) or absence of
Trauma 13 (8.6) 32.0826.8 SCH was also determined for each area by the anterior segment
Hypertension1 55 (36.2) 71.5810.1 photograph.
Diabetes1 15 (9.9) 65.785.8
Hyperlipidemia1 14 (9.2) 62.488.6 Statistical Analysis
Anticoagulant therapy1 6 (3.9) 69.787.0 The unpaired Student’s t test was used to compare mean val-
Idiopathic 59 (38.9) 61.1816.1 ues. One-way analysis of variance and Scheffe’s multiple compar-
ison test were used for multiple comparisons, while the ␹2 test was
Figures in parentheses are percentages. used to compare differences of percentages between the two
1
Some subjects had multiple factors. groups. The level of significance was set at p ! 0.05, and analyses
were done by using Stat View statistical software (Abacus Con-
cepts, Berkeley, Calif., USA).

were enrolled. SCH was diagnosed in a total of 151 patients (80

males and 71 females; age range 2–94 years) by slit lamp examina-
tion. Each patient’s age, gender, medical history and ocular his-
tory were assessed at the initial visit. Patients with atraumatic
subconjuctival hemorrhage were referred to general physicians,
and the diagnosis of hypertension, diabetes and hyperlipidemia
was based on data from their clinical records. Hypertension was
defined as treatment with antihypertensive drugs or a blood pres-
sure 1140/90 mm Hg. Contact lens wearers were excluded from
the study. Patients with dry eye-related symptoms, positive stain-
Results
Figure 1b shows the extent of SCH, revealing a peak of
3 regions. Figure 2 shows the number of areas affected by
SCH in each age group, revealing an age-related increase
in the extent of SCH (p = 0.00510, one-way analysis of
variance). Traumatic SCH was associated with a smaller
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 8
p = 0.0047
p = 0.0034
6
p = 0.0005

Number of areas
8
p = 0.0381
Number of areas

4
6

4
2

0
0

Hyperlipidemia

Idiopathic
Hypertension

Diabetes

therapy
Anticoagulant
Trauma
0–20 21–40 41–60 61–80 81–100
(n = 8) (n = 4) (n = 40) (n = 79) (n = 20)
Years

Fig. 2. The extent of SCH in each age group. The extent of SCH is Fig. 3. The extent of SCH in relation to associated factors. Data
expressed as the number of areas involved, which was determined are expressed as the mean 8 standard deviation.
as shown in fig. 1a. Data are expressed as the mean 8 standard
deviation.

the inferior areas than in the superior areas (55.3 vs.

% 25.0%, p ! 0.000001, ␹2 test), while no significant differ-
100 ence in its frequency was observed between the nasal and
temporal areas (44.7 vs. 50.0%, p = 0.2567, ␹2 test;
80 fig. 4).
In the patients with traumatic SCH, the frequency of
60
SCH was twice as high in the temporal areas compared
with the nasal areas (61.5 vs. 30.8%) as shown in figures 5
40
and 6a, but no significant difference was found because
20
of the small number of subjects (p = 0.1156, ␹2 test). In
patients with diabetes, the frequency of SCH was higher
0 in the temporal areas compared with the nasal areas (73.3
Area S S/N N I/N I I/T T S/T vs. 20.0%, p = 0.003414, ␹2 test), while no significant dif-
Superior Inferior Superior ference was observed between the 2 sides in patients with
Nasal Temporal
hypertension, hyperlipidemia or idiopathic SCH (fig. 5).
SCH due to anticoagulant therapy showed no statistical
patterns of area and extent, probably because of its low
Fig. 4. The frequency of SCH affecting each area in all patients. frequency (n = 6; fig. 3, 5, 6b).

extent of hemorrhage, but there was no significant differ-
ence in the number of areas involved among various as-
sociated factors for SCH (p = 0.71028, one-way analysis
of variance; fig. 3).
Figures 4 and 5 show the distribution of SCH. Overall,
SCH was most often localized to the inferior/temporal
areas (65.1%). SCH was significantly more common in
Discussion
Although SCH is a relatively common eye condition,
only a few studies have addressed the risk factors for SCH
and its localization. In this study, we made the first de-
tailed assessment of the clinical features and extent of
SCH. We found that the incidence of SCH increased with
age. The main reason for this was assumed to be that the
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 % %

100 100

80 Trauma (n = 13) 80 Hypertension (n = 55)

60 60

40 40

20 20

0 0
Area S S/N N I/N I I/T T S/T S S/N N I/N I I/T T S/T

% %

100 100

80 Diabetes (n = 15) 80 Hyperlipidemia (n = 14)

60 60

40 40

20 20

0 0
Area S S/N N I/N I I/T T S/T Area S S/N N I/N I I/T T S/T

% %

100 100

80 Anticoagulant 80 Idiopathic (n = 59)

therapy (n = 6)

60 60

40 40

20 20

0 0
Area S S/N N I/N I I/T T S/T Area S S/N N I/N I I/T T S/T

Fig. 5. The frequency of SCH due to each associated factor in each area.

prevalence of hypertension, which is a major risk factor
for SCH, also increases markedly after the age of 50 years
[8–12]. Additionally, diseases such as diabetes mellitus
and hyperlipidemia, as well as the complications of anti-
coagulant therapy, show an increase with age. In con-
trast, traumatic SCH tended to occur in younger patients.
Nontraumatic causes for SCH such as eye rubbing (espe-
cially when vigorous) and Valsalva maneuvers during
coughing, sneezing, lifting or straining at stool, may be
included as a possible cause of idiopathic SCH.
Trauma often resulted in localized SCH or hemato-
ma at the site of injury. In the patients with systemic
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Fig. 6. Anterior segment photographs
showing SCH. a An 18-year-old girl pre-
sented with a small temporal inferior SCH
of the left eye after accidental poking with
a finger. b A 62-year-old woman presented
with a large temporal SCH of the left eye
that was associated with anticoagulation a b
therapy.
vascular disorders such as hypertension, arteriosclero-
sis and diabetes, however, SCH was more likely to be
extensive. The typical location of SCH was confined to
3 areas of the conjunctiva, while the number of areas
involved showed an increase with age. SCH occurs in
the space between Tenon’s capsule and the conjunctiva,
and bleeding rarely extends under the entire conjunc-
tiva in healthy younger people. In contrast, the fragile
fibrous connections between the conjunctiva and Ten-
on’s capsule may allow easier spread of SCH in elderly
people because elastic and connective tissues become
more fragile with age.
Regarding the influence of associated factors, trau-
matic SCH tended to involve a smaller area than SCH as-
sociated with systemic vascular disorders such as hyper-
tension, diabetes and hyperlipidemia. There are 2 funda-
mental reasons for this. First, trauma may be more
common in younger persons whose conjunctiva still
maintains a strong connection with Tenon’s capsule. Sec-
ond, younger patients with traumatic SCH have no sys-
temic vascular disorders to promote continuous bleed-
ing. However, we cannot comment on the pattern of SCH
secondary to anticoagulant therapy because of the small
number of subjects.
SCH was more often found in the inferior areas of the
conjunctiva than in the superior areas. The origin of the
hemorrhage was presumably at the apex of the involved
area, and the effect of gravity would cause SCH to more
often occupy the lower areas of the conjunctiva, such as
the inferior/nasal, inferior or inferior/temporal areas.
The frequency of traumatic SCH was significantly
higher in the temporal areas than in the nasal areas.
There may be several possible reasons for this finding.
First, the temporal bulbar conjunctiva is larger than the
nasal conjunctiva. Second, the nose protects the nasal as-
pect of the eyeball from sources of trauma. Third, the
other eye can easily identify flying objects (such as balls,
insects, metal fragments and fireworks) on the nasal side,
94 Ophthalmologica 2010;224:90–95
Color version available online
while it is more difficult to detect projectiles in the tem-
poral field because of loss of binocular input.
The extent of SCH was larger in patients who had un-
dergone cataract surgery than in patients with cataracts
(data not shown). This suggests that conjunctivochalasis
after cataract surgery may be related to the occurrence
and extent of SCH. A scleral incision is made at the upper
limbus after the perilimbal conjunctival incision during
cataract surgery at our hospital. Conjunctival and scleral
incisions may cause more severe conjunctivochalasis af-
ter cataract surgery compared with corneal incisions.
Another reason is that the patients who had already un-
dergone cataract surgery were significantly older than
the patients with cataracts (73.4 8 6.7 vs. 68.8 8 7.1, p =
0.0366, unpaired t test). Accordingly, it is still unclear
whether age-related changes of the conjunctiva or post-
operative complications such as conjunctivochalasis are
more important for the occurrence of SCH in patients
undergoing cataract surgery. An age-matched case-con-
trol study of patients with and without cataract surgery
would be required to determine the main reason for SCH
after cataract surgery.
Several research groups have previously reported evi-
dence of a relationship between keratoconjunctivitis sicca
and conjunctivochalasis [13–16]. Additionally, we also
found that patients with idiopathic SCH had severe con-
junctivochalasis-induced dry eye including SPK (data not
shown). Dry eye-related conjunctivochalasis may have an
important role in the pathogenesis of idiopathic SCH.
One major limitation of this study is that it was not
designed to examine the initial site of bleeding. Regard-
ing SCH associated with systemic vascular disease, fu-
ture studies should be done to evaluate the site of subcon-
junctival vascular occlusion by fluorescein angiography.
In summary, we presented the first observational study
on the location and extent of SCH. We found that the ex-
tent of SCH increased with age, while typical traumatic
SCH was localized to the temporal bulbar conjunctiva.
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