INTRODUCTION — Trauma to the ocular surface often involves the conjunctiva. Mechanisms of injury to the conjunctiva include thermal or chemical burns and blunt or penetrating trauma. While injuries can be isolated to the conjunctiva, conjunctival injury can be the presenting sign of underlying intraocular trauma, including open globe injury. Careful evaluation, initial management, and triage of conjunctival injuries are essential to promote appropriate healing of the conjunctiva and other associated ocular injuries.
The approach to subconjunctival hemorrhage, conjunctival abrasions, conjunctival foreign bodies, and conjunctival lacerations will be reviewed here. The treatment of corneal abrasions and foreign bodies and ocular chemical burns are discussed separately.
CLINICAL ANATOMY — The conjunctiva is a thin, transparent tissue which covers the sclera and lines the inside of the eyelids (figure 1).
The conjunctiva is conventionally divided into two sections:
●Bulbar conjunctiva covering the sclera
●Tarsal conjunctiva covering the inside of the eyelids
The conjunctiva has multiple functions including producing components of the tear film and serving as a barrier to infection.
The anatomy of the eye is discussed in greater detail separately. (See "Approach to diagnosis and initial treatment of eye injuries in the emergency department", section on 'Basic Principles' and "Overview of eye injuries in the emergency department", section on 'Anatomy'.)
EPIDEMIOLOGY — Subconjunctival hemorrhages are common in the elderly (over 80 years of age), in whom they are most often associated with systemic disease, primarily hypertension. In patients under 40 years of age, ocular rather than systemic conditions, primarily minor trauma or complications from contact lens use, are the cause . Other risk factors at any age include coagulopathy (especially in patients receiving anticoagulation therapy), diabetes mellitus, and elevated venous pressure (Valsalva maneuver, coughing, vomiting). Other rare causes include amyloidosis and Kaposi sarcoma. Some adult patients report no history of trauma and note the hemorrhage after waking from sleep. Circumferential subconjunctival hemorrhage in the setting of significant blunt trauma to the eye may be a sign of globe rupture (picture 1).
Conjunctival lacerations are relatively uncommon and may be associated with an open globe, traumatic hyphema, or other serious ocular injury. In a large prospective study of patients presenting to an ocular trauma department, conjunctival or subconjunctival injuries accounted for 4 percent of the 5671 injuries evaluated . Most injuries occurred during work and involved periorbital and superficial ocular structures only. Conjunctival laceration has also resulted from airbag deployment following motor vehicle collisions [3,4]. In addition, several case series and case reports describe conjunctival lacerations in association with penetrating ocular injuries caused by exploded projectiles, eye injury from compressed air hoses, and high velocity blunt trauma from paintball guns [5-9].
Conjunctival foreign bodies most commonly consist of small particles like sand, dirt, eye lashes, or plant material. Metal from welding or grinding are also common. Rarely, foreign bodies retained in the conjunctival sac can cause prolonged symptoms [10-13].
Subconjunctival hemorrhage — Patients with subconjunctival hemorrhage may have a history of trauma or contact lens use or may report no history of trauma and note the hemorrhage after waking from sleep. A typical subconjunctival hemorrhage appears as a focal, flat, red region on the ocular surface representing a collection of blood between the sclera and the conjunctiva (picture 2). In instances of scleral rupture, intraocular blood can leak through the defect and pool in the subconjunctival space, creating a bullous, elevated subconjunctival hemorrhage (picture 3 and picture 4 and picture 1). Patients may note some foreign body sensation in the affected eye, but often have no symptoms.
The clinician should determine the most likely underlying cause. Key associated findings to elicit include :
●Minor trauma or complications from contact lens use (especially in patients younger than 40 years of age)
●History of elevated venous pressure (eg, Valsalva maneuver, coughing, or vomiting)
●Hypertension (especially in patients over 80 years of age)
●History of diabetes mellitus
●Coagulopathy (especially in patients receiving anticoagulation therapy or other signs of bleeding without an obvious alternative explanation for their subconjunctival hemorrhage) (see "Approach to the adult with a suspected bleeding disorder")
Subconjunctival hemorrhages are common in the newborn period and may persist for several weeks. However, isolated subconjunctival hemorrhages without a verifiable history of trauma in infants between the ages of 4 weeks and 12 months should raise concern for child abuse. (See "Child abuse: Eye findings in children with abusive head trauma (AHT)", section on 'Initial eye examination' and "Physical child abuse: Diagnostic evaluation and management", section on 'Physical examination'.)
Recurrent subconjunctival hemorrhages should be evaluated non-emergently by an ophthalmologist.
Conjunctival abrasion — Conjunctival abrasions occur from blunt injuries and mild chemical or thermal burns and present as an irregularity of the epithelial surface of the conjunctiva, best seen using fluorescein stain and a cobalt blue light. Regions of denuded epithelium will appear green. Corneal abrasions are also frequently present. (See "Corneal abrasions and corneal foreign bodies: Clinical manifestations and diagnosis".)
Conjunctival laceration — A conjunctival laceration results from a penetrating injury to the ocular surface and clinically presents as a full-thickness defect of the conjunctiva. Often there are associated conjunctival abnormalities, including chemosis and subconjunctival hemorrhage (picture 4) . Conjunctival lacerations may be associated with an open globe, traumatic hyphema, or other serious ocular injury. (See "Open globe injuries: Emergency evaluation and initial management" and "Traumatic hyphema: Clinical features and diagnosis" and "Approach to diagnosis and initial treatment of eye injuries in the emergency department".)
Conjunctival foreign body — Patients with conjunctival foreign bodies often report "something blowing into their eye." A history of working with power tools, blowers, or weed-whackers may indicate a higher risk of an intraocular foreign body. Conjunctival foreign bodies typically cause tearing and a foreign body sensation . If the conjunctival foreign body is embedded under the upper lid, it may cause vertical corneal abrasions with associated pain and photophobia. Lid eversion is usually necessary to locate upper lid foreign bodies. (See "Corneal abrasions and corneal foreign bodies: Clinical manifestations and diagnosis", section on 'Clinical manifestations'.)
Rarely, synthetic fibers, plant matter, or large conjunctival foreign bodies can be retained in the conjunctival sac between the inferior tarsal and bulbar conjunctiva (figure 1) [10-13]. If present for longer than a few days, these objects may be associated with local swelling, a firm palpable mass, granulation tissue, and conjunctival discharge.
Chemosis — Chemosis is a collection of serous fluid within the substance of the conjunctiva and is a nonspecific sign of conjunctival irritation. Chemosis can be seen in a wide range of conditions affecting the eye and orbit, including trauma, allergic reaction (picture 5), inflammation, hypoalbuminemic states or anasarca, and infection. It can also be seen in patients on chronic positive pressure ventilation. Rarely, chemosis may be the only conjunctival sign of an occult scleral laceration.
PRIMARY EVALUATION AND MANAGEMENT
Initial assessment — The standard trauma evaluation should be followed to evaluate for life-threatening injuries in multitrauma patients before attention is focused on the eyes. (See "Initial management of trauma in adults" and "Trauma management: Approach to the unstable child".)
The key to appropriate care of conjunctival injuries is rapid recognition of associated serious ocular injuries [14,16,17]. Any patient who has sustained a conjunctival laceration may have a concomitant open globe injury or traumatic hyphema. The clinical features and initial management of patients with these ocular injuries are summarized in the following rapid overviews (table 1 and table 2) and are discussed in detail separately. (See "Open globe injuries: Emergency evaluation and initial management", section on 'Initial emergency assessment and treatment'.)
In cooperative patients who do not have signs of an open globe injury, the eye exam should be performed in the standard fashion. (See "Corneal abrasions and corneal foreign bodies: Clinical manifestations and diagnosis", section on 'Eye examination' and "Slit lamp examination", section on 'Performing the exam'.)
Additional considerations for assessment by suspected condition include the following:
●Chemical burn – If a chemical burn to the ocular surface has occurred, copious irrigation of saline should be performed until the measured pH of the ocular surface is neutral. (See "Topical chemical burns: Initial assessment and management", section on 'Eye exposure'.)
●Corneal abrasion or foreign body – Corneal abrasions (picture 6) and foreign bodies (picture 7) are also frequently associated with conjunctival injuries and are best seen with slit lamp and fluorescein examination. If an open globe is obvious or highly likely, the clinician should not place eye drops or fluorescein in the eye. (See "Corneal abrasions and corneal foreign bodies: Clinical manifestations and diagnosis", section on 'Fluorescein examination'.)
Other important aspects of conjunctival foreign bodies include the following:
•Lower lid conjunctival foreign bodies may be visualized with a penlight or a slit lamp after gentle lid retraction and typically consist of particles of dirt, sand, plant material, or eye lashes.
•Upper lid conjunctival foreign bodies usually require lid eversion for visualization and removal and may be associated with parallel linear, vertically oriented corneal abrasions (movie 1). (See "Corneal abrasions and corneal foreign bodies: Clinical manifestations and diagnosis", section on 'Eyelid eversion'.)
•Rarely, large conjunctival foreign bodies can be retained in the conjunctival sac [10-13]. If present for longer than a few days, these objects may be associated with local swelling, a firm palpable mass, granulation tissue, and conjunctival discharge.
●Suspected open globe – At times, the extent of damage to ocular structures in a child with a conjunctival injury cannot be determined because the patient is unable to cooperate with the examination. In these situations, if an open globe is considered likely, the child should have an eye shield placed and arrangements be made for emergency examination by an ophthalmologist under procedural sedation in the emergency department or general anesthesia in the operating room.
Slit lamp examination and diagnostic imaging — If a small bulbar conjunctival laceration is present and there are no other signs of open globe injury (table 1), the laceration can be explored with the aid of the slit lamp. (See "Slit lamp examination", section on 'Performing the exam'.)
The eye should be anesthetized with a topical drop (ie, tetracaine or proparacaine) and the conjunctival laceration explored with a cotton-tip applicator, moistened with sterile water or normal saline. With the aid of a slit lamp, effort should be made to visualize the underlying sclera to ensure that it is intact. If a scleral laceration or prolapsed uvea is visible at any point during the exploration, manipulation of the eye should be stopped and treatment for an open globe initiated (table 1).
Although probing of a bulbar conjunctival laceration is ideally performed by an ophthalmologist with the aid of a slit lamp, clinicians with expertise in the use of a slit lamp may perform this test in cases where an ophthalmologist is not readily available, and definitive eye care will require prolonged patient transport. Large conjunctival lacerations can be an entry site for penetrating orbital injury.
If open globe injury or penetrating injury to the orbit cannot be ruled out in the case of a suspicious conjunctival laceration or a bullous subconjunctival hemorrhage, an orbital CT with thin cuts (<2 mm) should be performed. CT findings of open globe injury include an intraocular foreign body, intraocular air, eye wall deformity, volume loss of the eye, and irregular scleral contour (picture 4). If radiologic evidence of open globe injury or orbital foreign body is present, an eye shield should be placed and ophthalmology should be urgently consulted. However, ocular CT has limited ability to demonstrate an occult open globe injury and should not be used as the sole determining factor for decisions regarding the need for evaluation by an ophthalmologist. Exploration in the operating room may be required. (See "Open globe injuries: Emergency evaluation and initial management", section on 'Imaging'.)
INDICATIONS FOR OPHTHALMOLOGIC CONSULTATION OR REFERRAL — An ophthalmologist should be consulted for the following patients [14,16,18]:
●Emergency consultation (as soon as possible):
•Suspicion for an open globe or intraorbital penetration (table 1) requires emergency consultation and evaluation
•Signs of traumatic hyphema (table 2)
●Urgent consultation (same day):
•Conjunctival lacerations >1 cm in length that will require suturing
•Foreign bodies that are deeply embedded, subconjunctival, or associated with a conjunctival laceration
Patients with substantial traumatic subconjunctival hemorrhage, particularly in the setting of bullous conjunctival elevation, also warrant emergency consultation with an ophthalmologist to evaluate for deeper, underlying trauma and to assess for an occult open globe injury.
Subconjunctival hemorrhage — Spontaneous, nontraumatic causes of subconjunctival hemorrhage self-resolve over two to three weeks without ocular sequelae and require no treatment. In elderly patients, the clinician should perform a complete history to determine if any trauma occurred and measure the blood pressure. Coagulation studies should be performed to assess for a bleeding diathesis or overmedication (in patients who are anticoagulated) and if subconjunctival hemorrhages are recurrent or other signs of a bleeding disorder are present. (See "Approach to the adult with a suspected bleeding disorder".)
Subconjunctival hemorrhage resulting from trauma (or cases when trauma cannot be ruled out in patients who are poor historians), particularly in the setting of bullous elevation of the conjunctiva, warrants urgent ophthalmology consultation to evaluate for additional retinal trauma and definitively rule out open globe injury. (See 'Indications for ophthalmologic consultation or referral' above.)
Conjunctival abrasion or laceration — Conjunctival injury can be a sign of intraocular trauma, including open globe injury or penetration of a foreign body into the eye or orbit (table 1). When these associated conditions cannot be ruled out, ophthalmology consultation should be emergently obtained. (See 'Indications for ophthalmologic consultation or referral' above.)
Isolated conjunctival abrasions are treated with antibiotic ointment (eg, erythromycin ophthalmic ointment or bacitracin ophthalmic ointment applied four times daily for one week). Referral to an ophthalmologist for a complete eye examination within one to three days of injury is a reasonable precaution in patients who are contact wearers or for all other patients if symptoms are not resolving. These injuries typically heal within two to three days.
All patients with conjunctival lacerations should be discussed with an ophthalmologist if available. If a conjunctival laceration is determined to be superficial, not associated with any other serious intraorbital or ocular injury, and is small (<1 cm), the patient may receive treatment with an antibiotic ointment (eg, erythromycin ophthalmic ointment) and be referred for ophthalmologic evaluation in one to three days [14,18]. Larger lacerations warrant prompt repair that day by an ophthalmologist. (See 'Indications for ophthalmologic consultation or referral' above.)
Conjunctival foreign body — Any foreign body that is deeply embedded, subconjunctival, or present in the context of a conjunctival laceration should be referred for urgent removal by an ophthalmologist. Deep conjunctival foreign bodies should raise concern for penetrating injury. (See 'Indications for ophthalmologic consultation or referral' above.)
Superficial conjunctival foreign bodies can be removed at the slit lamp with the aid of a cotton-tipped applicator after the instillation of topical anesthetic (eg, proparacaine) (picture 8) . Alternatively, multiple or loose foreign bodies may be removed with normal saline irrigation.
Once the foreign body is removed, the patient may receive treatment with an antibiotic ointment (eg, erythromycin ophthalmic ointment) and be referred for ophthalmologic evaluation in one to three days.
OUTCOMES — Patients with an isolated conjunctival injury typically recover fully without any vision loss. In cases with an associated ocular injury, visual outcome depends on the severity of the intraocular injury. (See "Open globe injuries: Emergency evaluation and initial management", section on 'Outcomes'.)
INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)
●Basics topics (see "Patient education: Subconjunctival hemorrhage (The Basics)")
SUMMARY AND RECOMMENDATIONS
●Anatomy – The conjunctiva is a thin, transparent tissue that covers the anterior portion of the sclera and lines the inside of the eyelids (figure 1). Trauma to the ocular surface frequently involves the conjunctiva. (See 'Introduction' above and 'Clinical anatomy' above.)
●Ophthalmologic consultation – An ophthalmologist should be urgently consulted in patients with concern or evidence for the following (see 'Indications for ophthalmologic consultation or referral' above):
•Open globe (table 1)
•Traumatic hyphema (table 2)
•Conjunctival lacerations >1 cm in length that will require special suturing techniques
•Foreign bodies that are deeply embedded, subconjunctival, or associated with a conjunctival laceration
•Substantial traumatic subconjunctival hemorrhage, particularly with bullous conjunctival elevation
•Clinical features – Collection of blood between the sclera and the conjunctiva that appears as a focal, flat, red region on the ocular surface (picture 2). Most subconjunctival hemorrhages are not associated with intraocular injury. However, in instances of scleral laceration or rupture, intraocular blood or fluid can leak through the defect and pool in the subconjunctival space, creating a bullous, elevated subconjunctival hemorrhage, which may hide the laceration (picture 4). (See 'Subconjunctival hemorrhage' above.)
-Spontaneous, nontraumatic subconjunctival hemorrhage – These self-resolve over two to three weeks without ocular sequelae and require no treatment. Coagulation studies should be performed to assess for a bleeding diathesis or overmedication in patients who are anticoagulated if subconjunctival hemorrhages are recurrent.
-Traumatic subconjunctival hemorrhage – These include cases when trauma cannot be ruled out in patients who are poor historians. Particularly in the setting of bullous elevation of the conjunctiva, underlying retinal trauma and open globe injury must be ruled out. (See 'Subconjunctival hemorrhage' above.)
•Clinical features – These are frequently associated with intraocular or intraorbital trauma and warrant careful evaluation for an open globe (table 1) or traumatic hyphema (table 2). Identification of an open globe may require probing of the conjunctival laceration during slit lamp examination, preferably by an ophthalmologist. Computed tomography (CT) of the orbit may also be helpful (picture 4). (See 'Conjunctival laceration' above.)
-Conjunctival abrasions – Treat with antibiotic ointment (eg, erythromycin ophthalmic ointment). In patients whose symptoms have not fully resolved within one to three days or who wear contact lenses, refer to an ophthalmologist.
-Small (<1 cm) conjunctival lacerations – Treat with an antibiotic ointment (eg, erythromycin ophthalmic ointment) and arrange follow-up with an ophthalmologist in one to three days.
-Large (>1 cm) conjunctival lacerations – These warrant prompt, same-day repair by an ophthalmologist. (See 'Conjunctival abrasion or laceration' above.)
●Conjunctival foreign bodies
•Clinical features – Patients often report "something blowing into their eye." If the conjunctival foreign body is embedded under the upper lid, it may cause corneal abrasions with associated pain and photophobia. (See 'Conjunctival foreign body' above.)
•Management – Superficial conjunctival foreign bodies can be removed at the slit lamp with the aid of a cotton-tipped applicator after the instillation of topical anesthetic (eg, proparacaine). Alternatively, multiple or loose foreign bodies may be removed with normal saline irrigation. (See 'Conjunctival foreign body' above.)
ACKNOWLEDGMENT — The UpToDate editorial staff acknowledges Carolyn Kloek, MD, who contributed to an earlier version of this topic review.
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