Case 3

It is rare to see subconjunctival hemorrhages in infants from anything other than trauma. The differential diagnosis is direct trauma, valsava, strangulation, suffocation, birth trauma (resolves by a few weeks), hypertension, or coagulopathy.

Some people use the term "scleral hemorrhage," a misnomer. The sclera is an opaque white membrane extending from the edges of the cornea to the optic nerve with no vascularization. Vessels and nerves go through it from the conjunctiva and episclera, and it is covered by the conjunctiva. The hemorrhage is actually a result of injury to the capillaries in the conjunctival membrane (trapping blood in the subconjunctival area).

Petechiae on the face and around the eyes may or may not accompany subconjunctival hemorrhages from strangulation or suffocation. Coughing is a common cause in adults and can rarely cause this in infants. However, severe coughing in infants, as in pertussis, may present with subconjunctival hemorrhages.

Infants with subconjunctival hemorrhage should be examined thoroughly for other signs of trauma. Brain imaging and skeletal survey are usually recommended, since, like any other injury to head of an infant, we do not necessarily know the extent of the trauma. Ophthalmologic referral is recommended to look for signs of other trauma to the eye.

In addition, there needs to be an evaluation for bleeding disorders, including birth history, family history of bleeding, maternal menses history, cord bleeding, circumcision bleeding, and history of bruising, as well as an examination for occult bleeding (stool guaiac, urinalysis, other skin findings). Lab testing may include tests for bleeding disorders including PT and PTT, platelets, platelet function testing, etc., as suggested by the history and rest of the physical examination.