Subconjunctival hemorrhage after vomiting (localized red scleral patch)
A localized bright red patch on the white of the eye after vomiting is most consistent with a subconjunctival hemorrhage due to a ruptured superficial conjunctival blood vessel. [1] Uncomplicated subconjunctival hemorrhage is usually painless, does not change vision, and resolves spontaneously within 1 to 2 weeks. [1] [2]
Diagnostic features consistent with this presentation
A subconjunctival hemorrhage appears as a sharply demarcated red patch on the scleral surface that may be noticed after a transient increase in pressure such as coughing or vomiting. [1] [2] Vision is not expected to change and discharge is not expected. [2]
Treatment required
No specific treatment is required for uncomplicated subconjunctival hemorrhage. [1] [2] [3] Artificial tears may be used for symptomatic relief of irritation. [1] [3] Avoidance of eye rubbing and strenuous activity that could increase venous pressure is recommended. [1] Topical antibiotics or topical steroids are not recommended for uncomplicated subconjunctival hemorrhage. [1]
Natural history and expected course
Most cases resolve within 1 to 2 weeks. [1] [3] A typical reported course is spontaneous resolution over about 2 to 3 weeks. [2]
Indications for urgent evaluation
Urgent ophthalmology evaluation is indicated when subconjunctival hemorrhage is associated with pain, decreased vision, discharge, or other signs suggesting concomitant ocular injury. [1] [4] Emergency evaluation is also indicated after trauma with suspected intraocular or retinal injury. [1] Immediate evaluation is indicated for recurrent or unexplained episodes because systemic contributors may require assessment. [1] [3]
Medication and risk-factor considerations
Risk factors include sudden increases in head or neck pressure such as coughing or vomiting, high blood pressure, and use of blood thinners. [2] Evaluation for systemic contributors is reasonable when hemorrhage is recurrent or extensive. [1]
Common pitfalls to avoid
Assuming subconjunctival hemorrhage is harmless despite pain or vision change should be avoided because these features suggest a different or more serious diagnosis. [1] [4] Use of topical antibiotics or steroids in uncomplicated cases should be avoided because these therapies are not indicated and may be harmful. [1]
Follow-up approach when symptoms remain mild
If vision is preserved and no pain, discharge, or traumatic mechanism is present, reassurance and conservative management with supportive lubrication are appropriate. [1] [3] Reassessment is recommended if the redness does not improve over the expected 1 to 2 week period or if new symptoms develop. [1] [3]