Working Diagnosis:
Large Subconjunctival Hemorrhage, Secondary to Blunt Trauma

Treatment:
Treatment for this patient mainly comprised of protection, proper corneal hydration with artificial tears and tincture of time with close follow up and serial exams.

Outcome:
Her subconjunctival hemorrhage resolved over the next 3 weeks Case Photo #3 . She had no damage to the globe, lens or retina. Her vision was unharmed and she remained full go for the remainder of the season.

She returned to softball within a week of injury. Until the SCH resolved, she was instructed to wear eye protection during throwing, fielding and batting which included wearing a cage on her batting helmet and a field mask for fielding and catching.

Author's Comments:
Even though spontaneous subconjunctival hemorrhages are usually benign and heal without complications. In the setting of trauma, more serious eye injuries need to be considered. A traumatic 360 degree subconjunctival hemorrhage can be indicative of a globe rupture, therefore a prompt evaluation by an Ophthalmologist is mandatory. Another eye injury that must be considered with direct trauma is retinal detachment caused by the shearing forces produced by the compression of the globe.

It is essential to test and document visual acuity immediately following any eye injury and serially. Eye injuries that are not properly evaluated and treated can lead to a significant morbidity and liability.

When a subconjunctival hemorrhage is as massive and bulging as this one artificial tears are needed to maintain corneal hydration.

Finally, it is helpful to know which emergency departments in your community have 24 hour in-house Ophthalmology coverage.

Editor's Comments:
Subconjunctival hemorrhages result from ruptured capillaries within the conjunctiva. These can occur with anything that increase pressure within the eye such as sneezing or coughing, or from direct trauma to include rubbing your eyes. They present clinically within red spots within the conjunctiva itself. Management is conservative with eye protection and lubrication drops if needed.

References:
1.) Aoto BAP, et al. Eye Injuries in Summer Olympic Sports - A Mini Review. Adv Ophthalmol Vis Syst. 4:1-5, 2016.
2.) Cass SP. Ocular injuries in Sports. Curr Sports Med Rep, 11(1):11-15, 2012.
3.) Cronau H, et al. Diagnosis and Management of Red Eye in Primary Care. Am Fam Physician. 81:137-144, 2010.
4.) McCracken W, Smith D. Sports-Related Eye Injuries. Curr Sports Med Rep, CAQ Review. 16:64, 2017.
5.) Pokhrel PK, Loftus SA. Ocular Emergencies. Am Fam Physcian. 76:829-836, 2017. Weber TS Training Room Management of Eye Conditions. Clin Sports Med 24:681-693, 2005.

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