Hemorrhagic chemosis

Background

Hemorrhagic chemosis, sometimes referred to as subconjunctival hematoma or bloody chemosis, is a finding of raised subconjunctival hemorrhage resulting from the rupture of subconjunctival blood vessels.

Clinical Features

Often the patient's history will involve significant ocular trauma. Depending on the mechanism, other features may include change in visual acuity, painful eye or pain with eye movements,

Differential Diagnosis

While most cases of hemorrhagic chemosis occur following trauma, it is important to also consider whether the patient has an underlying coagulopathy or structural condition (ie. cavernous venous thrombosis) that would predispose them to this or a similarly appearing condition. When assessing a patient with hemorrhagic chemosis, the following associated conditions should be considered:

• Globe rupture
• Scleral laceration
• Penetrating foreign body

The following are conditions that may appear similarly to hemorrhagic chemosis but have an alternate etiology:

• Carotid-cavernous fistula
• Cavernous venous thrombosis (can present with chemosis + proptosis)

Evaluation

1. Check visual acuity
2. Visualize injury with slit lamp exam
3. Consult ophthalmology if available or consider transfer if not
4. Obtain orbital CT imaging

Once globe rupture is ruled out, continue with tonometry and fluoroscein exam.

Workup

• Coagulation studies
• Vessel imaging of the head if suspicion for CVT

Management

If globe rupture is suspected:

• Consult ophthalmology if haven't already or transfer patient as this is an ophthalmologic emergency
• Initiate broad spectrum antibiotics
• Check tenatus vaccine status and administer if due
• Consider placement eye shield as protective measure to avoid further damage

Disposition

Ultimate disposition often depends on the associated ocular trauma for which hemorrhagic chemosis may be a sign.