Patient Presentation
A 5-day-old male came to clinic for his well-examination. He was breastfeeding, stooling, and urinating well, and had no concerns for jaundice. The parents were worried about a red spot on his lateral right eye. The past medical history showed a term male born by spontaneous vaginal delivery to a G1P1 26 year old female. The family history and review of systems were non-contributory.
The pertinent physical exam showed an alert male with a weight of 3176 grams (25%), length of 49 cm (50%) and head circumference of 35.5 cm (25-50%). He had mild jaundice of the face. Lateral to the iris of his right eye he had a crescent shaped hemorrhage from ~ 7-10 o’clock. There were normal red reflexes noted and no other abnormalities on external examination of the eyes. The rest of his examination was normal.
The diagnosis of a healthy male with mild jaundice and a subconjunctival hemorrhage was made. The pediatrician had no concerns for possible non-accidental trauma based on the nursery records and the clinical encounter. The parents were concerned because the physicians in the newborn nursery had not said anything about the hemorrhage and they were quite worried. The pediatrician explained that subconjunctival hemorrhages were common, and that it could take a few weeks for it to fade. He noted that sometimes they were difficult to see because the newborn infants’ eyelids were commonly swollen and the hemorrhage was seen a few days later because of this. The hemorrhage was noted again at the 2 week examination but not at the 1 month examination.
Discussion
Newborn infants should have their eye red reflexes examined looking for signs of congenital cataract, retinoblastoma and other ophthalmological problems. This can be complicated by lid edema from birth, and also antibiotic prophylaxis for gonorrhea that may have been applied to the eyes. Sometimes the physician only gets a brief look at the red reflexes. Therefore serial exams over the first days to weeks of life are important.
Trauma and infection are most common in infants and young children, but causes of subconjunctival hemorrhage (SCH) include:
- Trauma
- Direct to globe and orbit
- Inadvertent – rubbing, foreign body
- Iatrogenic – surgery
- Infection – conjunctivitis
- Increased venous pressure – coughing, emesis
- Hypertension
- Coagulopathy
- Tumors
Learning Point
In 2019, the authors of the Neonatal Eye Screen Test (NEST) study reported their results for SCH. The NEST study was a prospective cohort study of 202 terms infants from July 2013-14 that had universally performed newborn ophthalmological screening at birth. They found 9% of newborn infants had SCH, and SCH was more common in high birth weight infants. They noted this was consistent with “…subconjunctival haemorrhages are more likely caused by a chest compression during the passage through the birth canal with a sudden increase of venous pressure in the head and neck.”
SCH are known to resolve over time consistent with other bleeding into tissues. This has also been noted in other studies performed in older age infants and children which have shown a small % of their study population with SCH. Some examples include:
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A 2013 study of 3573 infants performed after 42 days of life on most of the patients born in their hospital found ~21% had retinal hemorrhages and 1.4% had SCH.
A 2024 study of 2972 full-term infants performed at an average of 49 days (range 10-130 days of life) found 2.3% had retinal hemorrhages and 0.2% had SCH.
A 2022 study of 33,900 children age 2 days to 18 years, found an overall prevalence of SCH of 0.4% and of 0.2% for the 0-1 year olds with 73% due to trauma. Birth related trauma was only one of many traumatic causes.
Questions for Further Discussion
1. What causes red eyes? A review can be found here
2. What causes eyelid edema? A review can be found here
3. What are presentations of non-accidental trauma (i.e. child abuse)? A review can be found here
Related Cases
- Disease: Subconjunctival Hemorrhage | Eye Diseases | Eye Injuries
- Symptom/Presentation: Bleeding and Bruising | Red Eyes | Eye Trauma
- Specialty: General Pediatrics | Ophthalmology
- Age: Newborn
To Learn More
To view pediatric review articles on this topic from the past year check PubMed.
Evidence-based medicine information on this topic can be found at SearchingPediatrics.com and the Cochrane Database of Systematic Reviews.
Information prescriptions for patients can be found at MedlinePlus for this topic: Eye Diseases
To view current news articles on this topic check Google News.
To view images related to this topic check Google Images.
To view videos related to this topic check YouTube Videos.
Li LH, Li N, Zhao JY, et al. Findings of perinatal ocular examination performed on 3573, healthy full-term newborns. Br J Ophthalmol. 2013;97(5):588-591. doi:10.1136/bjophthalmol-2012-302539
Callaway NF, Ludwig CA, Blumenkranz MS, Jones JM, Fredrick DR, Moshfeghi DM. Retinal and Optic Nerve Hemorrhages in the Newborn Infant: One-year Results of the Newborn Eye Screen Test (NEST) Study. Ophthalmology. 2016;123(5):1043-1052. doi:10.1016/j.ophtha.2016.01.004.
Ji MH, Ludwig CA, Callaway NF, Moshfeghi DM. Birth-related subconjunctival and retinal haemorrhages in the Newborn Eye Screening Test (NEST) Cohort. Eye (Lond). 2019;33(11):1819. doi:10.1038/s41433-019-0523-y
Parikh AO, Christian CW, Forbes BJ, Binenbaum G. Prevalence and Causes of Subconjunctival Hemorrhage in Children. Pediatr Emerg Care. 2022;38(8):e1428-e1432. doi:10.1097/PEC.0000000000002795
Yenice EK, Petricli IS, Kara C. Findings of ocular examinations in healthy full-term newborns. ABO. 2022;87(1). doi:10.5935/0004-2749.2021-0536
Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa