Hyposhagmus

Subconjunctival, or intraocular hemorrhage, otherwise called hyposhagmus, occurs when a small blood vessel is damaged, as a result of which a small amount of blood is poured under the conjunctiva. The hyposhagmus has no effect on the quality of human visual function and manifests itself only externally. In the overwhelming majority of cases, this phenomenon does not require special therapy, and in healthy people they pass without any intervention within a couple of weeks. Emergency medical attention may be needed only if hyposhagmus is provoked by severe traumatic injury, a sharp increase in pressure (intraocular or arterial), as well as some other reasons. [1]

Epidemiology

The exact statistics of the occurrence of hyposhagmus is not kept, since most people with relatively small subconjunctival hemorrhages simply do not seek medical help. The incidence of hyposhagmus was 2.9% in a study of 8726 patients, and there was an increase with age, especially over the age of 50. [2]Also most common in young people of late adolescence and middle age;

The most common cause of the appearance of pathology is considered to be an increase in pressure (hypertension, physical or stress overload, lifting weights, vomiting, etc.), as well as injuries:

• industrial injuries;
• sports injuries (more often during football, hockey, tennis, baseball, boxing, paintball).

Somewhat less common are eye injuries that occur when an airbag is deployed in an accident.

Hyposhagmus is also common in children - blows and touches received in the process of active games often lead to its appearance.

Causes of the hyposhagmus

One of the main causes of trauma to the capillaries included in the blood supply system of the conjunctiva and conjunctival sac is high blood pressure. Blood with increased force affects the fragile capillary walls, which break through, hemorrhage occurs in the subconjunctival space, and hyposhagmus is formed.

Blood pressure in the capillaries can rise for many reasons, for example:

• direct injury to the eyes, head, cervicothoracic spine;
• insufficient blood clotting function;
• leukemia; [3]
• chronic pathologies of the cardiovascular system, such as hypertension, coronary heart disease, atherosclerosis, condition after a recent heart attack;
• Petechial hyposhagmus can occur in febrile systemic infections such as zoonosis (tsutsugamushi disease, typhus, leptospirosis), intestinal fever, malaria, meningococcal sepsis, subacute bacterial endocarditis, scarlet fever, diphtheria, influenza, smallpox, and smallpox. [4], [5]

Acute hemorrhagic conjunctivitis caused by enterovirus type 70, a variant of Coxsackie virus A24 and less commonly adenovirus types 8, 11 and 19, is characterized by the sudden onset of follicular conjunctivitis with mucous secretions, epiphora, photophobia, eyelid edema, and conjunctival chemosis. It is often associated with multiple petechial hemorrhages in the superior ocular and superior bulbar conjunctiva or widespread subconjunctival hemorrhage, especially in the temporal side. [6], [7]

Hyposhagmus was found in 22.9% of 61 young immunocompetent men during a measles epidemic in addition to conjunctivitis, which is a well-known diagnostic feature of measles. [8]It has been reported that patients with chickenpox and normal platelet counts developed unilateral hyposhagmus after the onset of typical skin rashes without any other ocular complications.[9]

• chronic pathologies of the gastrointestinal tract, accompanied by a violation of the stool, frequent or prolonged constipation;
• respiratory diseases that are accompanied by cough or sneezing attacks, for example, asthmatic bronchitis, whooping cough, pneumonia, tuberculosis, etc.;
• enteroviral hemorrhagic conjunctivitis;
• infectious and inflammatory intestinal pathologies, poisoning, accompanied by vomiting;
• any diseases or conditions in which asphyxia may develop.
• conjunctivochalasis. [10], [11]
• ocular amyloidosis. [12], [13]

Hyposhagmus may appear after surgical procedures (in particular, after laser vision correction), after retro and parabulbar administration of drugs  [14],  [15]and in women - after childbirth (especially severe ones associated with a long period of pressure).

Risk factors

Conjunctival capillaries are more vulnerable and fragile compared to other vessels of this caliber in the body. A variety of factors, both external and internal, can affect their integrity. A special role is played by alcohol abuse, systematic smoking, lack of vitamins and microelements, and a state of hypoxia. Under the influence of such reasons, capillary fragility is aggravated, and periodic hyposhagmus can acquire a chronic course with temporary impairment of visual function.

The most common provoking factors in the development of hyposhagmus are professional activities or engaging in certain sports, in which the risk of injury to the head, organs of vision, neck, and spine increases. Other possible causes include circulatory disorders, pathologies of the cardiovascular system, diabetes mellitus, atherosclerosis, and hypertension. [16]In these cases, treatment for hyposhagmus is carried out in accordance with the original disease. The significant increase in incidence is thought to be related to an increase in the prevalence of systemic hypertension after age 50; also diabetes mellitus, hyperlipidemia and anticoagulant therapy become more frequent with age. 

With atherosclerosis and hypertension, absolutely all the vessels in the body suffer: they lose elasticity, become brittle. Arteries narrow, and veins, on the contrary, expand. [17]

Patients with diabetes mellitus often develop retinal angiopathy (diabetic retinopathy), which can also be complicated not only by hyposhagmus, but also by retinal detachment with irreversible loss of visual function.

Other, less common factors that can lead to the development of hyposhagmus:

• tumor processes affecting the organs of vision, brain, spine; [18], [19]
• myopia, uveitis, iritis;
• vascular defects;
• physical and nervous overload.
• use of contact lenses. The incidence of hyposhagmus associated with contact lenses has been reported to be 5.0%. [20]
• taking certain medications. In addition to anticoagulants and antiplatelet drugs, several drugs related to hyposhagmus (SCH) have been described in the literature. It should be borne in mind that interferon therapy in patients with chronic viral hepatitis can cause subconjunctival hemorrhage, and retinopathy and antiviral therapy, including polyethylene glycated interferon plus ribavirin, can cause hyposhagmus in addition to vascular ophthalmic side effects. [21], [22]

Pathogenesis

Hyposhagmus is the release of blood (hemorrhagic fluid) from the vasculature of the conjunctival membrane with further accumulation in the gap between the sclera (white membrane of the eye) and the conjunctiva. The ocular conjunctiva is the outer fibrous membrane that is localized on the inside of the eyelids and the outside of the eye. Visually, it is a thin transparent film through which any subconjunctival hemorrhage is perfectly visible: against the background of the protein membrane, red spills, stripes or specks appear, which can change color to yellowish or dark.

The conjunctival membrane is very important for maintaining adequate functionality of the organs of vision: the membrane structures produce lacrimal secretions, without which the hydrolipidic state of the eyes will be disrupted. In addition, the shell is saturated with numerous small capillaries - vessels with a small diameter. The conjunctival capillary walls are quite vulnerable and fragile. It is not difficult to injure them if the blood pressure rises slightly - in particular, with a cough, vomiting, strong vibration, etc. [23]

The blood pouring out of the injured capillary flows under the connective membrane, mixes with lacrimal secretions, resulting in a hemorrhagic secret, which is the hyposhagmus.

Symptoms of the hyposhagmus

The symptomatology of hyposhagme is logical and quite understandable: the blood leaves the capillary vessel as a result of one reason or another (poor clotting, platelet abnormalities, disorders of the endothelium of the membrane, etc.), forms a blood clot, which manifests itself as a kind of scarlet spot. [24]

Most patients with hyposhagmus do not voice any clear complaints associated with visual impairment or severe discomfort and pain. In addition to external manifestations, other symptoms are extremely rare and can be characteristic only for the third degree of hyposhagmus, when the area of the lesion with a hematoma exceeds ¾ of the entire subconjunctival space. In a similar situation, the following signs of hyposhagmus join:

• slight discomfort that may bother you when you blink;
• poorly expressed feeling of a foreign object in the eye, in the absence of stabbing and cutting sensations;
• a red spot is outwardly visualized even from a great distance.

Since the conjunctival membrane does not have sensory light-receiving neurons, the appearance of hyposhagmus has no effect on the functioning of the visual analyzing system, therefore visual acuity (both central and peripheral) is not impaired.

The immediate moment of hemorrhage and the formation of the hyposhagmus usually passes imperceptibly. A person notices the first signs after he looks in the mirror. A red (bloody) speck of various sizes is found on the white part of the eye. Pain and visual impairment in the overwhelming majority of cases are absent.

Traumatic hyposhagmus of the eye

Trauma-induced subconjunctival hemorrhage is easily identified visually. The spot of the hyposhagmus can be small or quite extensive, occupying more than half or even the entire surface of the eyeball, and even extending beyond it.

A small hyposhagmus is harmless, does not cause visual impairment and dissolves without a trace in a short time. But it must be understood that extensive traumatic hemorrhage may indicate a subconjunctival rupture of the sclera, which indicates an open injury to the eye. For a medical professional, it is important to exclude a through rupture of the sclera in case of widespread hyposhagmus. This is taken into account when carrying out diagnostics, which necessarily include diaphanoscopy and revision of the sclera, as well as determining the symptom of Prypechek - pain in the projection of subconjunctival damage to the sclera in patients with massive hyposhagmus when probing with a glass rod. Symptom assessment is performed after pre-anesthesia of the eyeball.

Stages

The hyposhagmus is subdivided according to the area of the subconjunctival hemorrhage:

• At the first degree of hyposhagmus, the subconjunctival space is filled with less than ¼, while there is practically no discomfort for the patient.
• At the II degree of hyposhagmus, the filling of the subconjunctival space is from ¼ to ½, and the symptoms are extremely weak.
• In grade III, more than ½ of the subconjunctival space is affected, and patients may experience slight discomfort when blinking. Pain and visual impairment are uncommon.

If more than ¾ of the subconjunctival space is filled, then they speak of a pronounced third stage of the hyposhagmus. The condition may be accompanied by more severe discomfort, unpleasant sensations of a foreign object in the eye. In such a situation, you should consult a doctor.

Complications and consequences

Hyposhagmus is very rarely complicated by other pathologies. The hemorrhagic fluid that accumulates between the conjunctiva and the sclera gradually dissolves, the speck disappears. How quickly this process occurs depends on several factors, and the main one is the degree of hemorrhage. It can be identified by the color of the hyposhagmus.

A speck of red color indicates that only a few capillaries are damaged. This problem usually disappears after a few days, the capillaries quickly recover without any consequences.

A speck with a burgundy tint, which spreads to approximately 50% of the white surface, disappears within 2-3 weeks without complications.

A blood clot-like spot spreading over more than 50% of the ocular surface indicates damage to the optic tissue. In such a situation, complications with hyposhagmus are possible, it is better to seek qualified medical advice.

In difficult cases, it is possible to reduce the acuity and quality of visual function, the appearance of sparks, flashes of light and flying specks in front of the eyes. The likelihood of getting an infection with the development of infectious and inflammatory processes in the eye is not excluded.

The hyposhagmus has a rather unpleasant appearance, but this phenomenon should not scare: despite the external manifestations, the bloody speck does not affect the general state of health and does not affect the functionality of the organs of vision. However, if the spot is large or if it recurs, it is necessary to consult an ophthalmologist.

Diagnostics of the hyposhagmus

The initial stage of diagnosis for hyposhagmus consists of an external examination, an assessment of the visual state of the eye, determination of the spot size and the scale of the affected subconjunctival space.

To exclude the likelihood of infections and inflammatory processes in the conjunctiva, biomicroscopy is performed. To identify other possible hemorrhages and bleeding affecting the anterior ocular chamber, gonioscopy is performed - a procedure during which the anterior chamber is examined using a slit lamp and special glasses - goniolins.

During the examination, it is very important for the doctor to exclude damage to the integrity of the central venous vessel of the retina, as well as the retina itself and the optic nerve. For this, fundus ophthalmoscopy is performed.

Laboratory tests for hyposhagmus include a general blood test with a coagulogram. Such a diagnosis is necessary for the possible identification of provoking factors that require systemic therapy. We are talking about hemostatic disorders, coagulo and hemoglobinopathies, etc.

Instrumental diagnostics for patients with hyposhagmus is prescribed as part of the detection of ophthalmic pathologies, traumas of the visual apparatus, diseases of the cardiovascular system, and hematopoietic organs. In some cases, such diagnostic procedures are required:

• ultrasound examination of the abdominal organs;
• ultrasound examination of the chest, heart;
• angiography;
• MRI of the brain;
• fluoroscopy.

According to the results of the research, the doctor can draw up a complete clinical picture, find the cause of the appearance of hyposhagmus and make a diagnosis.

Differential diagnosis

It is very important to distinguish common hyposhagmus from other diseases with similar clinical manifestations - in particular, from hypophthalmos and hyphema.

	With hyposhagmus	With hyphema	With hemophthalmos
Location of hemorrhage	In the subconjunctival space	In the anterior ocular chamber in the iris zone	In the vitreous
Photophobia	Absent	Present	Present
The appearance of "fog" before the eyes	Absent	Present	Present
Dysfunction of the visual analyzing mechanism	Only at the III degree of pathology, when filling with a blood clot more than ¾ of the subconjunctival space	Present	Present
Neurological signs	Absent	Probable	In most cases, there are

Treatment of the hyposhagmus

In the vast majority of patients with hyposhagmus, the pathology disappears without any intervention within 1-3 weeks: there is no need for special treatment. The first treatment described in the literature was air therapy (AIR THERAPY). [25] Only sometimes is it necessary to carry out therapy that eliminates the root cause of the bleeding - for example, the doctor prescribes medications to correct blood clotting, etc.

Depending on the indications, with hyposhagmus, the doctor may prescribe the following drugs:

• Antimicrobial external agents - eye drops Levofloxacin, Levomycetin, Tobrex - are prescribed for a proven infectious process in the eye.
• Preparations for eliminating dryness of the mucous membrane - Vizin, Taufon, Artificial tears - are prescribed to maintain adequate hydration and activate cell regeneration. Thanks to such drugs, stabilization and compaction of the precorneal lacrimal film occurs, and the resorption of the hyposhagmus is accelerated. The indicated funds are instilled into the eyes 5-6 times a day.
• Preparations with angioprotective and vasodilating properties - Diosmin, Pentoxifylline, Vincarmine - facilitate capillary blood circulation, strengthen vascular walls, make them elastic. In addition, angioprotectors prevent vascular congestion in hyposhagmus.

Drug treatment is complemented by taking multivitamin complex preparations. This is necessary to correct visual function and improve the condition of the capillary walls. The complexes must contain ascorbic acid, vitamins A and E, B, as well as chromium, zinc. If the hyposhagmus has acquired a chronic recurrent course, then the dosage of vitamins is increased, vitamin P is added.

Patients with severe hyposhagmus caused by acute hemorrhagic conjunctivitis are given nasal and temporal subconjunctival injections of tissue plasminogen activator. [26],  [27], [28]

Patients with hypertension, diabetes mellitus, atherosclerosis are treated with the corresponding diseases. If a patient with hyposhagmus took antiplatelet or anticoagulant medications,  [29] then they are canceled and a comprehensive examination of the body is performed with further correction of the prescriptions.

Prevention

There are no specific preventive measures to prevent the appearance of hyposhagmus. Doctors advise to think in advance about preventing head injuries and, in particular, the organs of vision, why use protective devices when performing professional activities, while playing sports, etc. In addition, it is important to maintain your own health, monitor blood pressure and blood sugar levels...

Preventive measures can also be directed at optimizing the work of the cardiovascular system, at strengthening the vascular wall and ensuring its elasticity:

• Nutrition should be complete and varied, with the inclusion in the diet of plant foods rich in vitamins and minerals. It is imperative to regularly consume sea fish, herbs, vegetables, berries, legumes. These products will help strengthen the capillary network and prevent vascular fragility.
• In order to avoid the phenomena of tissue hypoxia, physical activity should be maintained, walk for at least 1-1.5 hours daily.
• In the presence of occupational hazards, it is important to protect the organs of vision with the help of special shields or glasses.
• Eye gymnastics should be performed daily, which includes a set of exercises to support vascular tone and improve microcirculation. Usually, such gymnastics consists of repetitive squeezing, blinking, rotating the eyeballs, etc.

In order to prevent hyposhagmus, it is necessary to visit an ophthalmologist at least annually. If there are somatic diseases - in particular, diabetes mellitus or hypertension - a compulsory medical examination every six months is important.

Forecast

Hyposhagmus is a pathological condition characterized by the release of blood and hemorrhagic fluid into the space between the protein of the eye membrane and the conjunctiva. The condition is usually not accompanied by the development of complications and is independently eliminated for several days (sometimes weeks). In the vast majority of cases, no special treatment is required. The need for drug therapy appears with the development of infectious and inflammatory processes, or in the presence of primary diseases that triggered the onset of hyposhagmus. [30]

In general, for patients with hyposhagmus, the prognosis is predominantly favorable. Practicing ophthalmologists note that this disorder rarely spills over into serious complications.

If a patient develops chronic recurrent hyposhagmus, then he is recommended to see a doctor for a preventive examination at least every 6 months. Regular check-ups will minimize the likelihood of relapse.