Coughing Kid and a Blood Red Eye

aka Ophthalmology Befuddler 006

A 14 year-old boy is brought into the emergency department by his weary mother. He has been keeping everyone awake at night with his incessant coughing. That, however, is not why they are here today. She is worried about bleeding under the surface of his eye.

EYE Subconjunctival hemorrhage


Q1. What is shown?
Answer and interpretation

Subconjunctival hemorrhage.

Q2. What are the possible causes?
Answer and interpretation

Subconjunctival hemorrhages may be related to minor injuries such as rubbing the eye or coughing. It is more common in those with a bleeding diathesis or those taking anticoagulants and antiplatelet agents.

Subconjunctival can also coexist with more serious ocular or orbital trauma — this needs to be ruled out. A subconjunctival haemorrhage with out inferior limit may be caused by a base of skull fracture.

Q3. What features on history and examined should be looked for?
Answer and interpretation


  • minor trauma, coughing, bleeding diathesis
  • rule out major trauma (e.g. base of skull fracture).


  • unilateral, localised and sharply demarcated confluent blood red discoloration with mobile overlying conjunctiva.
  • No evidence of inflammation, pain or discharge.
  • Normal visual acuity, red reflex and fundoscopy — rule out coexisting serious ocular or orbital trauma.

Q4. What is the appropriate management?
Answer and interpretation
  • Check blood pressure and assess for a bleeding diathesis (e.g. FBC and coags) as required.
  • Apply lubrication if needed, e.g. artificial tears.
  • Refer if pain develops or condition worsens.



Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also a Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.

After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.

He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE.  He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.

His one great achievement is being the father of three amazing children.

On Twitter, he is @precordialthump.

| INTENSIVE | RAGE | Resuscitology | SMACC

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