Discussion
The first presentation of patients with SCH is usually to the family
medicine and there are few studies on whether these patients should be
evaluated for bleeding disorder. SCH is a mucosal hemorrhage and is
expected in the qualitative deficiency of platelets or in platelet
function disorders and coagulation factor deficiencies. In most of the
non-traumatic SCH cases, the etiological causes are hypertension,
diabetes mellitus and drugs. In addition, coagulation factor deficiency
was detected in less than 1% of patients (10). During
anticoagulant and antiaggregant usage, and hemostatic alterations as
immune thrombocytopenia, congenital bleeding disorders and hematologic
malignancy as leukemia, SCH was reported in previous cases[3, 9-11]. However, in these cases SCH is considered
to be a part of other mucocutaneous bleeding, and patients often apply
to the hematology outpatient clinic.
Hypertension, diabetes mellitus and other systemic
vascular disorders play a major role in the etiology of
subconjunctival hemorrhage and their prevalence increases with age. Because of this, the
number of patients with SCH increases markedly over 50 years of age[12,13]. Although only spontaneous SCH were included
in our study, the mean age of patients was found to be over 50 years as
in previous studies. The frequency of non-traumatic SCH was reported to
be more common in women in previous studies [4,6].
In our study, although SCH was seen more frequently in women, it was
found to be close in frequency to each other in both sexes. In 32.7 %
of cases, spontaneous SCH was recurrent in the absence of any
identifiable causes or risk factors. This rate was higher than some
previous studies [7]. Lens usage is an exclusion
criteria in our study since it may lead to traumatic SCH. Although the
usage of glasses was not considered to be a risk factor for SCH, it was
determined that approximately one third of the cases were wearing
glasses. The incidence of SCH is similar in both eyes.
In our country patients pay attention to the SCH rather than cutaneous
bleeding. Therefore, patients may consult a doctor when they first
underwent SCH despite previous recurrent other mucocutaneous bleeding.
From this point we thought that the first finding of congenital bleeding
disorders such as vWD may be SCH and we expected increased frequency of
congenital or acquired bleeding disorders in patients with spontaneous
SCH. However we showed that the prevalence of hemostatic alterations in
patients with once or recurrent, spontaneous SCH is not different from
that in the general population. There was also no difference between
coagulation factor levels and hemostasis tests between those who had
once SCH and recurrent SCH.
In few studies, no difference was found in platelet count or coagulation
factor levels in recurrent SCH patients from that in the general
population as in our study [6,7,10]. Although few
studies have shown that homozygosity and heterozygosity for the Val
34Leu mutation of blood clotting factor FXIII is more frequent detected
in SCH cases, factor XIII antigen levels were within the normal limits
in all patients in our study [8,14]. Likewise in a study, there were no correlation between factor XIII antigen/activity
levels and SCH[6].
40 (76.9%) of the patients included in our study had a ISTH-BAT score
of 0 and no bleeding disorder was detected. When the other bleeding
findings of 2 patients with type 1 vWD were evaluated, it was learned
that they had bleeding attacks as epistaxis, cutaneous bleeding,
menorrhagia, bleeding after tooth extraction and bleeding from minor
wounds. The ISTH-BAT score of these two cases was 3 and 4, respectively.
Although there seems to be a strong relationship between ISTH-BAT scores
and vWD, there is no statistcal sample size to demonstrate this in our
study. The necessity of evaluating patients with spontaneous SCH for
bleeding disorder is stil a confusing. Although few studies suggest
that spontaneous SCH should be evaluated for bleeding disorder, the
conclusion to be drawn from our study is that, it is a more accurate
approach to investigate bleeding disorder only in SCH patients with a
history of bleeding [1,5]. It is also more cost
effective.
In addition, fibrinogen level was the only statistically significant
parameter in the comparison between patients with once SCH and recurrent
SCH and it was lower in patients with recurrent SCH. Thrombin time was
studied in five patients and all results were in normal
range. Although it was statistically significant, fibrinogen levels in
all patients were within normal limits and it was considered to have no
clinical significance. Dysfibrinogenemia was also not considered
clinically in any patient.
The first limitation of our study was the fact that the PFA-100 test was
performed by appointment, and therefore the PFA-100 test could be
performed at 2-3 weeks after subconjunctival hemorrhage in all patients.
The second, although factor XIII antigen levels were studied in all
patients, none of them had laboratory examination of factor XIII
activity and Light transmission aggregometry. However, according to the
data from previous studies, it is considered that this situation has no
effect on the results of our study.
Patients presenting with SCH should be questioned and examined in
details for common etiological risk factors such as hypertension,
diabetes mellitus, fever, trauma, drug use, conjunctivitis, blepharitis,
episcleritis, and corneal ulcer. If diseases such as dry eye or glaucoma
are suspected, the patient should be referred to an ophthalmologist for
eye examination.
In addition, in terms of other systemic bleeding findings such as
recurrent epistaxis, skin and mucosal, minor post-traumatic bleeding,
hematuria, gastrointestinal system bleeding, tooth extraction,
post-surgical bleeding, hemarthrosis, menorrhagia, intramuscular,
postpartum and central nervous system bleeding should be questioned. It
should be known that acutely developing hematological diseases such as
leukemias and thrombocytopenia may rarely present with SCH as a single
mucosal site. It should be kept in mind that it is often associated with
skin and other system bleeding. In congenital bleeding disorders,
patients often have a history of previous skin and mucosal bleeding, and
a history of prolonged bleeding after surgical procedures. Patients with
a history of bleeding should be referred to a hematologist. However, it
should be known that less than 1% of SCH patients will develop due to
hematological reasons.
In conclusion, we suggest not to examine patients with spontaneous SCH
for bleeding disorder, according to the data obtained from our study.
Patients with spontaneous SCH should be evaluated with ISTH-BAT score
instead of directly laboratory examination for bleeding disorder and
evaluation for the congenital bleeding disorders of patients with other
bleeding histories and high bleeding score would be more accurate.