2.01 Periorbital Ecchymosis (Black Eye)
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agk's Library of Common Simple Emergencies

Presentation
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The patient has received blunt trauma to the 
eye, most often from a fist, a fall, or a car 
accident, and is alarmed because of the 
swelling and discoloration. Family or friends 
may be more concerned than the patient about 
the appearance of the eye. There may be an 
associated subconjunctival hemorrhage, but the 
remainder of the eye exam should be negative 
and there should be no palpable bony deform- 
ities, diplopia or subcutaneous emphysema.

What to do:
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- Clarify as well as possible the specific 
   mechanism of injury. A fist is much less 
   likely to cause serious injury than a 
   baseball bat.
- Perform a complete eye exam including a 
   bright light exam to rule out an early 
   hyphema, a funduscopic exam to rule out a 
   retinal detachment or dislocated lens, and a 
   fluorescein stain to rule out a corneal 
   abrasion. Visual acuity testing should 
   always be performed, and with an uncomplica- 
   ted injury, would be expected to be normal. 
   All patients having contusions associated 
   with visual loss should be referred to an 
   ophthalmologist. Special attention should be 
   given to ruling out a blowout fracture of 
   the orbital floor or wall. Test extraocular 
   eye movements, look especially for diplopia 
   on upward gaze, and check sensation over the 
   infraorbital nerve distribution. Enophthal- 
   mus is usually not observed, although it is 
   part of the classic textbook triad associat- 
   ed with a blow-out fracture. Subcutaneous 
   emphysema is a recognized complication of 
   orbital wall fracture.
- Symmetrically palpate the supra- and 
   infraorbital rims as well as the zygoma, 
   feeling for a deformity such as one would 
   encounter with a displaced tripod fracture. 
   A unilateral deformity will be obvious if 
   your thumbs are fixed in a midline position 
   while you use your index fingers to palpate 
   the patient's facial bones simultaneously 
   both left and right.
- When there is a substantial mechanism of 
   injury or if there is any clinical suspicion 
   of an underlying fracture, obtain x-rays of 
   the orbit. CT scans are more sensitive and 
   can visualize subtle fractures of the orbit 
   and small amounts of orbital air. CT 
   scanning is indicated for patients with 
   abnormal physical examinations but normal 
   routine films.
- If a significant injury is discovered, then 
   consult with an ophthalmologist.
- When a significant injury has been ruled out, 
   reassure the patient that the swelling will 
   subside within 12-24 hrs with use of a cold 
   pack and the discoloration will take one to 
   two weeks to clear. Acetaminophen should be 
   all that is required for analgesia.
- Instruct the patient to follow up with an 
   ophthalmologist if there is any problem with 
   vision or pain developing after the first 
   few days. Uncommonly, traumatic iritis, 
   retinal tears, or vitreous hemorrhage may 
   develop later secondary to blunt injury.

What not to do:
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- Do not get unnecessary radiographs. Minor 
   injuries with normal eye exams and no 
   palpable deformities do not require x-rays.
- Do not brush off bilateral deep periorbital 
   ecchymoses ("raccoon eyes") especially if 
   caused by head trauma remote to the eye. 
   This may be the only sign of a basilar skull 
   fracture.

Discussion
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Black eyes are most commonly nothing more than 
uncomplicated facial contusions. Patients 
become upset about them because they are so 
"near the eye," because they produce such 
noticeable facial disfigurement, and because 
there is often secondary gain being sought 
against the person who hit them. Nonetheless, 
serious injury must always be considered and 
ruled out prior to the patient's discharge from 
your care.

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 from Buttaravoli & Stair: COMMON SIMPLE EMERGENCIES
 Longwood Information LLC 4822 Quebec St NW Wash DC
 1.202.237.0971 fax 1.202.244.8393 electra@clark.net
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