1. Periorbital Ecchymosis (Black Eye)
Presentation
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 deformities, diplopia or
subcutaneous emphysema.
What to do:
• 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 uncomplicated 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. Enophthalmus is usually not observed,
although it is part of the classic textbook triad associated with a blow-out
fracture. Sub- cutaneous 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.

2. What not to do:
• 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
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.