2.01 Periorbital Ecchymosis (Black Eye)

agk’s Library of Common Simple Emergencies

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.

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.

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from Buttaravoli & Stair: COMMON SIMPLE EMERGENCIES ©
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