Periorbital Ecchymosis (Black Eye)


Periorbital Ecchymosis

(Black Eye)


The patient has suffered blunt trauma to the eye, most often resulting from a blow inflicted during a fistfight, a fall, a sports injury, or a car accident, and he 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 examination should be normal, and there should be no palpable bony deformities, diplopia, or subcutaneous emphysema (Figure 22-1).


Figure 22-1 Blunt trauma to the eye.

What To Do:

image Determine, as well as possible, the specific mechanism of injury. A fist is much less likely than a line-drive baseball to cause serious injury.

image Perform a complete eye examination, including a bright-light examination to rule out an early hyphema (blood in the anterior chamber) or an abnormal pupil; a funduscopic examination to rule out a retinal detachment, vitreous hemorrhage, or dislocated lens; and a fluorescein stain to rule out corneal abrasion. Best-corrected visual acuity testing should always be performed and, with an uncomplicated injury, is expected to be normal. All patients having contusions associated with visual loss, severe pain, proptosis, pupil irregularity, new visual “floaters,” loss of red reflex, or extensive subconjunctival hemorrhage should be referred to an ophthalmologist immediately.

image Special attention should be given to ruling out a blow-out fracture of the orbital floor or wall. Test extraocular eye movements, looking especially for restriction of eye movement or diplopia on upward gaze, and check sensation over the infraorbital nerve distribution. Paresthesia in the distribution of the infraorbital nerve suggests a fracture of the orbital floor. Enophthalmos usually is not observed, although it is part of the classic textbook triad associated with a blow-out fracture. Subcutaneous emphysema is a recognized complication of orbital wall fracture.

image image Symmetrically palpate the supraorbital and infraorbital rims as well as the zygoma, feeling for the type of deformity that would be encountered 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, both left and right, simultaneously (Figure 22-2).


Figure 22-2 Proper hand placement for symmetrically palpating the supraorbital and infraorbital rims.

image When there is a substantial mechanism of injury or if there is any clinical suspicion of an underlying fracture, obtain a CT scan of the orbit. CT scans are more sensitive than plain radiographs and allow visualization of subtle fractures of the orbit and small amounts of orbital air.

image If a significant injury is discovered, consult an ophthalmologist. For diplopia resulting from a blow-out fracture, immediate surgical intervention is not required, and follow-up may be delayed for 7 to 10 days, after the edema has subsided. However, a patient with a hyphema should see an ophthalmologist within 24 hours. The patient should be instructed to rest with his head elevated. A protective metal shield should be placed over the eye, and the patient should be instructed to refrain from taking aspirin or nonsteroidal anti-inflammatory drugs (NSAIDs). Hospital admission is not required.

image Consider the possibility of abuse; when suspected, obtain the appropriate consultations and make the appropriate referrals.

image When a significant injury has been ruled out, reassure the patient that the swelling will subside within 12 to 24 hours, with or without a cold pack, and that the discoloration will take 1 to 2 weeks to clear. Acetaminophen should be sufficient for analgesia.

image Instruct the patient to follow up with an ophthalmologist if there is any problem with vision or if pain develops after the first few days. Rarely, traumatic iritis, retinal tears, or vitreous hemorrhage may develop later, secondary to blunt injury.

image With sports-related injuries, recommend protective eyewear made of polycarbonate. Polycarbonate lenses are available in prescription and nonprescription lenses in a sturdy sports frame.

What Not To Do:

image Do not order unnecessary radiographs. For minor injuries, if the eye examination is normal and there are no palpable deformities, radiographs and CT scans are unnecessary.

image 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.

Aug 11, 2016 | Posted by in EMERGENCY MEDICINE | Comments Off on Periorbital Ecchymosis (Black Eye)
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