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Black eye
Other namesPeriorbital hematoma
SpecialtyEmergency medicine

A periorbital hematoma, commonly called a black eye or a shiner (associated with boxing or stick sports such as hockey), is bruising around the eye commonly due to an injury to the face rather than to the eye. The name refers to the dark-colored bruising which is the result of accumulated blood and fluid in the loose areolar tissue following a blow to the head. This blood tracks freely under the scalp producing a generalised swelling over the dome of the skull but cannot pass into either occipital or the temple regions because of the bony attachments of the occipitofrontalis muscle. But this fluid can, however, track forward into the eyelid because the occipitofrontalis muscle has no bony attachment anteriorly. This leads to formation of hematoma a few hours after the head injury or cranial operation.[1] If injury is more extensive, potentially even a skull fracture, an apparent black eye can sometimes worsen and may require professional medical treatment before it will resolve. This is more likely if the area around both eyes has been injured (raccoon eyes) or if there is a history of prior head injury or fracture around the eye. Though disfiguring, the vast majority of black eyes are not serious, require little or no treatment, and will resolve spontaneously within a week or two.

Bleeding within the eye, a condition called a hyphema, is more serious: it can permanently reduce vision and can damage the cornea. In some cases, abnormally high pressure inside the eyeball (ocular hypertension) can also result.

Signs and symptoms

[edit]
Progression of periorbital hematoma over ten days: the blood is gradually absorbed, but the iron-laden pigments in the blood remain in the tissue leaving a discoloration that persists for longer.

Despite the name, the eye itself is not affected. Blunt force or trauma to the eye socket results in burst capillaries and subsequent haemorrhaging (hematoma).[2] The fatty tissue along with the lack of muscle around the eye socket allows a potential space for blood accumulation. As this blood decomposes and is resorbed, various pigments are released lending itself to the extreme outward appearance.[2]

The appearance (discoloration in purple and blue along with swelling) does not usually indicate a serious injury, and most black eyes resolve within a week. The tissues around the eye are soft and thus bruise easily when compressed against margins of bone which surround and protect the eye socket. The treatment is the same as that for bruises in other parts of the body – cold compresses during the first twenty-four hours. During the process of healing, and so long as there no breaks in the skin, a black eye can be made less conspicuous by using cosmetics designed to obscure discolorations of the skin. In a severe contusion, blowout of the floor of the orbit may occur, leading to double vision. Such an injury may require surgical correction.

Associated conditions

[edit]

Eye injury and head trauma may also coincide with a black eye. Some common signs of a more serious injury may include:

  • Double vision
  • Loss of sight and/or fuzzy vision could occur
  • Unconsciousness
  • Inability to move the eye or large swelling around the eye
  • Blood or clear fluid from the nose or the ears
  • Blood on the surface of the eye itself or cuts on the eye itself
  • Persistent headache or migraine

Treatment

[edit]

Unless there is actual trauma to the eye itself (see below), extensive medical attention is generally not needed.[2]

Applying an ice pack will keep down swelling and reduce internal bleeding by constricting the capillaries. Analgesic drugs (painkillers) can be administered to relieve pain.[2]

An anecdotal remedy for a black eye consists of applying raw meat to the eye area. Research has yet to find any evidence of this treatment being effective. Likely the raw meat was used when ice packs were not yet commercially available and meat was stored in iceboxes instead of in a protective gas. While cold but not freezing, meat is more gentle to the skin than ice and will not damage the surface of the skin as the skin temperature cannot go below freezing even in extreme cases. Meat is also soft and comes easier into contact with the skin than blocks of ice that were available.[citation needed]

References

[edit]
[edit]
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Black eye

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A black eye, medically known as a periorbital , is bruising and swelling around the eye that occurs when small blood vessels beneath the skin break due to trauma to the face or head, leading to blood leaking into surrounding tissues. This condition typically appears as dark discoloration on the eyelids and periorbital area, changing colors from purple or blue to yellow or green over time as the body reabsorbs the blood, and it usually resolves without complications within 1 to 3 weeks. Common causes include direct blows such as punches, falls, , or car accidents, though less frequently it can result from surgical procedures or even non-traumatic factors like severe allergies causing and venous pooling. Symptoms often involve pain, tenderness, and swelling that may worsen in the first day or two, but a black eye itself does not affect the eyeball unless underlying damage is present. While most cases are minor and self-limiting, they can signal more serious issues like orbital fractures, injuries, or , particularly if accompanied by vision changes, severe , or bruising around both eyes. Initial treatment focuses on reducing swelling and through cold compresses applied for 10 to 20 minutes several times a day in the first 24 to 48 hours, followed by warm compresses to promote healing, along with over-the-counter relievers like or ibuprofen. Medical evaluation is essential if symptoms include blood in the eye, blurred or double vision, persistent severe , or signs of such as fever or pus, as these may require imaging like X-rays or CT scans to rule out fractures or other complications. Prevention involves protective during sports and caution to avoid , emphasizing the importance of prompt care to prevent long-term issues like delayed healing or cosmetic concerns.

Definition and Causes

Definition

A black eye, medically termed periorbital ecchymosis or periorbital , refers to the bruising and accumulation of in the soft tissues surrounding the eye due to ruptured vessels. This condition arises primarily from trauma that damages the delicate network in the periorbital region, leading to extravasation of into the interstitial spaces. In non-medical usage, the term colloquially describes the visible bruised appearance around the eye resulting from incidents such as fights or accidents, but medically, it emphasizes the underlying vascular injury and tissue response. The involves the leakage of from damaged capillaries into the surrounding soft tissues, which causes initial discoloration and swelling. Due to the and gravitational effects in the periorbital area, the leaked tends to pool in the lower eyelids, resulting in the hallmark "black eye" appearance as it spreads and darkens. This process does not typically involve to the eyeball itself but affects the overlying and subcutaneous layers. It is important to distinguish a black eye from , a condition characterized by bilateral periorbital ecchymosis that stems from basal fractures or rather than direct trauma to the eye area. In , blood tracks along fascial planes from the fracture site, often appearing 24 to 48 hours post-injury and warranting immediate evaluation for underlying cranial damage. A black eye typically resolves in 1 to 2 weeks as the body reabsorbs the extravasated through natural phagocytic processes. During this period, the discoloration evolves from an initial red or purple hue—reflecting fresh hemorrhage—to green and yellow shades as breaks down into and , respectively.

Causes

A black eye, or periorbital ecchymosis, is most commonly caused by to the face, such as from punches, falls, or sports-related impacts, which rupture small vessels around the eye without necessarily fracturing underlying . Non-traumatic causes include certain surgical procedures, such as cosmetic surgery, sinus surgery, or facelifts, where from the surgical site can leak and pool under the thin skin around the eyes. Spontaneous black eyes can also arise from clotting disorders like hemophilia, which impair coagulation and lead to easy bruising even without injury. Additionally, severe allergic reactions causing and sinus pressure may result in "allergic shiners," a condition mimicking a black eye through pronounced periorbital swelling and discoloration. More serious underlying causes encompass basal skull fractures, which produce bilateral periorbital bruising known as due to blood leaking from the into surrounding tissues, occurring in 50-60% of such fractures. Orbital fractures or penetrating injuries from high-impact trauma can similarly cause extensive bruising by damaging orbital blood vessels or bone structures. Risk factors for developing a black eye include participation in contact sports like or , where ocular injuries account for a significant portion of sports-related trauma. Elderly individuals are at higher risk due to falls from balance issues, while medications such as increase bleeding propensity and severity. In children, black eyes may indicate , particularly if unexplained or bilateral, warranting careful evaluation. Epidemiologically, black eyes are prevalent in emergency settings, with approximately 68% of cases involving an underlying facial fracture, and they occur in 10-20% of severe presentations.

Signs and Symptoms

Appearance and Progression

A black eye typically begins with redness and swelling around the eye within hours of the injury, as and fluid accumulate in the loose tissues of the eyelids and periorbital area. This initial phase results from ruptured small vessels, leading to a visible bump or puffiness that can cause partial or complete closure in moderate to severe cases. As from the leaked starts to break down, the area progresses to a purple or blue discoloration within the first day or two, marking the peak of swelling and the onset of prominent bruising. Over the following days, the bruise undergoes characteristic color changes due to the metabolic breakdown of into and . Between days 3 and 5, the discoloration often shifts to a greenish tint from accumulation, while swelling begins to subside. By days 7 to 10, it fades to a yellowish hue as predominates, gradually lightening to brown before full resolution, which usually occurs within 2 weeks, though minor cases may heal in as little as 3 days. In darker tones, these changes may appear as variations in brown or rather than the typical purple-to-yellow sequence. The appearance can vary based on injury severity and location; a unilateral black eye affects one side, while bilateral bruising, known as , indicates potential trauma to the or sinuses and may show more extensive discoloration encircling both eyes. Severe injuries can lead to proptosis (bulging of the eye) alongside the bruising, depending on the volume of blood leaked and the extent of tissue damage. Factors such as thinner skin in the periorbital region make bruising more visible and pronounced, while greater blood volume from deeper injuries prolongs the discoloration. Individual healing rates also influence progression, with slower resolution in smokers due to impaired circulation or in diabetics from delayed tissue repair.

Accompanying Symptoms

A black eye, or periorbital ecchymosis, is frequently accompanied by around the eye area, which is often described as throbbing or aching and tends to intensify with the swelling. The typically peaks within the first 24 to 48 hours after , coinciding with maximum swelling, and the affected area is usually tender to touch. Functional impairments commonly arise from the swelling, which can cause the eyelids to close partially or fully, limiting the ability to open the eye. Temporary may occur due to pressure from the surrounding , while double vision () can develop if there is involvement of the orbital structures. Systemic symptoms such as and may accompany a black eye, particularly if associated with head trauma, and can result from ongoing discomfort. In mild cases, these accompanying symptoms are minimal and resolve with rest, but severe instances may involve or loss of consciousness, indicating a possible .

Diagnosis

Clinical Evaluation

The clinical evaluation of a black eye, or periorbital ecchymosis, begins with a thorough history to identify the mechanism of injury, such as from a fistfight, fall, sports incident, or accident, along with the timing of onset. Clinicians inquire about loss of , which may indicate associated head trauma, as well as any vision changes like , floaters, or that could suggest intraocular or orbital involvement. Additionally, the patient's use of anticoagulants or antiplatelet medications is assessed, as these increase the risk of extensive bruising and complicate . The physical examination focuses on visual acuity testing as an initial vital sign, followed by inspection for facial asymmetry, periorbital swelling, and ecchymosis extending beyond the immediate area. is evaluated with a penlight to check for equality, reactivity, and any irregularity, which might signal or iris injury. Extraocular movements are tested in all directions to detect restrictions, particularly in upward gaze, which could indicate entrapment of the ; sensation over the distribution is also assessed for . Palpation of the supraorbital and infraorbital rims, zygoma, and orbital floor is performed gently to identify step-off deformities, crepitus suggesting , or bony instability indicative of . Red flags warranting urgent intervention include (unequal pupils), severe headache, persistent vomiting, clear nasal discharge suggestive of (CSF) leakage from a , a large periorbital bruise, or very severe pain, as periorbital ecchymosis can be an early sign of such injury. These findings necessitate immediate and neurosurgical consultation to rule out intracranial complications. Triage involves distinguishing a simple contusion from more serious pathology like an , based on the presence of (sunken eye), restricted eye movements, or infraorbital hypesthesia, which suggest orbital floor disruption and require specialist referral. In uncomplicated cases without these features, the injury typically shows initial swelling peaking within 24-48 hours, followed by color changes from red-purple to yellow-green over 1-2 weeks.

Diagnostic Tests

Diagnostic tests for a black eye, also known as periorbital ecchymosis, are typically reserved for cases where complications such as orbital fractures, intraocular injuries, or underlying systemic issues are suspected, rather than routine mild presentations. These tests help confirm the , rule out fractures or hemorrhage, and identify any associated ocular or orbital damage. modalities play a central role in evaluating potential structural damage. The computed tomography (CT) scan is considered the gold standard for detecting orbital fractures, retrobulbar hemorrhage, foreign bodies, and globe deformities in blunt eye trauma associated with black eyes. Thin-cut coronal CT scans provide detailed visualization of the orbital walls and contents, particularly useful when there is suspicion of blowout fractures or entrapment. (MRI) may be employed for superior detail if CT findings are inconclusive or to assess involvement, though it is less commonly used due to availability and cost. X-rays can offer initial screening for gross fractures but are inferior to CT for comprehensive assessment. Ocular-specific tests focus on assessing visual function and internal eye integrity. testing, performed separately for each eye using a , evaluates potential vision impairment from trauma. Tonometry measures to detect elevated levels indicative of secondary or hypotony from rupture. Slit-lamp examination allows for detailed inspection of the anterior segment, identifying (blood in the anterior chamber), shallow anterior chamber, or signs of such as a teardrop . Fundus examination, often after dilation, checks for retinal involvement like commotio retinae, detachment, or vitreous hemorrhage. These tests are essential to exclude sight-threatening complications. In non-traumatic cases, such as spontaneous periorbital ecchymosis, blood work including coagulation studies (e.g., , , platelet count) is indicated to investigate clotting disorders or coagulopathies. Testing is warranted if clinical red flags are present, such as impaired vision, restricted eye movements, severe pain, (bilateral periorbital ecchymosis suggesting basal ), or suspicion of based on mechanism of . For uncomplicated mild black eyes without these features, diagnostic tests are not routinely necessary, as the condition is often self-limited.

Treatment and Management

Initial Home Care

For uncomplicated black eyes, initial home care focuses on minimizing swelling and promoting comfort through the protocol. Rest the affected area by avoiding strenuous activities that elevate for the first 1-2 days to prevent increased blood flow and further bruising. Apply using a cold compress wrapped in cloth for 20 minutes every hour during the first 48 hours, ensuring not to place directly on the skin to avoid ; this constricts blood vessels and reduces . Use gentle compression with the cloth-wrapped compress during icing sessions. Elevate the head, such as with extra pillows or in a at about a 30-degree angle, while resting or sleeping for the first 48 hours to facilitate drainage and limit fluid accumulation. After the initial 48 hours, transition to warm compresses applied similarly for 10-20 minutes several times a day to enhance circulation and aid in resolution. Pain and discomfort can be managed with over-the-counter analgesics such as acetaminophen or ibuprofen, following package dosing instructions. Aspirin should be avoided, as it can exacerbate and prolong bruising. Common myths about black eye care lack scientific support; for instance, applying raw or offers no benefit and risks bacterial from contaminants. Topical may provide mild relief for bruising in some cases but remains unproven for efficacy and can interact with blood-thinning medications. , used as an for skin irritation, shows limited evidence for reducing black eye swelling and is not recommended as a primary treatment. Monitor the injury closely for signs of improvement, such as reduced swelling within 48 hours, and track for worsening symptoms like increased pain, redness, or discharge, which warrant professional . Makeup should not be applied for at least 24 hours post-injury or until any open wounds have healed to prevent or .

Professional Medical Treatment

Professional medical treatment is indicated for black eyes that are large or very painful, as these may indicate a serious injury, or those associated with severe trauma, such as orbital fractures, significant vision impairment, or signs of underlying complications like or retrobulbar hemorrhage. In these cases, healthcare providers conduct a thorough to assess for structural damage and initiate targeted interventions beyond initial measures. For orbital fractures, surgical repair is often necessary to restore orbital anatomy and prevent long-term issues like or . Procedures typically involve open reduction and using titanium or resorbable plates to reconstruct the orbital floor or walls, particularly in cases of or large defects greater than 50% of the orbital volume. Emergent surgery is prioritized in children with muscle to avoid motility restrictions, while adults may undergo delayed repair for cosmetic or functional reasons. Large periorbital hematomas causing proptosis, pain, or vision compromise may require drainage to alleviate pressure on the . This can be achieved through needle aspiration for acute cases or surgical evacuation if clots are present, reducing the risk of . Medications play a key role in managing symptoms and preventing secondary issues. Prescription analgesics, such as opioids or nonsteroidal anti-inflammatory drugs, are prescribed for moderate to severe pain. Antibiotics are administered prophylactically if the injury involves an open wound communicating with the sinuses or if is suspected, while prophylaxis is given for contaminated or penetrating wounds. Systemic or topical corticosteroids may be used to reduce inflammation and swelling in associated conditions like traumatic , though their use is cautious due to risks like elevated . For ocular complications such as , topical corticosteroids and cycloplegic eye drops help control inflammation and prevent rebleeding, often alongside and shielding. Hospital protocols emphasize multidisciplinary care, including observation for in patients with head trauma indicators, such as altered mental status or severe . Patients with vision-threatening features, like or suspected , are urgently referred to , while those with complex fractures may involve oculoplastic surgeons. Observation periods typically last 24 hours in moderate cases, with monitoring of and serial exams. Follow-up care involves re-evaluation within 24-48 hours for high-risk cases to monitor , swelling resolution, and any delayed complications. Persistent after bruising fades may warrant referral for cosmetic , such as revision or orbital implants, to address aesthetic concerns.

Complications and Associated Conditions

Potential Complications

A black eye, resulting from periorbital trauma, can lead to several ocular complications if not properly evaluated and managed. One significant risk is , where blood accumulates in the anterior chamber of the eye, potentially causing increased that may progress to . Untreated also heightens the chance of , a condition where the separates from its underlying support tissue, risking permanent vision impairment. Additionally, trauma may cause , damaging the eye's outer layer and leading to pain, infection, or scarring if overlooked. Orbital complications arise when trauma affects deeper structures around the eye socket. Infection, such as , may develop if there is an associated skin laceration or extension from , causing severe , proptosis, and restricted eye movement. This may compress the , resulting in permanent vision loss if pressure is not relieved promptly. Scarring from unresolved or trauma can distort eyelid architecture, leading to where the lower lid turns outward, exposing the to further irritation and dryness. Systemic risks emerge particularly if infection spreads beyond the orbit. Untreated can propagate to , a life-threatening clot formation in the brain's venous sinuses, characterized by , fever, and neurological deficits. In immunocompromised patients, such as those with or on immunosuppressive therapy, healing of the periorbital may be delayed, prolonging and increasing susceptibility to secondary infections. Cosmetically, a black eye may result in persistent or facial due to uneven resolution of bruising and swelling, sometimes necessitating laser therapy or surgical correction for aesthetic restoration. These outcomes underscore the importance of timely medical intervention to prevent long-term functional and appearance-related issues. A black eye, characterized by periorbital ecchymosis, can be mimicked by non-traumatic conditions that produce similar swelling and discoloration around the eyes. Allergic periorbital , often resulting from hay fever or contact allergens, leads to puffy, darkened under-eye areas known as allergic shiners, which resemble bruising due to venous congestion and thin skin in the region. Insect bites near the eye can cause localized and , creating unilateral swelling that may be mistaken for a traumatic black eye, particularly if accompanied by minor hemorrhage. , a superficial bacterial typically caused by , can affect the periorbital area, resulting in acute, sharply demarcated redness, swelling, and tenderness that mimics the inflammatory phase of a black eye without underlying trauma. In cases of trauma leading to a black eye, particularly from assaults or accidents, several associated injuries frequently accompany the periorbital bruising. often co-occurs with black eyes from head impacts, as the bruising signals potential brain injury, with symptoms like or disorientation warranting immediate . Maxillofacial fractures are found in approximately 68% of patients presenting with a black eye in the context of minor head trauma. may develop alongside black eyes in nasal trauma, presenting as a painful, blood-filled swelling within the that requires prompt drainage to prevent complications like cartilage . Systemic conditions can also produce spontaneous periorbital resembling a black eye, often without trauma. In , such as , periorbital ecchymosis may arise from leukemic infiltration (chloroma) or , leading to easy bruising around the eyes that mimics . , particularly , causes fragile vessels and spontaneous bilateral periorbital due to deposition, a hallmark sign that can appear after minor straining or spontaneously. in result from blood tracking along fascial planes from basal skull or orbital roof disruption, typically manifesting 1-3 days post-hemorrhage and indicating serious intracranial bleeding. Distinguishing a black eye from other entities like chalazion or orbital tumors relies on clinical history and imaging. A chalazion, a chronic granulomatous cyst of the meibomian gland, presents as a painless, localized eyelid nodule with minimal ecchymosis, unlike the diffuse bruising of trauma, and is confirmed by lack of injury history and ultrasound showing a cystic lesion. Orbital tumors, such as hemangiomas or lymphomas, may cause proptosis, restricted eye movement, and secondary ecchymosis from vascular involvement or compression, differentiated via CT or MRI revealing a mass effect absent in simple periorbital hematoma.

Prevention

Protective Strategies

Protective strategies for preventing black eyes focus on minimizing through targeted equipment and environmental modifications in high-risk settings. In , where blunt impacts from balls, sticks, or collisions are common causes of eye injuries, the use of certified protective is essential. For instance, goggles are recommended for to shield against flying elbows or ball strikes, while helmets equipped with full-face shields provide robust protection in contact sports like hockey. In , helmets with integrated visors or shatter-resistant help guard against and low-branch impacts. These devices, when meeting standards such as those from the American Society for Testing and Materials (ASTM), can prevent up to 90% of sports-related eye injuries. Home environments pose risks from falls, particularly for vulnerable groups, and simple adaptations can significantly reduce these incidents. For the elderly, installing grab bars near toilets, bathtubs, and showers offers stability to prevent slips that could lead to facial impacts against fixtures or floors. Childproofing measures, such as securing heavy furniture to walls and using safety gates on stairs, help avoid tumbles that might cause head or eye trauma in young children exploring their surroundings. Additionally, consistent seatbelt use in vehicles is critical, as it significantly reduces the risk of head, face, and injuries, including those around the eyes, during crashes by restraining occupants from striking dashboards or windows. In occupational settings involving hazards like flying particles or sparks, regulatory-compliant gear is mandatory to avert eye trauma. Construction workers should wear face shields over safety glasses to protect against from tools or materials, while welders require auto-darkening helmets with integrated shields to block intense light and molten particles. For roles in security or other assault-prone professions, and equips individuals to avoid physical confrontations that could result in periorbital bruising. General practices further bolster prevention efforts. Avoiding altercations through skills minimizes the risk of punches or strikes to the face, a leading non-accidental cause of black eyes. During vehicle , proper seating—reclined at least 10 inches from the —combined with seatbelts, mitigates eye injuries from deployment, which can propel chemicals or fragments toward the face at high speeds.

Risk Factor Management

Managing modifiable risk factors for black eye, a periorbital hematoma typically resulting from , involves targeted adjustments to medications, lifestyle habits, and health screenings to minimize both the incidence of injury and the severity of bruising. Individuals at elevated risk, such as those on blood-thinning therapies, should consult healthcare providers about potential adjustments to anticoagulants like or direct oral anticoagulants, particularly before elective surgeries where bleeding complications could exacerbate bruising. Similarly, nonsteroidal drugs (NSAIDs) such as ibuprofen can impair platelet function and increase bruising tendencies, so temporary discontinuation or alternatives may be recommended under medical supervision to reduce hemorrhage risk during trauma-prone activities. Lifestyle modifications play a crucial role in preventing falls and accidents that lead to black eyes. For older adults, incorporating balance training exercises, such as or targeted strength programs, can significantly lower fall risk, which is a common cause of facial injuries in this population. Moderating alcohol intake is advisable, as even moderate consumption impairs coordination and visual processing, heightening the likelihood of accidents resulting in trauma. Additionally, enhances vascular health and promotes faster tissue repair, mitigating prolonged bruising and swelling from injuries like black eyes. Routine health monitoring helps identify and address underlying vulnerabilities. Screening for clotting disorders, such as , through blood tests can reveal predispositions to excessive bruising, allowing for proactive management in at-risk individuals. Similarly, osteoporosis screening via (DXA) in postmenopausal women or those with fracture history is essential, as low increases fall propensity and subsequent injury risk. For those frequently exposed to wounds, maintaining up-to-date vaccinations, including boosters every 10 years or post-injury prophylaxis, prevents secondary infections that could complicate black eye recovery. Tailored approaches for specific populations further reduce incidence. Child safety education programs, emphasizing recognition of abuse indicators like unexplained facial bruising, empower caregivers and communities to intervene early and prevent physical harm. For athletes, conditioning regimens focused on neck strengthening and proprioceptive training can decrease vulnerability to high-impact forces, thereby lowering the chance of periorbital trauma during sports. These strategies complement external protective measures but prioritize internal risk mitigation.

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