Black eye

A black eye is bruising and swelling in the skin and soft tissues around the eye. The medical term is periorbital bruising or periorbital ecchymosis. It usually develops when an injury breaks small blood vessels under the skin. Blood and fluid then collect in the surrounding tissues.

The bruise may look red or purple at first. As it heals, it can become blue, green, yellow, or brown. Swelling may partly close the eyelids. Because the skin around the eye is thin and loose, even a minor injury can cause noticeable discoloration.

Most uncomplicated black eyes improve with home care. However, the appearance of the bruise does not show how serious the underlying injury is. A blow strong enough to cause a black eye may also damage the eyeball, the bones around the eye, or the brain. Careful attention to vision, eye movement, pain, and head-injury symptoms is important.

A black eye can occasionally appear without a direct blow to the eye. Blood from an injury to the forehead, scalp, nose, or face can move through tissues and settle around the eyelids. Bruising around both eyes after a significant head injury needs prompt assessment because it can be associated with a skull fracture.

Typical symptoms include discoloration around the eye, tenderness, and swelling of the eyelids or nearby face. The eye may be difficult to open because of swelling, but vision should be normal once the eyelids are gently separated.

A straightforward bruise often changes color and gradually fades. Swelling may be most noticeable during the first day or two. The bruising can take a couple of weeks to disappear completely.

Symptoms suggesting more than a simple skin bruise include:

• Blurred, reduced, or double vision
• New flashes, floaters, shadows, or a curtain-like area in the field of vision
• Severe eye pain or pain when moving the eye
• Trouble moving the eye normally
• An eye that looks pushed forward, sunken, or out of position
• Blood visible over the colored part of the eye
• An irregularly shaped pupil or pupils of different sizes
• Numbness of the cheek, upper lip, teeth, or side of the nose
• A cut on the eyelid or an object that may have entered the eye

A head injury can cause a concussion even when there is no loss of consciousness. Possible symptoms include headache, dizziness, nausea, confusion, memory problems, sensitivity to light or noise, and unusual tiredness.

Call emergency services for loss of consciousness, a seizure, increasing confusion, weakness, slurred speech, repeated vomiting, a worsening severe headache, or difficulty waking the injured person. Emergency care is also appropriate for sudden vision loss, major bleeding, an object embedded in the eye, or an eye that appears cut or ruptured. Do not press on the eye in these situations.

A direct blow is the most common cause of a black eye. This may happen during a fall, collision, sports activity, physical assault, or motor vehicle crash. The injury does not have to strike the eyeball itself. A blow to the eyebrow, nose, cheek, or forehead can allow blood to spread into the tissues around the eye.

Black eyes can also occur after surgery involving the eyelids, nose, sinuses, face, or teeth. In this setting, the treating clinician should explain what degree of bruising is expected and which symptoms require a call.

Certain factors can make bruising easier or more extensive. These include older age, fragile skin, bleeding disorders, and medicines that affect blood clotting. Examples include anticoagulants like warfarin or apixaban, sometimes called blood thinners, and antiplatelet medicines. Aspirin and some anti-inflammatory pain medicines can also increase bleeding.

Do not stop a prescribed blood thinner because of a black eye without speaking to the prescriber. The reason for taking the medicine may be more important than the bruise. A clinician can assess whether the injury or bleeding changes the treatment plan.

Dark areas beneath both eyes are not always bruises. Allergies and nasal congestion can cause shadowing known as “allergic shiners.” These usually develop without an injury and do not change color like a healing bruise.

Bruising around both eyes after a significant blow to the head is different. Sometimes called “raccoon eyes,” it may not appear immediately. It can indicate blood tracking from a fracture at the base of the skull and requires urgent medical assessment.

A clinician first asks how the injury occurred, when it happened, and whether there was loss of consciousness. It is important to describe any change in vision, vomiting, headache, memory problems, neck pain, or use of medicines that affect bleeding.

The examination usually includes checking vision in each eye separately. The clinician may assess pupil shape and response to light, eye movements, visual fields, eyelid injuries, and the position of the eye. The bones around the eye and other parts of the face may be checked for tenderness, numbness, or an abnormal step in the bone.

A magnifying microscope called a slit lamp may be used to inspect the front of the eye. Special dye can reveal scratches on the cornea, the clear surface at the front of the eye. Depending on the injury, the clinician may also examine the retina and optic nerve at the back of the eye.

Imaging is not needed for every black eye. A computed tomography, or CT, scan may be ordered when there is concern about a facial or orbital fracture, bleeding behind the eye, an object in the eye, or a serious head injury. The orbit is the bony socket that holds the eye.

An uncomplicated black eye usually needs protection, cold compresses, and time. During the first one to two days, place a cold pack over the closed eyelids for about 10 to 20 minutes at a time. Repeat periodically while awake.

Wrap ice or a frozen pack in a thin towel. Do not place ice directly on the skin, and do not press on the eyeball. A bag of frozen peas can mold around the area, but it should also be wrapped.

Keeping the head raised, including during sleep, may help limit swelling. Avoid rubbing the eye. Do not try to force swollen eyelids open, massage the bruise, or drain it.

After the early swelling has started to settle, a warm—not hot—compress may be soothing. It may help the body clear the trapped blood. Stop if warmth increases pain or swelling.

For pain relief, acetaminophen may be an option for many people when used according to the package directions. Aspirin can increase bleeding. Ibuprofen and similar anti-inflammatory medicines may not be suitable after some injuries or for people with certain medical conditions. A pharmacist or clinician can help identify an appropriate choice. Children and teenagers should not receive aspirin for pain unless a clinician specifically directs it.

Avoid contact sports, rough activity, and situations where the eye could be struck again until pain and swelling have resolved and vision is normal. A diagnosed eye injury, fracture, or concussion may require a longer recovery plan and medical clearance before returning to sports.

Treatment changes if there is deeper damage. An orbital fracture may need observation, specialist follow-up, or surgery, depending on eye position, trapped eye muscles, and other findings. Bleeding inside or behind the eye requires urgent specialist care. Cuts, corneal injuries, and infections have their own treatments. These should not be managed with leftover eye drops.

Do not apply raw meat or unclean materials to the bruise. They do not improve healing and can introduce bacteria. Avoid eye drops unless they were recommended for the specific injury.

Most black eyes heal without lasting problems. Complications are usually related to the force that caused the bruise rather than the bruised skin itself.

An orbital fracture is a break in one of the bones surrounding the eye. It can cause double vision, numbness in the cheek, limited eye movement, or a sunken appearance. Some fractures do not require surgery, but they still need appropriate evaluation.

A hyphema is bleeding in the front chamber of the eye, often seen as a pool or layer of blood over the colored iris. It can raise pressure inside the eye and threaten vision. It requires urgent eye assessment.

Bleeding behind the eyeball can rapidly increase pressure within the eye socket. This is called a retrobulbar hemorrhage and may lead to orbital compartment syndrome. Warning signs include severe pain, reduced vision, a bulging eye, tight swelling, or trouble moving the eye. This is an emergency because treatment may be needed quickly to protect the optic nerve.

Other possible complications include retinal injury, inflammation inside the eye, corneal damage, infection of a wound, concussion, or more serious brain injury. New symptoms can develop after the initial injury, so worsening pain or vision should not be dismissed just because the bruise looked minor at first.

Routine home monitoring is reasonable when the injury was minor, vision is normal, the eye moves normally, pain is mild, and swelling is gradually improving. The bruise should change color and fade rather than become increasingly painful or swollen.

Arrange a routine medical review if the bruise is not improving, remains unexplained, or happens repeatedly. A clinician should also review easy bruising elsewhere, frequent nosebleeds, or other unusual bleeding. These symptoms may need an assessment of medicines or blood clotting.

Seek same-day medical advice for blurred or double vision, persistent eye pain, difficulty moving the eye, blood inside the eye, facial numbness, a deep eyelid cut, or significant swelling that prevents the eye from being assessed. People taking prescribed blood thinners should have a lower threshold for contacting a clinician after a head or facial injury.

After a diagnosed concussion, eye injury, or facial fracture, attend the recommended follow-up even if the bruise looks better. Vision testing or specialist review may detect problems that cannot be judged from appearance alone.

Use emergency services for sudden loss of vision, severe or rapidly worsening eye pain, a bulging eye, an embedded object, uncontrolled bleeding, loss of consciousness, seizure, repeated vomiting, increasing confusion, new weakness, or difficulty waking.