Black eye: just a bruise, or a blow worth getting examined?

A black eye is a haematoma of the eyelids: small vessels ruptured by the blow let blood spread beneath very thin skin. The bruise itself is not dangerous and usually clears up on its own. What matters is what the blow may have hit behind it: the eye and the bone around it. In a Swiss study of 1,676 patients who came to the emergency department with a black eye after a blow to the head (Büttner, 2014), a CT scan showed a facial fracture in 68.3% of them; these patients had been seen in a trauma centre, which does not reflect all blows to the eye. Even without any discomfort, a direct blow to the eye always warrants an ophthalmological examination, including the back of the eye (fundus). Reduced vision, double vision, pain on moving the eye or a numb cheek mean seeing an ophthalmologist the same day or, failing that, going to the eye emergency department.

UNDERSTANDING

Why the eyelid turns black and swells so quickly

The skin of the eyelids is very thin, and the tissue beneath it is loose: blood and swelling spread through it unimpeded. That is why the eye can swell shut within a few hours even though the blow seemed moderate. Blood also tracks downwards with gravity: a blow to the forehead or the nose can darken the eyelids a day or two later, sometimes on both sides.

The colour changes as the body breaks down the blood: red, purple or blue at first, then green, then yellow or brown. This order is usual, but it is not a calendar. A systematic review of bruises in children (Maguire, 2005) showed that every shade can be seen on a recent bruise as well as an old one, and that doctors date a bruise to within 24 hours in fewer than 40% of cases.

An eyelid haematoma with no other signs most often heals without after-effects. The swelling usually goes down within a few days; the discolouration fades more slowly, over several weeks.

What the blow may have hit behind the bruise

The bruise is only the visible part. The same blow can fracture the bone around the eye, damage the eye itself or cause bleeding behind it. These injuries are not always visible from the outside, and a swollen eye often keeps them from being noticed.

The bone of the orbit: the floor fracture

The eye rests on a very thin bony floor, above the sinus in the cheek. A direct blow, from a fist or a ball, can make it give way: this is an orbital floor fracture. It shows itself as double vision, especially when looking up or down; numbness of the cheek, the upper lip or the upper teeth, because the nerve that supplies sensation to the cheek runs through this floor; a nosebleed; or swelling that crackles under the finger when air from the sinus has passed under the skin.

In the Swiss series cited above (Büttner, 2014), these signs, when present, almost always pointed to a fracture: a numb cheek had a specificity of 96.4%. But in the same series, they were absent in most of the patients who had a fracture, with a sensitivity of 10.8 to 22.2% depending on the sign. Their absence therefore does not rule out a fracture: it is the examination, and the CT scan if needed, that decides.

Most of these fractures are not operated on. In a US series of 451 patients with fractures of the orbital walls (Ray, 2023), 16.9% needed surgery. The operation is performed by a maxillofacial or ENT surgeon when the eye remains sunken, when double vision persists or when a muscle is trapped. In a Zurich series of 282 patients operated on for a midface fracture (Blumer, 2020), the most frequent eye injuries were minor, swelling of the conjunctiva and a patch of blood beneath it; double vision was present in 18.4% of them before the operation.

The eye itself: blood in front of the iris, a shaken retina

A blow can cause bleeding inside the eye, in front of the iris: this is a hyphaema (blood in the anterior chamber), seen as a red level at the bottom of the coloured part, or as a red veil over the vision. It requires an examination the same day, because a fresh bleed and a rise in the pressure of the eye can occur in the days that follow. A 2023 Cochrane review (Woreta), covering 30 trials and 2,969 participants, did not demonstrate an effect on vision for any of the treatments studied, whether medication, bed rest or an eye dressing; monitoring of the pressure of the eye therefore keeps its full place.

The risk is higher with sickle cell disease or sickle cell trait. In a US series of 99 eyes of children hospitalised for a hyphaema (Nasrullah, 1997), among the children whose status was known, a fresh bleed occurred in 9 of 14 eyes in carriers of the trait, and in none of the 57 eyes of non-carriers. This point should be mentioned as soon as you are seen.

The blow can also shake the retina: this is commotio retinae (retinal concussion), which gives a pale, swollen retina and reduces vision. It most often recovers. In a Birmingham series (Blanch, 2013), 74% of the patients affected at the centre of the retina, the macula, and 95% of those affected at the periphery regained at least 20/30, or about 7/10. Lastly, a blow can cause, sometimes weeks later, a tear or a retinal detachment: flashes, a shower of black dots or a veil mean contacting the practice as a priority or, outside its opening hours, the eye emergency department.

Bleeding behind the eye: the real emergency

More rarely, blood builds up behind the eye, in the orbit, which is a closed space. The pressure rises there and compresses the optic nerve: this is orbital compartment syndrome. The eye pushes forward and becomes hard, the eyelid is tense, the pain is severe and vision falls. A review aimed at emergency physicians (Murali, 2021) points out that this diagnosis rests on the examination and that the decompression procedure, a small incision at the outer corner of the eye, must not wait for imaging. You must go to the eye emergency department without delay.

When a black eye comes with a blow to the head

A black eye is often part of a head injury. Loss of consciousness, even brief, vomiting, drowsiness, confusion, a headache that is getting worse, or a clear fluid running from the nose or the ear mean calling 15. Two black eyes, like a pair of spectacles, appearing without a direct blow to the eyes may point to a fracture of the base of the skull. A Brazilian study of 136 head-injured patients (Solai, 2018) shows that these signs are imperfect for making this diagnosis, but that they accompany the most severe head injuries: they justify going to the emergency department.

What you notice, and what to do

TREATING

The first few days: what helps

For an isolated bruise, with none of the signs above, a few simple measures limit the swelling and the discomfort while waiting for the examination.

• Cold, wrapped in a clean cloth, for a few minutes several times a day for the first two days, as is common practice; never ice directly on the skin.
• Head raised on a pillow at night, to limit the swelling.
• A simple painkiller if needed, avoiding aspirin and anti-inflammatory drugs in the first few days, because they encourage bleeding.
• Do not blow your nose hard until a fracture has been ruled out: air from the sinus can pass into the orbit and make the eyelid swell suddenly.
• Remove your contact lenses and avoid make-up while the eye is swollen.

Cold is the measure with the most evidence behind it. After nose surgery, which leaves comparable eyelid haematomas, a meta-analysis of 11 trials and 627 patients (Lee, 2017) found less swelling and bruising with cold during the first 24 hours, and with arnica during the first week. The authors nevertheless call for further trials, and these data do not concern blows. No cream should be applied inside the eye. As for raw steak, a traditional home remedy, it provides nothing but the coldness of the meat, with a risk of infection: a clean cold pack provides the same cold without that risk.

In children, a trap to know about

In children, the bone of the orbit is more flexible. It can split and then close again like a trapdoor on one of the eye’s muscles: this is a trapdoor fracture. The eye looks almost normal, with little bruising and little redness, but the child has pain on moving the eye, sees double, has nausea, vomits or feels unwell. A review of orbital fractures in children (Joshi, 2011) points out that this trapped muscle, which can trigger a reflex that slows the heart, calls for urgent surgical management.

The vomiting is sometimes put down to a blow to the head. In a child who vomits after a blow to the eye, the parents can also check whether the eye follows the finger upwards and downwards, and ask the child whether he or she sees double, without this test replacing the examination. If in any doubt, the examination is done in the eye emergency department.

In sport, suitable eyewear

Large balls, small balls and rackets are a frequent cause of blows to the eye (see our article on eye injuries in sport). A systematic review of racket sports (Mazarelo, 2024) found that a median of 93% of eye injuries occurred in players without protection. It also notes that ordinary prescription glasses, contact lenses or protectors without lenses could make some injuries worse, because the squash ball deforms on impact. In this review, only protectors that met recent standards were associated with no injuries.

When to consult

Any direct blow to the eye warrants an ophthalmological examination, including the back of the eye (fundus), even without any discomfort: an isolated bruise, with none of the signs below, should be examined in the days that follow, after first aid at home. You should, however, see an ophthalmologist the same day or, failing that, go to the eye emergency department (see our page on ophthalmic emergencies) if you notice:

• blurred vision, or vision that is getting worse;
• double vision;
• pain on moving the eye;
• blood visible in front of the iris, or a distorted pupil;
• numbness of the cheek, the upper lip or the upper teeth;
• a nosebleed, or an eye that looks sunken;
• a blow from a pointed object or one thrown at high speed, or a wound to the eyelid.

An eye that bulges forward, hard and very painful, calls for the eye emergency department without delay. Loss of consciousness, vomiting, drowsiness or confusion mean calling 15 (the French emergency medical number). Flashes or a shower of black dots in the days or weeks that follow mean contacting the practice as a priority or, outside its opening hours, the eye emergency department.

The examination checks vision, the pressure of the eye, its movements and the back of the eye (fundus), and points to a CT scan or a facial surgeon if a fracture is suspected. Dr Tourabaly sees patients for consultations at the Cachan and Paris 13 practices, and at the Sorbonne Saint-Michel ophthalmology practice (Paris 5th). Children are seen from the age of 3 at the Cachan practice; a younger child who has had a blow to the eye, or any child who needs to be examined urgently, is a matter for the eye emergency department.

Frequently asked questions

Consultations in Cachan, in Paris 13 and at the Sorbonne Saint-Michel practice (Paris 5th) · Tel. +33 1 45 47 08 11

Scientific sources

• Büttner M, et al. Is a black eye a useful sign of facial fractures in patients with minor head injuries? A retrospective analysis in a level I trauma centre over 10 years. Br J Oral Maxillofac Surg. 2014. PMID 24793410
• Ray CN, et al. Review of 451 patients presenting with orbital wall fractures: a retrospective analysis. J Craniofac Surg. 2023. PMID 35994738
• Blumer M, et al. Associated ophthalmic injuries in patients with fractures of the midface. Craniomaxillofac Trauma Reconstr. 2020. PMID 33456682
• Woreta FA, et al. Medical interventions for traumatic hyphema. Cochrane Database Syst Rev. 2023. PMID 36912744
• Nasrullah A, Kerr NC. Sickle cell trait as a risk factor for secondary hemorrhage in children with traumatic hyphema. Am J Ophthalmol. 1997. PMID 9535622
• Blanch RJ, et al. Visual outcomes after blunt ocular trauma. Ophthalmology. 2013. PMID 23618228
• Murali S, et al. Orbital compartment syndrome: pearls and pitfalls for the emergency physician. J Am Coll Emerg Physicians Open. 2021. PMID 33733246
• Solai CA, et al. Clinical signs of basilar skull fracture and their predictive value in diagnosis of this injury. J Trauma Nurs. 2018. PMID 30216260
• Joshi S, et al. Overview of pediatric orbital fractures. J Craniofac Surg. 2011. PMID 21772188
• Mazarelo JFD, et al. A systematic review on the effectiveness of eyewear in reducing the incidence and severity of eye injuries in racket sports. Phys Sportsmed. 2024. PMID 37070274
• Maguire S, et al. Can you age bruises accurately in children? A systematic review. Arch Dis Child. 2005. PMID 15665179
• Lee HS, et al. The effectiveness of postoperative intervention in patients after rhinoplasty: a meta-analysis. Eur Arch Otorhinolaryngol. 2017. PMID 28314960

This article is for information purposes and does not replace a medical consultation. Indications, expected benefits and risks depend on each individual situation. For any question about your vision, consult an ophthalmologist.