What is the recommended workup and management for a patient who presents with diplopia and raccoon‑eye periorbital bruising after a fall?

Immediate CT Imaging Without Contrast is Mandatory

A patient presenting with diplopia and raccoon-eye periorbital bruising after a fall requires immediate non-contrast CT of the orbits and head to evaluate for orbital fractures, skull base fractures, and intracranial hemorrhage 1, 2.

Critical Initial Assessment

The combination of raccoon eyes (periorbital ecchymosis) and diplopia following trauma is highly concerning for:

• Orbital fractures (floor, roof, medial/lateral walls)
• Anterior skull base fractures (most common cause of raccoon eyes in trauma)
• Traumatic optic neuropathy
• Orbital compartment syndrome
• Extraocular muscle entrapment or injury

Specific Physical Examination Findings to Document

• Pupillary examination: Check for afferent pupillary defect (Marcus Gunn pupil), which may be the only sign of traumatic optic neuropathy in obtunded patients 1
• Proptosis assessment: Severe proptosis with posterior globe tenting requires emergent orbital decompression 1
• Extraocular motility: Document specific pattern of diplopia (which direction of gaze worsens symptoms)
• Visual acuity: Any vision loss requires urgent intervention
• Cranial nerve function: Assess cranial nerves III, IV, and VI specifically 2
• Other basilar skull fracture signs: Battle's sign, hemotympanum, CSF otorrhea/rhinorrhea (though these are rarely present together with raccoon eyes) 3

Imaging Protocol

Non-contrast CT of the orbits is the gold standard initial imaging 1, 2. Key technical specifications:

• Use high-resolution thin-slice bone windows (1-mm slice thickness) to detect subtle orbital roof fractures that may otherwise be missed 4
• CT maxillofacial imaging typically extends from frontal bone through mandible
• CT orbits focuses on smaller field of view centered at orbits 1
• Both studies are often complementary and may be ordered together 2

Why CT Over MRI Initially

CT is superior for:

• Detecting acute fractures and bone fragments
• Identifying orbital compartment syndrome
• Rapid acquisition in trauma setting
• Detecting optic canal fractures and bone impingement 1

Urgent Surgical Indications

The following findings on CT require immediate ophthalmology and/or neurosurgical consultation:

• Trapdoor fractures (especially in pediatric patients - require urgent repair within 24-48 hours)
• Bone fragment impingement on optic nerve
• Hematoma within optic canal
• Expanding retrobulbar hematoma with proptosis
• Severe proptosis with posterior globe tenting (requires emergent orbital decompression to preserve vision) 1
• Orbital compartment syndrome

Fracture-Specific Considerations

Orbital Floor Fractures

• Diplopia is particularly common with depressed orbital floor fractures affecting anterior or middle thirds with soft tissue herniation 1
• Fractures >2 cm more likely associated with enophthalmos 1
• Most can be repaired on delayed basis after acute swelling subsides (7-14 days), unless trapdoor fracture or compartment syndrome present

Lateral and Superior Orbital Wall Fractures

• Increased risk of traumatic optic neuropathy 1
• Blunt trauma forces transmit toward optic canal, exposing optic nerve to shearing injury 1

Optic Canal Fractures

• Place optic nerve at increased risk
• Emergent surgical intervention generally only for: bone fragment impingement, hematoma within canal, or expanding retrobulbar hematoma 1

Additional Diagnostic Considerations

High-Resolution CT is Critical in Older Adults

A recent case report demonstrates that older adults with diabetes may develop raccoon eyes from minor posterior head trauma with subtle orbital roof fractures that require 1-mm bone slice thickness CT to detect 4. Standard CT may miss these injuries.

Rule Out Carotid-Cavernous Fistula

If diplopia develops or worsens days to weeks after initial trauma, particularly with:

• Pulsatile exophthalmos
• Conjunctival chemosis
• Pulse-synchronous bruit
• Progressive symptoms

Consider CT angiography (CTA) or MR angiography (MRA) to evaluate for traumatic carotid-cavernous fistula 5. This is an uncommon but serious delayed complication requiring endovascular intervention.

Common Pitfalls to Avoid

1. Don't assume raccoon eyes always means basilar skull fracture: While this is the most common association, periorbital ecchymosis can occur with convexity fractures, facial fractures, or even isolated soft tissue injury 3

2. Don't rely on other "classic" basilar skull fracture signs: Only 3 of 15 patients with basilar skull fractures in one series had Battle's sign, and most had no other classic signs 3

3. Don't use plain radiographs: Orbital or skull X-rays are insufficient and have been supplanted by CT 2

4. Don't delay imaging for "observation": Unlike isolated cranial nerve palsies in non-trauma settings, post-traumatic diplopia with raccoon eyes requires immediate imaging 6, 7

5. Don't forget to assess for globe rupture before any manipulation: If globe rupture is suspected, avoid ocular ultrasound and protect the eye with a rigid shield 1

Management Algorithm

1. Immediate non-contrast CT orbits + head (high-resolution bone windows)
2. Emergent ophthalmology consultation if:
   • Visual acuity decreased
   • Afferent pupillary defect present
   • Proptosis present
   • Trapdoor fracture identified
   • Optic canal fracture with nerve impingement
3. Urgent ophthalmology consultation (within 24 hours) if:
   • Diplopia with orbital fracture and soft tissue herniation
   • Large orbital floor fracture (>2 cm)
   • Enophthalmos present
4. Delayed ophthalmology follow-up (7-14 days) if:
   • Small orbital fracture without entrapment
   • No vision-threatening features
   • Diplopia improving

Most orbital fractures without vision-threatening features can be managed conservatively or with delayed surgical repair after swelling subsides 1, 8.