What is the best initial treatment for a periorbital hematoma (bruise to the eye)?

Management of Periorbital Hematoma (Black Eye)

The best initial treatment for a periorbital hematoma (black eye) is the application of cold compresses, compression, and elevation of the head to reduce swelling and prevent further bleeding. 1

Initial Assessment and Management

Immediate Care (First 24-48 Hours)

• Cold application: Apply cold compresses for 15-20 minutes every 1-2 hours
• Head elevation: Keep head elevated while sleeping or resting
• Gentle compression: Apply light pressure without restricting blood flow
• Pain management: Use oral analgesics (NSAIDs or acetaminophen) as needed

Examination Priorities

• Assess visual acuity to rule out vision-threatening complications
• Check pupillary response for relative afferent pupillary defect
• Examine for signs of globe injury or orbital fracture
• Evaluate for intraocular pressure elevation if equipment available
• Check for blood in anterior chamber (hyphema)

Treatment Algorithm

For Simple Periorbital Hematoma

1. Cold compresses for first 24-48 hours
2. Switch to warm compresses after 48 hours to promote absorption
3. Oral analgesics for pain management
4. Avoid aspirin and other anticoagulants unless medically necessary
5. Follow up if symptoms worsen or vision changes occur

For Complicated Cases (Any of the following)

• Decreased visual acuity
• Abnormal pupillary response
• Proptosis (bulging eye)
• Restricted eye movement
• Severe pain
• History of trauma with potential orbital fracture

Immediate ophthalmology referral is required

Special Considerations

Warning Signs Requiring Urgent Care

• Vision loss or significant blurring
• Double vision
• Severe pain not relieved by analgesics
• Progressive swelling after 48 hours
• Blood visible in the eye (hyphema)
• Signs of infection (increased redness, warmth, purulent discharge)

Contraindications

• Avoid topical anesthetics for outpatient use as they can delay healing and lead to complications 2
• Avoid patching the eye as it may delay healing and increase infection risk 2
• Do not massage the area as it may worsen bleeding

Follow-up Recommendations

• Most uncomplicated periorbital hematomas resolve within 2 weeks
• Follow up within 24-48 hours if symptoms are severe or worsening
• Seek immediate care if vision changes occur

Evidence and Considerations

While there is limited high-quality evidence specifically for periorbital hematoma management, the principles of treating bruises apply. The application of cold, compression, and elevation are well-established first-line treatments for bruising 1. These measures help reduce bleeding, swelling, and pain by causing vasoconstriction and decreasing blood flow to the injured area.

In severe cases where significant swelling prevents examination of the eye or causes concerning symptoms, more invasive interventions may be considered, but these are not first-line treatments and should only be performed by specialists 3, 4.

The American Academy of Ophthalmology principles for managing ocular trauma emphasize careful assessment and appropriate referral for potentially vision-threatening conditions, which should guide the approach to periorbital hematomas as well.