Treatment of Raccoon Eyes (Periorbital Ecchymosis)
The treatment of raccoon eyes depends entirely on identifying and treating the underlying cause, not the ecchymosis itself—the periorbital bruising requires no direct intervention and will resolve spontaneously once the primary condition is addressed.
Diagnostic Priority: Identify the Underlying Etiology
The critical first step is determining what caused the periorbital ecchymosis, as this dictates all subsequent management:
Life-Threatening Causes Requiring Immediate Workup
- Basal skull fracture: Look for history of head trauma, CSF rhinorrhea/otorrhea, Battle's sign, hemotympanum 1, 2
- Neuroblastoma: Most common in infants/children; obtain urine catecholamines, abdominal imaging, bone marrow evaluation if suspected 3, 4
- AL amyloidosis: Check serum free light chains (κ and λ), look for proteinuria, M-protein on immunofixation 5
- Hematologic malignancy: Complete blood count, peripheral smear, coagulation studies; acute lymphoblastic leukemia can present this way 4
- Multiple myeloma: Serum protein electrophoresis, skeletal survey in adults 3, 5
Benign/Self-Limited Causes
- Birth trauma with subgaleal hematoma: Resolves spontaneously over weeks; monitor hematocrit 2
- Vomiting-induced: History of forceful emesis; spreads beyond tarsal plate (not true "raccoon eyes") 1
- Direct facial trauma: Bruising extends beyond orbital septum 1
Treatment Approach by Etiology
For Basal Skull Fracture
- Neurosurgical consultation immediately
- Avoid nasogastric tube placement (use orogastric route)
- Prophylactic antibiotics are controversial; follow institutional protocols
- No direct treatment of ecchymosis needed 1
For Neuroblastoma
- Immediate oncology referral for staging and risk stratification 3
- Treatment depends on stage: observation, chemotherapy, surgery, or multimodal therapy
- The periorbital ecchymosis resolves with tumor treatment 3
For AL Amyloidosis
- Hematology consultation for chemotherapy (typically melphalan-based regimens or bortezomib combinations) 5
- Avoid trauma-inducing procedures when possible (though kidney biopsy may be necessary for diagnosis) 5
- Ecchymosis resolves as disease is controlled 5
For Hematologic Malignancy
- Pediatric or adult oncology referral based on age 4
- Chemotherapy per disease-specific protocols
- Supportive care with transfusions as needed 4
For Benign Causes
- No specific treatment required 1, 2
- Reassurance and observation
- Resolution typically occurs within 2-6 weeks 2
Critical Pitfall to Avoid
Do not assume trauma or child abuse without thorough investigation—this delays diagnosis of potentially fatal conditions like neuroblastoma or amyloidosis 3. The presence of bilateral periorbital ecchymosis without clear traumatic mechanism mandates systemic workup, particularly in children 3, 4.
What NOT to Do
- Do not treat the ecchymosis itself with topical agents, ice, or compression—these are ineffective and unnecessary 1, 5, 2
- Do not discharge a patient with unexplained raccoon eyes without imaging and laboratory evaluation 3, 5
- Do not use the term "raccoon eyes" for bruising that extends beyond the tarsal plate, as this suggests non-skull-base pathology 1