Black Eye Treatment
For a patient presenting with a black eye, immediately perform a thorough eye examination to rule out serious underlying injury before initiating symptomatic treatment, as 68.3% of patients with periorbital ecchymosis have an underlying facial fracture requiring CT imaging. 1
Initial Assessment - Critical Red Flags
A "black eye" is never just a cosmetic issue until proven otherwise. Before applying any treatment, you must actively exclude:
- Hyphema (blood in anterior chamber) 2
- Iris distortion or irregular pupil 2
- Corneal laceration or occult perforation 2
- Intraocular bleeding from retinal tear 2
- Orbital or facial fractures (present in 68.3% of cases with black eye) 1
Do not rub the eye, as this can worsen injury and damage the corneal epithelium. 3
When to Order CT Imaging
Order CT scan for any patient with a black eye and minor head trauma (GCS 13-15), as the black eye itself has 68.3% positive predictive value for underlying fracture. 1
Additional clinical signs that increase specificity for fracture include:
- Diminished skin sensation (96.4% specificity) 1
- Diplopia or ocular motility disorders (89.3% specificity) 1
- Palpable fracture steps (99.8% specificity) 1
- Epistaxis (95.5% specificity) 1
- Subconjunctival hemorrhage (90.4% specificity) 1
- Subcutaneous emphysema (99.6% specificity) 1
Protective Measures
Tape a hard plastic eye shield, paper cup, or plastic cup over the eye to prevent unintentional touching or rubbing. 3
This is particularly important if any corneal involvement is suspected, as mechanical trauma can worsen epithelial defects.
Corneal Protection Protocol
If fluorescein staining reveals corneal epithelial disruption:
Apply nonpreserved hyaluronate or carmellose eye drops every 2 hours during the acute phase to maintain corneal epithelial integrity. 3
Prescribe broad-spectrum topical antibiotics (moxifloxacin 0.5% four times daily) if corneal fluorescein staining or frank ulceration is present. 3
Consider topical corticosteroid drops (nonpreserved dexamethasone 0.1% twice daily) to reduce ocular surface damage in the acute phase, but only after ruling out infection and perforation. 3
Cold Compress Application
Apply cold compresses with ice packs for 20 minutes every hour for 4 hours, as this provides equivalent efficacy to 48-hour protocols for reducing edema, ecchymosis, and pain. 4
The 4-hour protocol is more practical and equally effective compared to extended application. 4
Pain Management
Prescribe over-the-counter oral acetaminophen or NSAIDs for residual discomfort. 3
Follow-Up Requirements
Daily ophthalmological review is necessary during the acute illness if any corneal involvement or intraocular pathology is identified. 3
Regular follow-up is necessary to monitor healing and detect early signs of infection. 3, 5
Common Pitfalls to Avoid
- Never assume a black eye is benign without proper examination - more mistakes are made by not looking than by not knowing 2
- Never patch the eye if contact lens wear is involved, as this increases bacterial keratitis risk 5
- Never use combination steroid-antibiotic drops as initial therapy for corneal abrasions; steroids should only be added after 2-3 days of antibiotic-only therapy 5
- Never use corticosteroids if infection is suspected, particularly with Acanthamoeba, Nocardia, or fungal organisms 5
Patient Education
Instruct patients to seek immediate care if they develop: