ECCHYMOSIS AND BLUNT ORBITAL TRAUMA

Signs and Symptoms

The word ecchymosis takes its origin from the Greek words ek (to extravasate blood from) and chymos (juice) to mean “a spilling out of blood from the juice.”1 Patients with eyelid and periorbital injuries will present with varying degrees of eyelid swelling, eyelid edema, bruising and bleeding.2,3 Eyelid hematomas and periorbital tissue swelling results from blunt force injuries ranging from falls and fists to missile impacts (balls, bats, clubs, tools, air bags, etc.) and skull base fractures (raccoon eyes or panda sign).2-16 Non-traumatic ecchymosis has been documented after severe vomiting, violent coughing and sneezing.15-17

Ecchymosis may be shallow with fluid and blood only layering under the skin, or may be more substantial, seeping into muscle or subcutaneous dermal tissues. The characteristics and coloration of the bruise at the site of the injury will range from red to purple and is subject to: the severity of the impact; amount of bleeding that has occurred; depth of the injury; color, complexion, tone and condition of the skin; coagulative state of the patient; and the age of the injury.18 Yellowing can be noted as the injury heals. Accompanying injuries in traumatic cases which produce ecchymosis may include blow-out orbital fracture, canalicular laceration, subconjunctival hemorrhage, eyelid laceration, globe rupture, corneal or conjunctival laceration, corneal abrasion, iritis, iridodialysis, hyphema, lens luxation, levator disinsertion, commotio retinae, posterior vitreous and retinal detachment, vitreous hemorrhage and optic nerve contusion and evulsion.2-10

Depending upon the cause, symptoms may include pain, photophobia, lacrimation and crepitus (the crackling sound of air escaping from soft tissues following bony fractures) if bones have been broken and air has invaded the tissue (pneumatic or orbital emphysema).17 If blow-out fracture has occurred, diplopia may be present from extraocular muscle entrapment. As the lid swells, vision will be compromised secondary to obstruction of the visual axis. If concomitant internal injuries have occurred, vision may remain reduced despite opening of the eyelid. If retinal detachment has ensued, tractional photopsias (flashes and floaters) may be present. If there is a significant iritis, the patient may be photophobic. Intraocular pressure may be high or low depending upon the status of the ciliary body with respect to aqueous humor production, the amount of anterior chamber inflammation, the presence of hyphema or concurrent damage to the drainage angle.2-5,14

The epidemiology of blunt ocular injury is heavily skewed toward young males, often during the warmer months, and there are more incidences of blunt ocular injury related to work and sports.2-10 Accidental injuries occurring in or around home show a more balanced gender distribution.14

Pathophysiology

The eyelid and ocular adnexa are well vascularized, containing multiple tissue types (supportive and muscular) and sensory nerves (V1, ophthalmic division of the trigeminal nerve). The intricate architecture permits the formation of a thin but formidable cohesive barrier anchoring the skin, levator aponeurosis (LA), orbicularis oculi and tarsal plate into the mainframe of the upper eyelid.19 As the frontalis muscle does not have a bony insertion point on the skull superiorly, there is no limit to the travel of a bruise in that direction. Gravity, however, encourages the extravasated fluids to seep inferiorly into the lid and upper cheek. The anterior portion of LA interdigitates with the orbital septum superiorly, creating an additional barrier keeping released fluid from accessing the orbit.18 The barrier is completed by tarsal plate as its orbital border attaches to the orbital septum, while the marginal border attaches to the lid margin.10 These barriers limit extravasation of blood into the periorbital skin and the subcutaneous tissues around the eyes. Raccoon eyes or panda sign are distinctive types of periorbital ecchymosis where the bruising is mitigated by the orbital septum, limiting the spread of the discoloration beyond the tarsal plate.15,16 Completing the layers of the eyelid, the muscle of Müller rides underneath the anterior and posterior layers of the LA. It extends superiorly to connect to the inferior branch of the levator palpebrae superioris, which is contiguous with the LA and frontalis.19 The subcutaneous connective tissue under the eye, referred to as the nasojugal fold, is the bony fascial attachment of the skin and connective tissue limiting the inferior movement of ecchymotic swelling.

Ecchymosis results from capillary leakage secondary to traumatic insult.15-19 The etiology can be traced to a combination of two mechanisms: shear stress (push-pull) or hydraulic-induced (pressure-related) tensile stress.20 Results from experiments testing both models of disruption have demonstrated that the predominant mechanism of failure is hydraulic-induced tensile stress.19 This was concluded via observations made directly under impact zones where capillaries bifurcate.20 These results are supported by the concept that bruising can occur via blunt trauma in which no shearing incisions or lacerations occur.15-19 As blood and its constituents are liberated from the capillaries, it flows with the assistance of gravity into the tissues until it reaches a barrier or until hemostasis begins the process of clotting and repair.15,16,21 Patients who are on anticoagulation therapy or have primary hemostatic clotting disorders demonstrate a propensity for easy and more extensive bruising.21 Patients with secondary hemostatic disorders typically manifest with delayed, deep bleeding into muscles and joints.21

Immediately following an insult, blood-laden dermal layers take on a darkened red-blue-purple appearance. The amount of pain and discomfort is proportionate to the sensitivity of the affected nerves and the total area of damage. Damaged capillary endothelial cells release endothelin, a hormone that causes a narrowing of blood vessels, which begins hemostasis.22-25 Secondarily, von Willebrand factor is released, initiating comprehensive coagulation.21-24 Bruises change color (black-brown-green-yellow) due to the breakdown of red blood cell hemoglobin.22-25 The colors of a bruise are caused by the phagocytosis and sequential degradation of hemoglobin into biliverdin (green), bilirubin (yellow) and hemosiderin (red/brown/blue). As the products are reabsorbed in demolition and repair, the bruise disappears.22-25

Any disruption of the external skin will enable pathogens access to the internal anatomy and communicative vasculature. This creates the potential for infection and preseptal cellulitis. Impacts that are significant enough to create eyelid hematomas are also capable of fracturing and bruising bones of the orbit or initiating intraorbital bleeding, resulting in sight-threatening retrobulbar hemorrhage.25,26 Life-threatening intracranial complications such as epidural hematoma and subarachnoid hemorrhage from transmitted forces are possible as well.27

Management

If any bleeding is present, it must be arrested and the patient’s overall systemic health must be evaluated. History is critical in assessing the nature and extent of the injury. The area of injury must be inspected for breaks in the skin or irregularities at the lid margin or nasolacrimal apparatus. The globe and ocular tissues must be examined completely; a dilated ophthalmoscopic examination should be completed unless a contraindication such as lens subluxation or globe rupture is uncovered. The area of injury should be palpated to rule out the presence of crepitus and orbital emphysema.11-17

In cases where the eyelid is tight and full and cannot be elevated manually, it can be lifted with a lid retractor. This is necessary for obtaining initial visual acuity, ocular tissue inspection, intraocular pressure and fundus examination. If crepitus or orbital emphysema is detected—indicating an orbital wall fracture—oral antibiotic prophylaxis with a broad-spectrum antibiotic such as cephalexin, amoxicillin, dicloxacillin and erythromycin may be necessary.17,25-28

Small abrasions or cuts without evidence of laceration can be prophylactically protected by topical ophthalmic antibiotic ointment BID-TID. In most cases, periorbital swelling will subside naturally over two to four weeks. It can be hastened with cold compresses, upright sitting and head elevation during sleep. This encourages the blood to settle and enhances the environment for reabsorption. In the event that pain and edema are severe, a short course of oral steroids can help. Pain management can be accomplished by over-the-counter analgesics such as acetaminophen or ibuprofen.

A novel consideration to hasten the resolution of ecchymosis is hydrogen peroxide 15% carbamide gel under occlusion.22 Hydrogen peroxide in water is sold over the counter as a topical antiseptic. Carbamide peroxides are used as over-the-counter teeth whiteners, earwax softeners and hair bleachers.22 Hydrogen peroxide causes hemolysis. Since a bruise is made up of red blood cells extravasated into the dermis and subcutaneous tissue, the hydrogen peroxide mixture theoretically causes localized lysis and breaks the double bonds in erythrocyte pigments, hastening bruise resolution.22 Because of its corneal toxicity, this mixture should be used with extreme caution around the eye and likely used only in extreme situations where cosmesis is crucial; the study used to document the effect reported concerned a bruise on the thigh.22 Overall, it is better to let ecchymosis resolve on its own.

Clinical Pearls

Ecchymosis is not a diagnosis, but rather a finding associated with blunt force injury. The description of raccoon eyes or panda sign should be limited to the specific circumstance of periorbital ecchymosis from skull base trauma.

Substantial ecchymosis can inhibit the levator from opening the lid and limit the extraocular muscles from moving the globe, altering function and mobility.

Oral antibiotics are necessary for protecting against infection in confirmed or suspected cases of fracture.

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