Black eye

A black eye is blood that has leaked from small vessels into the skin of the eyelids and around the eye socket after a blow, a fall or facial surgery. On its own it is nearly always harmless and clears in two to three weeks with no treatment at all. What matters is something else: the same blow may have reached the eyeball, the walls of the socket or the skull, and those injuries cannot wait. So the central question with a black eye is not "what do I put on it" but "what else was damaged".

Why the area turns black so fast

Eyelid skin is the thinnest on the body, and under it lies loose tissue with no partitions. Blood from torn vessels spreads through it freely and follows gravity: the blow landed on the eyebrow, and by morning it is the lower lid that has darkened. For the same reason a bruise on one side can creep across to the bridge of the nose within a couple of days and show up under the other eye, though nothing struck there.

Swelling builds over the first day or two and then subsides. The colour changes predictably: deep red in the first hours, blue-purple from the second to the fourth day, greenish towards the end of the first week, yellowish in the second. That is haemoglobin breaking down, and the sequence never runs backwards. Full clearance usually takes two to three weeks; in older people and in anyone on blood-thinning medicines, longer.

The lids can swell so much that the eye will not open. That in itself is not dangerous as long as vision behind the closed lid is intact — but checking sight in the first few hours is essential, one eye at a time, covering the other with a hand.

What actually helps in the first days

• Cold for the first day or two: an ice pack or a bag of frozen vegetables, always wrapped in a towel, 10 to 20 minutes several times a day. Ice never goes straight onto the skin — eyelids are easy to freeze.
• Sleeping with the head raised, on two pillows. Morning swelling is noticeably less.
• Of the painkillers, paracetamol is the simplest choice. Ibuprofen and especially aspirin interfere a little with clotting, and the bruise may spread wider on them; aspirin without a doctor's instruction is best avoided altogether with a fresh injury, and in children and teenagers it is not advised for other reasons too.
• From the third day, once bleeding has certainly stopped, the opposite helps: warmth. A warm, not hot, damp cloth for a few minutes several times a day speeds up reabsorption.
• Take contact lenses out straight away and leave them out until the swelling settles and the stinging has gone.

What not to do: press on the bruise, massage it, rub the eye, apply heat on the first day, or use vasoconstrictor drops "for the redness" on your own initiative. Alcohol in the first days makes the swelling worse. Heparin ointments and herbal creams do not shorten the timeline to any noticeable degree, though they do no harm.

When it is the eye itself that is injured

Everything below means urgent eye care is needed — within the hour, not "if it hasn't settled by tomorrow".

• blood is visible inside the eye, a level of blood in the front chamber behind the cornea and over the iris;
• the pupil is misshapen or oval, or does not narrow in light;
• vision has dropped, doubled, or there are floaters, flashes, or a dark curtain at one side;
• the eye hurts when you look at light or when you move it;
• the eye will not move in one direction, most often upwards — that is how a fracture of the orbital floor with a trapped muscle shows itself;
• the skin of the cheek, the side of the nose or the upper lip has gone numb on the injured side;
• the eyeball looks sunken or, on the contrary, is pushed forwards;
• air crackles under the skin of the lids, especially after blowing the nose — a sign that the socket now connects with a sinus;
• the injury was from a sharp object, or a fragment went into the eye.

Driving yourself in that situation is not acceptable: vision and depth judgement are unreliable. Ask someone to take you or call the emergency number — 112 across Europe. Bring the list of medicines you take, especially anything that affects clotting.

When the bruise is telling you about a head injury

There is a separate and far more dangerous situation: bruises around both eyes appearing after a blow to the head rather than to the face. Symmetrical "spectacles" with no direct blow to the lids, particularly alongside bruising behind the ear or clear fluid leaking from the nose or ear, point towards a fracture of the base of the skull. That needs emergency care immediately.

Emergency help is also the answer if, after a head injury, the person lost consciousness, cannot recall the moment of impact, is vomiting repeatedly, is drowsy or behaving oddly, if the headache is building, or if weakness in an arm or leg or slurred speech appears. In anyone taking anticoagulants, and from about 65 onwards, the threshold for concern should be lower: bleeding inside the skull can follow a mild knock, sometimes a day or two later.

An injury in a child is its own chapter: if the account of what happened does not match the appearance of the injury, or there are bruises of different ages, the doctor is obliged to look into it, and that is a normal part of the job.

The bruise that should not be there

If dark rings around the eyes have come up on their own, with no blow, this is no longer an injury and needs a different line of thought.

• Bruises all over the body from the lightest knocks, bleeding gums, long periods, pinpoint red spots on the shins — these point to a shortage of platelets or a clotting disorder. A full blood count is needed, and not in a month's time.
• Bruising around both eyes with no trauma is a rare but recognised sign of amyloidosis, in which an abnormal protein is deposited in vessel walls. It also occurs in some blood diseases.
• In a child, bruising around the eyes without a blow, especially with a protruding eye and pallor, calls for quick investigation: a neuroblastoma can present this way.
• If the lid has not merely darkened but is hot and bright red, the swelling is growing quickly, there is fever and moving the eye hurts, this is no longer a bruise but orbital cellulitis. It is treated in hospital with intravenous antibiotics and tolerates no delay.

If the bruise does not fade

Three weeks is a reasonable time to wait. If at three weeks the darkening on the lid is much as it was, it is worth being seen. The same applies if a firm lump can be felt under the skin, if double vision or a sense that the eye is out of place persists, or if bruises under the eyes keep coming back from the slightest touch. In people with diabetes, on hormone treatment or on anticoagulants healing runs slower, which is worth allowing for without blaming everything on age.

Online consultation

In an online appointment a doctor can judge, from the account of the blow and from a photograph, whether there are signs of damage to the eye itself or to the bones of the socket, ask the questions about vision and eye movement that people rarely put to themselves, say whether an X-ray or a scan is needed and which specialist to see — eye doctor, maxillofacial surgeon or trauma doctor — and explain how to control the pain without interfering with clotting. If the account shows the problem lies in the eyeball or in the head, the doctor will say plainly to go to emergency care now.

This material is for information only and does not replace medical advice.