Raccoon Eyes - Causative Factors, Diagnosis, Complications, and Treatment

Introduction

Raccoon eyes, also known as panda eyes, panda sign, or the periorbital hematoma, are characterized by a purplish halo around the orbit due to the collection of blood outside the eyes' blood vessels under the soft tissues of the eyes.

What Are the Causative Factors Associated With Raccoon Eyes?

Multiple factors cause raccoon eyes. These factors include:

• Trauma

  • The trauma to the orbit, including non-accidental injuries, and trauma to the thorax, are associated with raccoon eyes.

  • Trauma to the orbit leads to entrapment of air in the paranasal sinus and the development of raccoon eyes.

• Vascular Diseases - Vascular conditions also contribute to the formation of raccoon eyes. The vascular lesions include:

  • Narrowing of the ophthalmic arteries.

  • Giant cell arteritis.

  • Benign intracranial hypertension.

  • Acute migraine.

• Infections - Infections of the head and neck region clinically presenting as raccoon eyes are:

  • Severe adenovirus infection.

  • Frontal sinus mucocele.

  • Leukoedema.

• Genetic Conditions - Genetic diseases like hemophilia also present clinically as raccoon eyes.

• Post-surgeries - In some cases, the raccoon eyes manifest after surgery due to the rupture of the arteries surrounding the eyes. Surgeries linked to the development of raccoon eyes are:

  • Systemic amyloidosis.

  • Rhinoplasty.

• Cancer - Some malignancies are also associated with raccoon eyes:

  • Blood cancer.

  • Neuroblastoma.

  • Orbital malignancies.

  • Kaposi sarcoma.

  • Multiple myelomas.

• Metabolic Diseases - The primary metabolic diseases that cause raccoon eyes are:

  • Amyloidosis. The deposition of amyloid protein inside the blood vessels increases the fragility of the vessels, leading to the rupture of the vessels.

  • Sarcoidosis.

• Immune-mediated Skin Disorders - Several skins develop raccoon eyes due to the inflammatory reactions, vascular damage, and edema initiated by the disease. Skin lesions causing raccoon eyes are

  • Lichen planus pigmentosus.

  • Sweet syndrome.

  • Neonatal erythematosus.

What Is the Main Mechanism Involved Behind the Formation of Raccoon Eyes?

Raccoon eyes are the clinical sign presented because of the damage caused to the blood vessels surrounding the orbits. There is pooling and seepage of the blood from the vessels into the adjacent skin. The damage to the blood vessels can occur due to several reasons, mainly because of the skull base fracture.

What Are the Clinical Signs Presented by Patients With Raccoon Eyes?

The presentation of the raccoon eyes may involve either one eye or both eyes—periorbital hematoma forms within seventy-two hours of the injury. In addition, there is purplish discoloration of the skin surrounding the orbit—patients who have raccoon eyes present with three classical signs.

• Bulging eyes.

• Discoloration of orbital skin.

• Swelling or edema.

Other clinical presentations associated with raccoon eyes are:

• Blood behind the ears (battle's sign).

• Loss of hearing.

• Increase in blood pressure.

• Double vision.

• Bruises around the eyes.

• Distorted vision.

• Bleeding nose.

• Weakness of face and nose.

• Red-eye.

What Are the Symptoms Reported by Patients Having Raccoon Eyes?

Patients with periorbital hematoma often complain of:

• A localized pain in the region of the edema.

• Sensory Changes - There is a change in sensory functions of smell, hearing, and vision.

• Muscle weakness.

• Patients with neuroblastoma also complain of dilation of the pupil and bone pain.

• Amyloidosis patients suffer from drooping of the eyelids, eyeball protrusion, growth in the surrounding region, and pain.

• Change in the function of smell.

What Are the Various Diagnostic Techniques Adopted in Patients With Raccoon Eyes?

Raccoon eyes are itself a clinical sign caused by an underlying disease. Therefore, the primary goal of the specialist remains to identify the primary cause of the entity. The diagnosis thus comprises:

• Clinical Examination - A comprehensive evaluation of ocular structures, including the head and neck region, is essential.

• History - The specialist should acquire complete history from the patient regarding trauma, the onset of the discoloration, and medical history.

• Imagings - Imagings such as computed tomography (CT) of the skull before surgery help delineate the skull base fractures.

What Are the Complications That Can Occur in Patients Exhibiting Raccoon Eyes?

Raccoon eyes are a clinical sign. Hence raccoon eyes themselves will not cause any complications. The basal cause, such as the skull base fracture, amyloidosis, etc., if left untreated, might result in several complications such as -

• Infection of the meninges.

• Blood in eyes.

• Paralysis of facial muscles.

• Brain hemorrhage (bleeding).

• Cerebrospinal fluid leaks.

• Skull abnormality

• Facial deformity.

• Injury to cranial nerves.

• Spine injuries.

What Are the Conditions to Be Considered During the Diagnosis of Raccoon Eyes?

Raccoon eyes are most commonly caused by trauma to the anterior skull base. However, clinical conditions which can also present with raccoon eyes include:

• Amyloidosis.

• Multiple myeloma.

• Kaposi's sarcoma.

How Are Patients With Raccoon Eyes Treated?

Raccoon eye does not require any treatment; the ecchymosis resolves within two to three weeks. Patients are advised not to blow their noses vigorously or sneeze to avoid tearing the meninges. However, the hidden cause responsible for the clinical manifestation requires treatment.

• Surgery and rehabilitation of the fracture are advised in case of skull fractures.

• Neuroblastoma or tumors related to that region requires surgical excision or chemoradiation management.

• Amyloidosis associated with raccoon eyes is treated by reducing the amount of amyloid protein in the blood.

• Cosmetic surgery may be performed if the facial structure is compromised.

What Is the Post-treatment Protocol to Be Followed in Patients With Raccoon Eyes?

Patients with raccoon eyes are kept under regular follow-up to monitor the progress of the underlying disease before and after treatment.

What Is the Role of Health Care Professionals in Managing Raccoon Eyes?

The healthcare teams, including nurses and primary care physicians, dealing with patients presenting with raccoon eyes should ask about the history of trauma or any other diseases. Prompt referral and diagnosis of the causative factor will help get a better resolution of the disease condition.

What Is the Overall Outlook of Raccoon Eyes?

The end outlook of the disease entity depends on the severity and prognosis of the underlying disease. Eventual healing of the skull base fracture results in fading away of the sign; however, some conditions require professional intervention.

Conclusion

Raccoon eyes are the primary clinical manifestation of trauma to the skull. It is caused due to the pooling of damaged blood vessels. Therefore, complete patient history and evaluation are crucial in forming an appropriate diagnosis and treatment strategy.