Sir,

A heavily lined eye of the falcon god Horus, also called the ‘Eye of Ra’, was said to have healing and protective powers in ancient Egypt. We describe a patient who developed the eye of Horus after a traumatic scalp injury, a unique association not previously reported.

Case report

A 31-year-old woman with newly diagnosed acute myeloid leukaemia fell out of bed while reaching for a bedside commode. On examination, she had a left eyelid haematoma with a striking outline of the upper and lower lids, resembling the eye of Horus (Figure 1). The orbital haemorrhage extended over the left eyebrow, creating a shadow. She had small subconjunctival haemorrhages bilaterally and no visual changes. Noncontrast axial computed tomography of the brain revealed a left frontoparietal subgaleal soft tissue haematoma and no intracranial bleeding or skull fracture (Figure 2). The patient had profound neutropenia and thrombocytopenia as a result of intensive chemotherapy, with platelet count below 10 000/cu mm. After the patient shaved her head, a purpuric skin lesion, surrounded by extensive resolving scalp ecchymosis was evident (Figure 3). She was supported with platelet transfusions, with resolution of her skin findings over the next several days.

Figure 1
figure 1

The Eye of Horus.

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Figure 2
figure 2

Subgaleal haematoma.

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Figure 3
figure 3

Purpura and ecchymosis.

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Comment

Cranial trauma infrequently leads to clinically significant subgaleal haemorrhage (SGH), but even minor trauma can result in bleeding into the subgaleal (epicranial subaponeurotic) loose connective tissue in the scalp in vulnerable individuals such as infants,1 patients with platelet or coagulation disorders, those undergoing intensive chemotherapy, or the elderly.2 Blood spreads easily in the subgaleal loose connective tissue layer, and can enter the eyelids and the root of the nose because the frontalis muscle inserts into the skin and subcutaneous tissue and does not attach to the bone. ‘Black eyes’ can result from an injury to the scalp or forehead and most blood enters the upper eyelid, although some may also enter the lower one. Most often, conservative management is sufficient. Occasionally, SGH can lead to bilateral orbital haemorrhages with loss of vision needing surgical intervention.3

Kohl eyeliner4 was worn by both men and women in ancient Egypt for adornment and to reduce solar glare and ward off evil spirits. How the practise originated is less clear. We hypothesize that dark outlining of the eye, as in the eye of Horus, had its origin most likely as an astute observation of what may have been the clinical manifestations of a SGH, similar to that seen in our patient. This ancient practise of outlining and shadowing the eye became immortalized in art throughout the world and continues to be a symbol of beauty throughout the ages – an instance of art imitating life.