Characteristics of non-vitreoretinal ocular injury in child maltreatment: a systematic review

Abstract

explicit confirmation of injury aetiology, age <18 years, examination conducted by an ophthalmologist. Exclusion: post-mortem data, organic diseases, review articles. Standardised critical appraisal and narrative synthesis was conducted of included publications by two independent reviewers.ResultsOf 1492 studies identified, 153 full texts were assessed, 49 underwent full review, resulting in five included studies: three case series and two case reports. The 26 included cases describe a wide variety of ocular, facial and skeletal injuries occurring as a consequence of child maltreatment. Ocular signs included periorbital oedema, chemosis, injection, abrasion, hyphaema, and cataract. Of interest all children that had suffered physical abuse with ocular injury had subconjunctival haemorrhages. Children presenting with abusive ocular injuries had a mean age of 13.9 months (range 1-68), while those who suffered violent corporal punishment were considerably older (mean 96 months). All cases, apart from severe corporal punishment, underwent screening for occult fractures, but neuroimaging only apparent in 2/5 eligible cases.ConclusionAlthough, the face is the most common site of abusive injury, there is a paucity of high-quality data on non-vitreoretinal ocular abusive injury. Thus, while subconjunctival haemorrhages are a potential sentinel injury of maltreatment, and may warrant further evaluation, the lack of large-scale published data limits our ability to highlight further specific characteristics of non-vitreoretinal ocular injury indicative of child abuse.

Subconjunctival haemorrhage in 147 dogs

“…A statistical association between non-accidental injury and subconjunctival haemorrhage has been identified in dogs and cats (Intarapanich et al 2016). Similar findings are reported for human non-accidental injuries and it has been suggested that subconjunctival haemorrhage may be a sentinel injury for physical abuse in children (Kleemann et al 1995, Spitzer et al 2005, Betts et al 2017. However, there is also evidence in the veterinary and human literature that subconjunctival haemorrhage is not specific for abuse but also occurs in accidental or self-inflicted injuries (Sperry 1993, Alexander & Jentzen 2011, Bamber et al 2014, Ghazanfari-Nasrabad et al 2016, Intarapanich et al 2016) and also associated with systemic diseases including coagulopathies (Griggs et al 2016), envenomation (Martins et al 2016) and vasculitis (Davidson et al 1989).…”

“…, Betts et al . ). However, there is also evidence in the veterinary and human literature that subconjunctival haemorrhage is not specific for abuse but also occurs in accidental or self‐inflicted injuries (Sperry , Alexander & Jentzen , Bamber et al .…”

A comparison of pediatric ocular injuries based on intention in patients admitted with trauma

“…A study evaluating non-ophthalmologist accuracy in the diagnosis of retinal hemorrhages found that 13% were incorrectly documented as normal [14]. While retinal findings in NAT are widely reported, there are limited studies of other ophthalmic injuries resulting from assault [15]. Outside the ophthalmic literature, several studies have investivated the epidemiology of assault in children, comparing resulting injuries to unintentional trauma, to identify disparate patterns [1, 3, 16–19].…”

Predictive value of non‐ocular findings for retinal haemorrhage in children evaluated for non‐accidental trauma

“…Few studies focus on anterior segment findings in patients with suspected NAT. A systematic review of 26 cases reported co-occurrence of subconjunctival haemorrhage (SCH), chemosis, injection, hyphema and cataract (Betts et al, 2017). Li et al (2011) reported that none of the 11 children with SCH in their study had RH.…”