The eye in child abuse: Key points on retinal hemorrhages and abusive head trauma

Abstract

This review presents an up-to-date overview of ocular injuries resulting from child abuse, with a spotlight on abusive head trauma. Retinal hemorrhage is a principle finding of inflicted head trauma. The specific pattern of hemorrhages holds valuable diagnostic information, which can help to guide multidisciplinary assessments of the likelihood of abuse. Indirect ophthalmoscopy through dilated pupils by an ophthalmologist is necessary for adequate examination and documentation of retinal findings. Initial pediatrician evaluation of the eye and indications for ophthalmological consultation are reviewed. Focus is then placed upon understanding retinal hemorrhage patterns, their diagnostic significance and likely pathophysiological mechanisms. The differential diagnosis of retinal hemorrhage in young children is discussed, highlighting key distinctions among retinal hemorrhage patterns, severity and frequencies, as well as other ocular findings. The most common cause of retinal hemorrhage in an infant is trauma, and most other causes can be identified by considering the hemorrhage pattern, ocular or systemic signs and the results of laboratory and imaging tests, when indicated.

Update on abusive head trauma

“…It is well known that retinal hemorrhages are encountered in up to 50-100% of children who have sustained an abusive head injury [30]; however, retinal hemorrhages are not exclusive to AHT and have previously been reported in other conditions (e.g. [14,15]) with varying prevalence.…”

The First Cause of Traumatic Death in Children < 1 Year: A Review on Abusive Head Trauma

“…The number, type, and distribution patterns of RH have significant diagnostic value. Typically, RHs associated with AHT are multiple, bilateral, confluent, multilayered (involving both preretinal and intraretinal layers), and extended from the posterior pole to the far retinal periphery (27). Moreover, the presence of retinoschisis and retinal folds in an infant with brain injury may be diagnostic of shaking (25).…”

“…An ophthalmologist should be consulted within 24 hours if an AHT is suspected. The indirect ophthalmoscope, preferably through dilated pupils, provides a three-dimensional view of the retina, allowing for an adequate examination of the posterior pole (27,29). Differential diagnosis of RH also includes systemic conditions such as birth trauma, anemia, coagulopathy, increased intracranial pressure, leukemia, meningitis, hypernatremia/hyponatremia, and thrombocytopenia.…”

Venous injury in abusive head trauma

“…Although retinal hemorrhage has been described in retinal vein thrombosis, these hemorrhages are readily distinguished from those that occur in AHT, and multiple, multilayered retinal hemorrhages have not been described in any child with primary cortical sinus and venous thrombosis. In contrast, retinal hemorrhages are present in approximately 80% of children with AHT, the number, pattern and distribution of which are quite distinctive in most cases, and their presence has been highly correlated with AHT in multiple studies [36].…”