Retinal Findings Differ Between Abusive and Accidental Head Trauma in Children

Deborah Brauser

May 03, 2010

Dr. Andrew Shaw

May 3, 2010 (Orlando, Florida) — Retinal hemorrhages (RH) in children are more common after abusive head trauma (AHT) than after accidental, non-AHT, according to results from a systematic review of 62 studies presented here at the American Association for Pediatric Ophthalmology and Strabismus 36th Annual Meeting.

"The incidence of [RH] in cases of suspected abuse has become a key feature suggestive of inflicted trauma," said lead investigator Andrew Shaw, MBBS, MRCOphth, ophthalmology registrar at the University Hospital of Wales in Cardiff, during his poster presentation. "In such cases, the influence of intraocular findings may be high, with obvious implications for child protection verdicts."

However, he reported, the specificity of RH has recently been called into question, particularly in relation to non-AHT. So the purpose of this review was to "determine characteristic retinal findings as a consequence of AHT and to evaluate whether certain retinal features or patterns of retinal findings were more likely to represent accidental [or] inflicted injury."

Results Confirm RH as a Finding in Abuse

Of 8422 potential studies identified from a literature search of databases, journals, conference abstracts, and Web sites, the investigators focused on 62 published since 1965. These studies consisted of children younger than 11 years with RH due to confirmed AHT (n = 363) or confirmed non-AHT (n = 465) and no retinal comorbidity. All children had also undergone a detailed examination by an ophthalmologist.

Results showed that the overall prevalence of RH was 78% in patients with AHT and just 5.3% in those with non-AHT.

In addition, 83% of the RHs in the AHT patients were bilateral, whereas just 8% of those in non-AHT patients were.

For AHT patients, 63% of the RHs extended to the periphery and 37% of them were in the posterior pole and peripapillary areas. For the non-ABT patients, only 9% of the RHs extended to the periphery; 91% of them were located in the posterior pole and peripapillary.

"When described, [RHs] were more commonly bilateral, multilayered, and extending to the periphery in the AHT group," reported Dr. Shaw. "Non-[AHT] as a cause of RH was very rare, but when present, they were frequently unilateral, few, and restricted to the posterior pole."

Schisis cavities and retinal folds were commonly found in AHT cases, "but were rarely described in [non-AHT cases]," he added.

"I think the findings of this review lend a lot of weight to particular features being consistent with abuse but, given the observational nature of the data, we're cautious with the findings right now and hope to do more stringent analyses," said Dr. Shaw.

He said that the take-away message is that it's important for these children to be reviewed by an ophthalmologist. "I would stress the importance of documentation, not just if there's [RH present], but also of its certain characteristics (including the number present), because we know that that has an impact of value in strengthening your case for an abusive injury."

Dr. Shaw noted that in the United Kingdom, the diagnosis of child abuse rarely comes down to one subspecialty. "It's a multidisciplinary approach to the problem. From an ophthalmologist's point of view, it's important to document exactly what is found with as much detail as possible."

He said that his investigative team is hoping to next look prospectively at cases of head trauma, both accidental and inflicted, "with a very standardized way" of recording information.

"That will be quite tricky, but in an ideal world, that's the type of data that you'd most like to have," said Dr. Shaw.

Outside Comments

"I thought this was very valuable information. It was a review of several studies over a long period of time with very objective findings. And the difference between the study groups was quite marked," said Annick Fournier MD, head of pediatric ophthalmology at the Children's Hospital of Eastern Ontario in Ottawa.

"In cases of [RH], I would tell clinicians to be as descriptive as possible and to observe as far out into the retinal periphery as possible," said Dr. Fournier, who was not involved in this study. "Definitely in the abusive group, the percentage of [RHs] extending out into the periphery was far higher than in the accidental group, which I think is a very important point to take home."

She noted that the other take-away message is that although there can be RHs in non-AHT, "there is a context of nonocular findings that needs to be understood."

"RHs aren't the only findings with abuse cases. There's always a context of other physical findings, such as bruising and subdural hematomas," concluded Dr. Fournier. "The implications [of abuse] are so dire that I would say to definitely take the patient and their entire circumstances in context."

This study was supported in part by the National Society for the Prevention of Cruelty to Children and by a grant from the Royal College of Pediatrics and Child Health. Dr. Shaw and Dr. Fournier have disclosed no relevant financial relationships.

American Association for Pediatric Ophthalmology and Strabismus (AAPOS) 36th Annual Meeting: Abstract 103/Poster 72. Presented April  7, 2010.

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