This prospective study found that retinal hemorrhages were present in 15 percent of critically ill children admitted to a pediatric intensive care unit who were older than six weeks and hadn’t undergone penetrating eye injury or suspected or proven abusive head trauma. Most retinal bleeding was not extensive in terms of area and layers of retina involved or severity of bleeding.
Higher numbers and extent of retinal hemorrhage were observed only in the presence of severe coagulopathy or leukemia, in one victim of a road traffic accident, and in one child who sustained a significant fatal fall down the stairs that was witnessed—all circumstances that would be readily distinguished by history and laboratory testing from abusive head injury.
Subjects were 159 children older than six weeks without a penetrating eye injury or suspected or proven abusive head injury admitted to a London intensive care unit.
Retinal hemorrhages were identiﬁed in 15 percent of patients. Half of the hemorrhages were bilateral. The severity was mild (< 5 retinal hemorrhages) or moderate (5 to 20 retinal hemorrhages) in 75 percent.
The location was in zone 1 in 45.8 percent, zones 1 and 2 in 33.3 percent, zone 2 alone in 8.3 percent, and not described in 8.3 percent. Schisis cavities and perimacular folds were identiﬁed in two patients, with one having a pseudohypopyon appearance; another patient had bilateral hemorrhagic retinal detachments. Three patients had exudates or scarring consistent with cytomegalovirus infection.
Severe extensive retinal bleeding was uncommon but could be seen in children with severe coagulopathy and severe accidental traumatic head injury. The authors say that these are also the most severely ill children and if retinal hemorrhages are not seen in this population then they are highly unlikely to be seen in children presenting with milder severity of the same illnesses.
In keeping with the medical literature to date, the study demonstrates that extensive hemorrhagic retinopathy (i.e., ‘too numerous to count’, confluent hemorrhages extending to the ora, with or without macular retinoschisis and perimacular folds) is not seen after accidental head injury except for fatal head crush, 11 m fall onto concrete and fatal motor-vehicle accidents, all situations that would be readily discernible based on the history. This study adds an additional case of a witnessed severe fatal fall to these reports.
The authors highlight the necessity of investigating any child found to have retinal hemorrhages for an underlying medical condition, in particular a coagulopathy. In many conditions, examination by an ophthalmologist would identify other findings, which would suggest an underlying problem other than possible abusive head trauma, such as scarring or exudates consistent with the diagnosis of CMV retinitis or a retinal pseudohypopyon appearance suggestive of leukemia.