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  • Distinguishing pediatric retinal hemorrhages unrelated to abuse

    Comprehensive Ophthalmology

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    This prospective study found that retinal hemorrhaging is generally not extensive in critically ill children older than six weeks with no abusive head trauma.

    To the authors’ knowledge this is the first prospective study to estimate the prevalence of retinal hemorrhages in critically ill children and provide a detailed description of the retinal findings.

    Subjects were 159 children older than six weeks admitted to an emergency pediatric care unit over a two-year period. Those with a penetrating eye injury or suspected or proven abusive head injury were excluded.

    Each child underwent dilated funduscopic examination, either photographic using a RetCam II (Clarity Medical Systems USA) with a 130 degree field lens or by a pediatric ophthalmologist using a binocular indirect ophthalmoscope. The RetCam was used either by intensive care staff trained to use the instrument or an ophthalmologist.

    Retinal hemorrhages were found in 15 percent of patients and were bilateral in 50 percent of cases. The severity was mild (less than 5 retinal hemorrhages) or moderate (5 to 20 retinal hemorrhages) in 75 percent of patients. 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.

    The authors note that extensive retinal hemorrhaging was observed only in the presence of severe coagulopathy, leukemia, one victim of a road traffic accident, and one child who sustained a significant fatal witnessed fall down the stairs all circumstances that would be readily distinguished by history and laboratory testing from abusive head injury.

    They conclude that this study emphasizes the importance of a detailed pediatric ophthalmological assessment of children with retinal bleeding.