Available online 8 May 2024, 101141

Author links open overlay panel, , ABSTRACT

A leading cause of death and disability in infancy is abusive head trauma (AHT) and there are common clinical signs that help to establish this diagnosis. Children diagnosed with AHT can have many ophthalmologic findings, including retinal hemorrhages, retinoschisis, subconjunctival hemorrhages, corneal injury, and globe rupture. If any such injuries are suspected, an ophthalmologic consultation, with indirect ophthalmoscopy, should be completed. In addition to a complete physical exam, a thorough history imaging, and lab work, should be obtained to investigate the etiology of ophthalmic pathology including accidental and systemic causes. In general, studies show that retinal hemorrhages that are multilayered, too numerous to count, and located from the posterior pole to the ora serrata are highly suspicious for abusive head trauma.

Section snippetsINTRODUCTION

Abusive head trauma (AHT) is a form of child physical abuse in young children and our understanding of its implications has increased over time. Infants under 2 years are at highest risk for AHT, however, the Center for Disease Control and Prevention's (CDC) definition includes children up to 5 years. The most common mechanism for these injuries is rapid acceleration and deceleration with rotation of the head. Most often, one thinks of this occurring if a young child is shaken but it can also

EYE FINDINGS IN AHT

Classically, children with abusive head trauma have subdural hemorrhages, encephalopathy, and retinal hemorrhages without a sufficient trauma history to explain these findings. While retinal hemorrhages (RH) are commonly associated with AHT, there can be other intraocular and extraocular findings. Extraocular injuries are most often caused by direct impacts to the eye. These include periorbital bruising, subconjunctival hemorrhage, corneal abrasion, laceration, hyphema, cataract, lens

EVALUATION

Though many medical providers are familiar with direct ophthalmoscopy, this tool provides only a limited view of the retina even in children whose pupils are dilated. The most thorough evaluation can be done with an indirect ophthalmoscope and requires the expertise of an ophthalmologist. An indirect ophthalmoscope allows a view to the retina's periphery which would not otherwise be visualized. Indirect ophthalmoscopy should be completed within 72 hours of presentation, but ideally within 24

RETINAL HEMORRHAGES: NON-ABUSIVE ETIOLOGIES

While abusive head trauma is an important consideration in patients with retinal hemorrhages, they are also seen in other clinical scenarios. History, presentation, physical exam, lab, and imaging data are used to differentiate between AHT and these other causes of RH. Some of the most common alternative etiologies of RH will be discussed below, however, it is important to note that AHT is still one of the most common causes of RH.

RETINAL HEMORRHAGES AND CORRELATIONS TO BRAIN INJURY SEVERITY

Retinal hemorrhages tend to be more numerous in cases where the trauma is more severe.12 Thus far, there is no consistent correlation between the location of intracranial injury and the location of retinal hemorrhages.1 Patients with retinoschisis and retinal folds tend to have a poorer visual prognosis compared to patients without, which is likely indicative of worse neurologic injury.10

VISUAL OUTCOMES IN AHT

Retinal detachment, macular scarring or fibrosis, and visual deprivation due to vitreous hemorrhage—which can result in amblyopia if it does not resorb without surgery—are among the retinal causes of vision loss from AHT.12 Significant corneal injuries may necessitate emergency surgery, which might result in scar tissue and visual abnormalities due to astigmatism.1

In a study of 34 children with AHT who had follow-up, 65% had normal vision, 26% had some limitation of their vision, and 9% had no

CONCLUSIONS

Abusive head trauma is a serious diagnosis with implications to both a child's immediate health and their long-term welfare. While ophthalmologic findings related to AHT are often distinct from other conditions or disorders, a thorough history and examination can aid in making a diagnosis. Most commonly, severe retinal hemorrhages that occur diffusely throughout the retina are identified as being caused by rapid acceleration-deceleration forces. These retinal hemorrhages have the potential for

CRediT authorship contribution statement

Disha Jain: Writing – original draft, Writing – review & editing. Lien Le: Conceptualization, Resources, Writing – original draft, Writing – review & editing. Natalie Kissoon: Conceptualization, Project administration, Resources, Supervision, Writing – review & editing.

Declaration of competing interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

References (32)LA Morgan et al.Clinical comparison of ocular and systemic findings in diagnosed cases of abusive and non-abusive head trauma

Clin.ophthalmol

(2018)

SA Maguire et al.Retinal haemorrhages and related findings in abusive and non-abusive head trauma: A systematic review

Eye (Lond)

(2013)

G Binenbaum et al.Odds of abuse associated with retinal hemorrhages in children suspected of child abuse

Journal of American Association for Pediatric Ophthalmology and Strabismus

(2010)

J Wright et al.Disability and visual outcomes following suspected abusive head trauma in children under 2 years

Arch.Dis.Child

(2021)

Bhardwaj G, Chowdhury V, Jacobs MB, Moran KT, Martin FJ, Coroneo MT. A systematic review of the diagnostic accuracy of...Christian CW, Levin AV. The eye examination in the evaluation of child abuse. . 2018;142(2)....View full text

© 2024 Published by Elsevier Inc.