Child maltreatment, abusive head injury and the eye

Chapter 67 Child maltreatment, abusive head injury and the eye

Presentation of child abuse victims to the ophthalmologist

In the majority of cases the child is referred to the ophthalmologist by pediatricians who suspect an abusive injury. However, it is incumbent on the ophthalmologist to not only recognize cases that occasionally present to them with bruising or unexplained injury who may be maltreated, but to also refer them on for multiagency assessment of possible abuse or neglect.9

The presenting features alerting the professional to child maltreatment include:

Protocols for referral to an ophthalmologist vary in different institutes, but are usually governed by the signs and clinical presentations detailed above.


Clinical presentation to an ophthalmologist may be either:

Clinical records

This should contain a detailed history, supplementing information recorded by other medical personnel and a thorough clinical examination. Local protocols for child protection records vary; however, completion of a standardized ophthalmology clinical record supplemented with wide field retinal photography (i.e. Retcam 130) improves documentation, which is helpful when giving evidence in family or criminal courts11,12 (Fig. 67.2).

There are a number of ways of describing the distribution, location, and types of retinal hemorrhages. Their use in routine clinical practice, however, has not been evaluated.13,14 Recent systematic reviews of retinal hemorrhages in abusive injury identified the need for consistent and standardized description of retinal findings that would hold under scrutiny in medico-legal cases and help with future research in differentiating patterns of retinal hemorrhages from various causes.

Fluorescein angiography and optical coherence tomography help demonstrate retinal perfusion and vitreo-retinal interface pathology, but their use is yet to be established in practice.15,16

Each page of the clinical record should be identified with the child’s name and date of birth. The entry should include the clinician’s name, designation, signature, date, and time of examination. It should include a differential diagnosis, suggesting appropriate further investigations. A standard list of investigations in suspected abusive head injury has been suggested along with a multidisciplinary assessment involving medical teams, social services, and the police.17

A date for a follow-up examination should be clearly indicated on the clinical record.

Medico-legal issues19

These issues may vary with different legal systems; however, the underlying principle concerning the welfare of the child remains the same.

The case considered may be subject to:

Ophthalmic features of physical abuse

Indirect injury

A number of synonyms have been used to describe the presence of intraocular injury associated with brain and skeletal injury. These include whiplash syndrome, battered baby syndrome, shaken baby syndrome, and shaken impact syndrome. Abusive head trauma (AHT) or injury is the currently accepted terminology as the previous names suggest a mechanism, which may or may not be established.

1. Subconjunctival hemorrhages. These may be present in AHT with or without intraocular injury.26 The presence of subconjunctival hemorrhages in cases of suspected child abuse should prompt a full child protection and ophthalmology assessment (Fig. 67.4).

2. Retinal hemorrhages. The presence of retinal hemorrhages is not necessary to establish the diagnosis of AHT though they are highly suggestive. There is no pathognomic type (flame shaped, dome shaped, dot, blot, white-centered), size, distribution, or location of retinal hemorrhages seen exclusively in abusive head injury27 (Fig. 67.5). Bilateral hemorrhages are reported in 74% of cases (sensitivity of 75% and specificity of 94%) of abusive head injury.28

Retinal hemorrhages in the presence of head injury have a 71% positive predictive rate of abusive injury29 (Fig. 67.6). The prevalence of retinal hemorrhages in AHT varies between 77% and 83%.18 Preretinal hemorrhages, dome-shaped hemorrhages, situated in the posterior pole are seen commonly in AHT27 (Fig. 67.7). Retinal hemorrhages may range from a few scattered hemorrhages to widespread hemorrhages extending from the posterior pole to the periphery and situated in multiple layers of the retina30 (Fig. 67.8). Extensive retinal hemorrhages correlate with severe intracranial injury and poor visual outcome.31 A recent systematic review reported that in the presence of head injury retinal hemorrhages have a 91% probability of abusive etiology (odds ratio 14.7).32

3. Retinal folds. Perimacular folds, an important sign, are seen in 6% to 8% of live AHT cases (Fig. 67.9) and 23% of postmortem cases18,28,33 ( Fig. 67.10). There are also isolated case reports in Terson’s syndrome in adult patients34 and accidental head injury.3538

4. Retinoschisis. Cystic intraretinal cavities (Fig. 67.11) in the macular area are recognized by vessels coursing over the surface or an electronegative electroretinogram. Schisis cavities are seen in 14% to 23% of case studies involving live and postmortem findings. It has been stated that traumatic hemorrhagic macular schisis in not seen in any other condition except AHT;39 however, recent case reports suggest similar cavities are seen with severe trauma or crush injury.37,38

5. Vitreous hemorrhage. Hemorrhage in the vitreous occurs in 14% of cases and is more frequent in autopsy specimens.18 It is believed to occur with break-through of the dome shaped preretinal hemorrhages into the vitreous cavity (Fig. 67.12

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Jun 4, 2016 | Posted by in OPHTHALMOLOGY | Comments Off on Child maltreatment, abusive head injury and the eye

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