The presence of retinal hemorrhages is an exception to most of the other problems included in the symptoms section of this book. It is a sign, rather than a symptom, and therefore it is not an abnormality reported by parents or children. Pediatricians usually identify retinal hemorrhages because they are specifically looking for them due to associated problems. They are almost never noted during routine examinations due to their rarity and the difficulty of examining the retina in young children. Children with retinal hemorrhages should be referred to a pediatric ophthalmologist.

What Shouldn’t Be Missed

The presence of diffuse retinal hemorrhages in a previously healthy infant or toddler should raise the strong suspicion of child abuse. If there is no other identifiable etiology, the patient will require an evaluation for occult systemic diseases and other evidence of child abuse.

• 1. Normal birth. Retinal hemorrhages are quite common after normal births. They are more common following vaginal deliveries, but also can occur after caesarean section. These usually resolve within the first few weeks of life and do not cause visual problems.
  
• 2. Child abuse. Retinal hemorrhages are an important finding in children who are victims of nonaccidental trauma. They are frequently associated with intracranial hemorrhages and other signs of trauma, such as bone fractures. They are not a universal finding, however, and other disorders may cause mild hemorrhages. Therefore, the presence of no or a few hemorrhages does not assist in the diagnosis of child abuse. The presence of diffuse multilayered hemorrhages (Figure 20–1) without another explanation is strong evidence for abuse, and the presence of perimacular folds and retinoschisis cavities is almost pathognomonic for abuse (Figure 20–2).
  
• 3. Major trauma. Even severe trauma rarely results in more than mild retinal hemorrhages. A rare exception is a severe crush head injury, which may mimic the finding of abuse.
  
• 4. Systemic disease. A number of systemic diseases may be associated with retinal hemorrhages (Table 20-1). The findings are variable and depend on the underlying disorder. These diseases include bleeding disorders, sepsis, hypertension, and hematological malignancies. Infectious diseases, such as congenital cytomegalovirus, may cause retinitis with retinal hemorrhage (Figure 20–3). Glutaric aciduria type 1, in particular, may cause retinal hemorrhages that are similar to those seen in abuse.