17.13  The Role of the Ophthalmologist

Physicians are rarely in the position to make a diagnosis with such profound significance to patients and their families. Ascertainment of child abuse is critical to prevent potentially fatal recurrence in victims. Extensive intraocular hemorrhage in young infants in the setting of acute brain injury, and in the absence of a history of severe accidental trauma or underlying medical cause, must be considered to be nonaccidental injury until otherwise proven.

If AHT is suspected, examination of the eye through undilated pupils with a direct ophthalmoscope is inadequate for complete evaluation. Indirect ophthalmoscopy with pharmacologic dilation of the pupils (unless contraindicated from a neurologic standpoint, or if the pupils are fixed and dilated as a result of severely compromised neurological status) is an essential aspect of diagnosis, The primary role of the ophthalmologist in the care of these children is to provide a complete evaluation of the ocular injuries including proper detailed documentation of the eye findings, along with retinal photography when available. The written consultation should reflect the current state of the medical literature: if the child has severe multilayered retinal hemorrhages, too numerous to count, and extending to the retinal periphery with no obvious explanatory cause, then the diagnosis is AHT until proven otherwise. If there is a nonspecific mild hemorrhagic retinopathy with a just a few posterior pole intraretinal hemorrhages, then AHT should be mentioned in the differential diagnosis (it is the most common cause of retinal hemorrhage in young children after birth hemorrhage) with suggestions for other causative entities to be considered.

The eye examination may also provide prognostic information. Ophthalmologists should coordinate longterm management of the frequent visual complications. In cases of a fatal outcome, the ophthalmologist can help direct the pathologist’s postmortem examination by suggesting the desired evaluation of the eyes, orbital tissues, and optic nerves as discussed above.

Ophthalmologists, and for that matter all physicians, are not responsible for determining who perpetrated the act of abuse. It may be that the perpetrator is a parent who is present during the eye care of the child. The ophthalmologist must continue to act in the same professional manner with these caretakers as they would with any parent. Remember that the overwhelming majority of perpetrators did not purposely set out

to injure the child, but rather lost control in rage often responsive to the stresses of life, a crying baby, or other frustrations of child rearing. There is a remarkable parallel between the normal crying curve of infancy and the incidence of AHT [93]. When the ophthalmologist is called to court as an expert witness (an uncommon occurrence), the testimony should be kept within the ophthalmologist’s comfort level for knowledge on this subject, impartial to the side for which they were asked to testify, and restricted to the medical evidence rather than feelings about whom the perpetrator might be.

Physicians who treat infants and children are mandated to report suspected child abuse to child welfare agencies for investigation, and ophthalmologists who encounter children with ophthalmic manifestations of abuse need to ensure that proper steps are taken to protect their patients from further harm. Ophthalmologists should work as a part of the multidisciplinary team that collaborates in unison to identify cases of abuse and ensure optimum diagnostic accuracy.

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