Retinal Hemorrhage

The Problem

Retinal hemorrhage

Common Causes

Normal birth

Child abuse

Other Causes

Major trauma

Systemic disease

Glutaric aciduria type 1

Bleeding disorder

Sepsis

Hypertension

Neoplasm

KEY FINDINGS

History

Normal birth

More common after vaginal delivery Frequent (even after uncomplicated delivery)

Child abuse

History often not reliable

Findings not consistent with given history

Major trauma

Retinal hemorrhages uncommon Systemic disease

History corresponding to underlying disorder

Examination

Normal birth

Range from few scattered to diffuse hemorrhages

Child abuse

Widely variable, from no to massive retinal hemorrhage

Retinoschisis cavity almost pathognomonic for shaking injury

Major trauma

Usually only mild hemorrhage, even with severe injury

Severe crush injuries very rarely cause retinoschisis

Systemic diseases

Varies with underlying disorder

WHAT SHOULD YOU DO?

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.

120 ■ Section 2: Symptoms

COMMON CAUSES

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

FIGURE 20–2 ■ Retinoschisis cavity following nonaccidental injury. The cavity is a clear, dome-shaped elevation over the posterior retina. A small, white perimacular fold is visible at the edge of the cavity (arrow). This finding is pathognomonic for nonaccidental injury (shaken baby) in the absence of a severe crush head injury.

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.

FIGURE 20–1 ■ Diffuse multilayered retinal hemorrhages in a patient with nonaccidental injury (child abuse).

Table 20–1.

Causes of Retinal Hemorrhages in Children

■Normal childbirth

■Nonaccidental injury (child abuse)

■Severe intracranial trauma

■Massive intracranial hemorrhage (e.g., vascular malformation)

■Overwhelming sepsis

■Retinal infection (e.g., cytomegalovirus)

■Malignancy (e.g., leukemia)

■Bleeding diathesis

■Metabolic disease

Glutaric aciduria type 1 Osteogenesis imperfecta

■ Extreme hypertension

FIGURE 20–3 ■ Retinal hemorrhage secondary to congenital cytomegalovirus infection. The white appearance of the retina beneath the hemorrhage is due to retinal necrosis.

APPROACH TO THE PATIENT

The identification of retinal hemorrhages requires examination of the retina with an ophthalmoscope. Pediatricians use the direct ophthalmoscope for this examination. Direct ophthalmoscopy is often difficult in small children due to the small pupil, frequent eye movements, and limited field of view. Ophthalmologists use the indirect ophthalmoscope to evaluate the retina. This instrument provides a panoramic, 3-D view of the retina and can be performed through a small pupil even if the patient’s eyes are moving.

CHAPTER 20 Retinal Hemorrhage ■ 121

History

Retinal hemorrhages will only rarely be noted during a routine pediatric examination due to their rarity and the difficulty of examining the retinas in young children. Most commonly, they will be identified because the patient has a specific problem that prompts retinal evaluation.

One of the most frequent and important causes of retinal hemorrhages in children is nonaccidental trauma. The presence of hemorrhages in patients suspected of shaking injuries may assist in the diagnosis, and severe ocular injuries may cause visual loss. The possibility of child abuse is usually raised when a child presents with injuries that are out of proportion to the history provided by the child’s caretaker. An example is an obtunded child with an intracranial hemorrhage who is reported to have fallen a few feet from a couch onto a carpeted floor. Such children require a multidisciplinary evaluation to look for other evidence of abuse and rule out systemic diseases that could explain the findings. This includes intracranial and bone imaging, and evaluation for overwhelming infection, bleeding disorders, and hematological malignancies.

Examination

Examination of the retina in young children is difficult without indirect ophthalmoscopy. An exception to this is a comatose child with nonreactive pupils, which may occur if a child has been abused, suffered other major trauma, or has a severe systemic disease.

122 ■ Section 2: Symptoms

PLAN

Children in whom retinal hemorrhages are identified, or who require examination to look for hemorrhages, should be referred to a pediatric ophthalmologist for indirect ophthalmoscopy. The presence and type of hemorrhages may be useful in establishing a diagnosis (Figure 20–4). Children with severe hemorrhages may be at risk for vision loss.

WHAT SHOULDN’T BE MISSED

Retinal examination is an important component of the evaluation of children who may have been abused. The presence of diffuse hemorrhages in the absence of

another disorder that could explain them strongly suggests abuse. These children require a multidisciplinary evaluation and should not be returned to their homes until their safety can be assured.

When to Refer

■Usually will not be noted during routine pediatric care

■Outside of period immediately after birth, any patient with retinal hemorrhages should be referred for further evaluation