Robin N. Ginsburg
THE CLINICAL CHALLENGE
Child abuse is a pervasive problem in the United States of America (USA), with rates of maltreatment up to 8.9/1000 children. Children under 12 months old have the highest rates of victimization (25.7/1000) and are most vulnerable to dying from maltreatment (22.9/100 000).1 Abusive head trauma (AHT) is a catastrophic form of child abuse that includes cranial, ocular, and spinal injuries from shaking, blunt trauma, or both. Rates of AHT in the USA are thought to be 38.8 cases per 100 000 infants younger than 12 months old.2
Epidemiology and Pathogenesis
The histories provided by caregivers of infants with AHT are usually false. One should suspect AHT when there are inconsistencies between the history of the injury mechanism and the injury severity.3 Additionally, children with persistent neurologic abnormalities, with a history of either no or low-impact trauma, are also more likely to have AHT. Clinical factors differentiating AHT from nonabusive head trauma include a seizure at or within 24 hours of presentation and apnea at presentation.
Infant crying is the most commonly reported trigger for a caregiver to shake an infant.4 The developmental peak of crying in healthy infants occurs around 2 months of age. The characteristics of crying that may lead a frustrated caregiver to hurt an infant include the infant’s unpredictable and inconsolable nature, the perception that it is painful, and prolonged duration.
Subdural hematoma (SDH) is the primary intracranial injury in AHT. The specificity of SDH for AHT is increased when associated with retinal hemorrhages (RHs) and underlying diffuse parenchymal injury.5
Ocular and Orbital Injuries Associated With Abuse
Physical child abuse can present with protean manifestations involving any part of the eye caused by either direct or indirect trauma. Ocular injury associated with unexplained neurologic findings or seizures should also prompt concern for abuse. Injuries presenting also include traumatic hyphema or new-onset strabismus from elevated intracranial pressure. RHs noted on routine examination in infants and children should be carefully documented and should raise suspicion of abuse if appropriate. RHs, a cardinal feature of AHT, are seen in over 50% of cases of AHT,5 of which most are bilateral. RHs are seldom seen without apparent ocular injury or evidence of significant head trauma. When assessing infants who are believed to be physically abused but present without neurologic symptoms of AHT, brain imaging should be strongly considered, and ophthalmic consultation is needed only to provide supportive evidence if AHT is suspected.
APPROACH/THE FOCUSED EXAM
It can be quite challenging to distinguish which ocular injury in children may be abusive. Blunt trauma can result in injury to any aspect of the eye or periocular structures. Many of these injuries are nonspecific and can be seen in both nonabusive and abusive head trauma and other systemic diseases. Owing to the transient presence of RHs, ocular evaluation, including indirect ophthalmoscopy, is ideally performed in the first 24 to 72 hours.3
The anterior segment can be evaluated with a penlight or slit lamp if necessary. Optic nerve injury can be assessed by examination for an afferent pupillary defect before pharmacologic dilation. Fractures to the orbital or frontal bones can occur but are less common in young children and infants, especially in cases of abuse.
Bilateral periorbital ecchymosis in children can be caused by direct forehead trauma or secondary to basilar skull fracture, blunt thoracic trauma, leukemia, and neuroblastoma. Corneal abrasions, lacerations, and iris damage can occur. Penetrating or blunt trauma can result in globe rupture; the globe should be protected with a shield as soon as its integrity is called into question.6
Subconjunctival hemorrhages are quite common in cases of abuse with ocular trauma and can be caused by direct or indirect etiologies (Figure 44.1). The extensive list of etiologies presenting with subconjunctival hemorrhages in childhood is well reported.6 Causes are not specific for abuse and include infectious, hematologic, and neoplastic disease; Valsalva maneuver; increased intrathoracic pressure; vomiting, birth; and nonabusive trauma. In the absence of these etiologies, abusive injury must be considered.
Traumatic hyphema, defined as blood in the anterior chamber, can occur after high-velocity blunt or penetrating trauma. The complications of hyphema can lead to visual impairment and blindness caused by corneal blood staining, elevated intraocular pressure (IOP), optic atrophy, and glaucoma, making diagnosis and treatment essential for preserving vision. Nontraumatic hyphemas have been reported in retinoblastoma (masquerade syndrome), juvenile xanthogranuloma, and inflammatory conditions, including keratouveitis, leukemia, and hemophilia. Traumatic cataracts may be noted at the time of presentation or may occur later, necessitating a careful history of trauma if noted on routine examination.
Vitreoretinal Findings in AHT
Other than birth trauma, AHT is the leading cause of RH in infancy. Concomitant findings help distinguish RHs associated with AHT from other causes and should be well documented by detailed descriptions, drawings, and photo documentation when possible. Despite several attempts to provide a grading tool for RHs associated with AHT, no standard nomenclature has been accepted, highlighting the need for detailed documentation.7 It is imperative to note that documentation should include the level of concern for suspected AHT, differential diagnosis, and suggestions for additional medical and ophthalmologic evaluation.
Figure 44.1: Subconjunctival hemorrhage in an infant. (Courtesy of Edna Asumang: Sub-conjunctival Haemorrhage Guidelines in Newborn Infants; Sheffield Children’s NHS.)
It is essential that the ophthalmologist document the variability of RHs because this can be of significance in determining their etiology. RHs can vary in terms of size, shape, location, and number and be unilateral or bilateral.5 The distribution of the hemorrhages in the posterior pole, periphery, or peripapillary area is vital, and the location or layer of the hemorrhages as subretinal, intraretinal, or preretinal or extending into the vitreous must also be documented, because such locations can help distinguish abusive from nonabusive injury. Particular attention should be paid to RHs too numerous to count because bilateral, multilayered hemorrhages extending to the periphery are highly specific for AHT8 (Figure 44.2).