Photographic assessment of retinal hemorrhages in infant head injury: the Childhood Hemorrhagic Retinopathy Study.

BACKGROUND: Retinal hemorrhages (RH) in babies in the absence of severe trauma or a medical cause have been strongly associated with abusive head trauma (AHT). We examined the pattern of RH in accidental head injury and AHT objectively using widefield retinal imaging. METHODS: A total of 118 infants and children 1-36 months of age admitted with head injuries at two centers were included in this prospective, consecutive, comparative cohort study. Dilated fundus examination was performed with indirect ophthalmoscopy and widefield imaging. Designation of AHT was made using predetermined criteria independent of retinal findings. Retinal images were graded by two independent observers. RESULTS: There were 21 cases of AHT. RH were present in 14 cases (66%); macular retinoschisis or retinal folds, in 8 (38%). There were 86 cases of accidental head injuries, with RH present in 2 (2%); there were none with retinal folds or retinoschisis. In cases of head injury with intracranial hemorrhage, the positive likelihood ratio of AHT with RH was 5.7 (95% CI, 2.6-12.00) and negative likelihood ratio was 0.26 (95% CI, 0.11-0.62). A severe, panretinal pattern with multilayered hemorrhages was the most specific for AHT. CONCLUSIONS: Our imaging study confirmed that RH in infants with head injury have a high positive likelihood ratio for AHT. A severe hemorrhagic retinopathy, particularly in association with perimacular folds or macular retinoschisis, has the highest positive predictive value for AHT.

Grading system for retinal hemorrhages in abusive head trauma: clinical description and reliability study.

PURPOSE: There is currently no universally accepted grading system for describing retinal hemorrhages (RH) in abusive head trauma (AHT). The purpose of this study was to devise and evaluate a novel grading system and descriptive nomenclature for RH in AHT for clinical and research purposes. METHODS: A traumatic hemorrhagic retinopathy (THR) grading system was developed for assessing and quantitatively analyzing retinal findings in abusive head trauma. The criteria for the THR grade included the extent, spread, and morphology of RH. Extent was classified as region 1 (posterior pole) or region 2 (peripheral). Spread, based on number of retinal hemorrhages, was classified as mild (10 or fewer RH), moderate (more than 10 RH) and severe (more than half of involved regions covered by RH). Morphology was classified by its intraretinal or extraretinal involvement. Two independent graders calculated the THR grade from RetCam images of 38 eyes of 19 patients <3 years of age with retinal hemorrhages associated with head injury. Grading was performed on two separate occasions. Intra- and interobserver reliability was assessed with Spearman correlation coefficient (r) and intraclass correlation coefficient (ICC). RESULTS: There was a high level of intraobserver agreement across both assessments (97% agreement [Spearman r = 0.997; P < 0.0001] and 100% agreement [Spearman r = 1.0; P < 0.0000]). Intraclass correlation (ICC, 0.995; 95% CI, 0.991-0.997; P < 0.0001) confirmed a very high level of agreement overall. CONCLUSIONS: The traumatic hemorrhagic retinopathy grading system demonstrated excellent intraobserver and interobserver reliability. The nomenclature is easily understood and may be useful in medical records and medicolegal reports.

Terson syndrome with ipsilateral severe hemorrhagic retinopathy in a 7-month-old child.

In infants with intracranial hemorrhage, the most common cause of intraocular hemorrhages is abusive head trauma. Terson syndrome is rare in infants, and the retinal findings, although not well reported in the literature, are generally limited to the posterior pole. We report a case of a 7-month-old boy who developed ipsilateral, extensive preretinal and intraretinal hemorrhage after subarachnoid hemorrhage from a ruptured intracranial aneurysm.

A systematic review of the diagnostic accuracy of ocular signs in pediatric abusive head trauma.

TOPIC: To review systematically the diagnostic accuracy of various ocular signs for pediatric abusive head trauma (AHT). CLINICAL RELEVANCE: Intraocular hemorrhages (IOH), perimacular retinal folds, traumatic retinoschisis and optic nerve sheath hemorrhages have been reported as cardinal signs of AHT. The evidence base supporting the accuracy of this interpretation, however, has not been systematically reviewed. METHODS: A systematic keyword search of MEDLINE, EMBASE, and Evidence-Based Medicine Reviews was conducted for original studies reporting ocular findings in AHT. Articles were graded using a checklist for systematic reviews of diagnostic accuracy. RESULTS: The initial search yielded 971 articles, of which 55 relevant studies were graded, and 20 studies met inclusion criteria and were included in the review. The overall sensitivity of IOH for AHT was 75% and their specificity was 94%. Intraretinal hemorrhage at the posterior pole was the most common finding, although extensive, bilateral, and multilayered IOH were the most specific for AHT. Optic nerve sheath hemorrhages had a sensitivity and specificity for AHT of 72% and 71%, respectively. Traumatic retinoschisis and perimacular retinal folds were reported in 8% and 14% of AHT, respectively, but were not reported in other conditions. CONCLUSIONS: Prospective, consecutive studies confirm that IOH in infants-particularly bilateral, extensive, and multilayered-are highly specific for AHT. Optic nerve sheath hemorrhages are significantly more common in AHT than in other conditions, in autopsy studies. Traumatic retinoschisis and perimacular folds are present in a minority of AHT, but rarely seen in other conditions.