Recognizing retinal hemorrhage patterns aids in diagnosing abuse
Click Here to Manage Email Alerts
Gil Binenbaum, MD, MSCE, proposed a “slightly new way” of interpreting retinal hemorrhage at the virtual American Association for Pediatric Ophthalmology and Strabismus annual meeting.
“There are many causes of retinal hemorrhage in young children, and usually the question being asked of us is, ‘Are these hemorrhages due to abusive head trauma?’” he said.
Rather than trying to diagnose abuse based on number, type and location of retinal hemorrhages, Binenbaum suggested a new paradigm that would identify retinal hemorrhage patterns that would indicate trauma, as well as distinguish between trauma and medical causes.
“There’s good evidence that retinal hemorrhage is associated with increasing likelihood of abusive rather than accidental head trauma, which is why it’s important to describe in detail what you see on your examination. But this paradigm is incomplete,” Binenbaum said. “Retinal hemorrhage severity is not perfectly correlated with abuse. There are missing useful patterns. And it doesn’t address medical causes of retinal hemorrhages. With regard to severity, there is generally more overlap than appreciated between abusive and accidental retinal hemorrhages.”
Binenbaum and colleagues at Children’s Hospital of Philadelphia reviewed 188 fundus photographs of retinal hemorrhage from many causes to identify patterns that distinguish medical from traumatic causes. Traumatic patterns included perimacular, central macular sparing, mid-peripheral sparing, cherry hemorrhages, carpeting and excessive hemorrhages with non-radiating areas. Medical patterns included sectoral distribution, numerous retinal hemorrhages in a radiating pattern, superficial peripapillary retinal hemorrhage with disc swelling, and primarily peripapillary preretinal or vitreous hemorrhage. Presence of focal white lesions or lipid or disc swelling also supported a medical cause, according to the presentation.
“The question becomes, is there a pattern of hemorrhage that tells us this is trauma instead of a medical cause of retinal hemorrhage? If a traumatic pattern is identified, only then would we secondarily consider the severity of retinal hemorrhage along with the severity of non-ocular findings as a gauge for the severity of trauma that can be considered by the child abuse team as they consider the history provided by the caregivers,” Binenbaum said.
The key points are to think about diagnosing trauma and not to think about trying to diagnose abuse, Binenbaum said.
“Look for a pattern of retinal hemorrhage that tells you this is trauma and then you can make that statement clearly. Then simply describe the severity of the retinal hemorrhage you see to the child abuse team so that they can gauge the severity of trauma and make a determination of the likelihood of abuse,” Binenbaum said.
Collapse
Binenbaum G. Retinal hemorrhage patterns: A new paradigm. Presented at: American Association for Pediatric Ophthalmology and Strabismus annual meeting; April 9-11, 2021 (virtual meeting).
Read more about
Click Here to Manage Email Alerts