Ocular signs can lead to recognition of non-accidental trauma in children

Child abuse involves a multidisciplinary diagnosis, and optometrists, as primary eye care providers, are uniquely positioned to be the first to detect it, according to Andrew R. Buzzelli, OD, MS, dean and professor at the Rosenberg School of Optometry at the University of the Incarnate Word in San Antonio, Texas.

Brian J. Forbes, MD, PhD, a surgeon at Children’s Hospital of Philadelphia and associate professor of ophthalmology at the University of Pennsylvania, said the best thing clinicians can do is keep their antennas up and always be aware of the possibility of abuse.

“If eye care practitioners see hemorrhages that are unexpected in a child, they need to make certain to go through the differential diagnosis and look at the entire body, not just the eyes,” he said in an interview.

The type and severity of injury resulting from child abuse largely hinge on the child’s age, according to Natalie Kerr, MD, a pediatric ophthalmologist and professor at the University of Tennessee College of Medicine and the Hamilton Eye Institute, Memphis, Tenn.

“The type of non-accidental trauma that you see in babies is different from the type of non-accidental trauma that you see in older children,” Kerr said in an interview.

Buzzelli told Primary Care Optometry News: “Most child abuse is going to be pre-verbal. A pre-verbal child is generally looking up, so if the abusers don’t shake the children, they will hit downward. And the first thing the hand or the fist comes down on is the eye.”

Aside from evidence of striking, practitioners may see optic atrophy, subluxated lenses and traumatic mydriasis, he said. However, the most common ocular signs of child abuse are intraocular and intracranial hemorrhages, with the most common abnormality manifesting as retinal hemorrhage.

“This is where optometrists have such a critical role in looking at these hemorrhages – seeing where the intraocular hemorrhage is and at what stage of healing,” Buzzelli said. “That’s when you can determine that the history is incompatible with what you’re seeing.”

Signs of shaken baby syndrome

The lack of external evidence of trauma is a hallmark feature of shaken baby syndrome, according to Alex V. Levin, MD, MHSc, of Wills Eye Institute, Philadelphia.

Levin, along with Forbes, Randell Alexander, MD, PhD, and Carole Jenny, MD, MBA, authored a statement on abusive head trauma and shaken baby syndrome posted on the American Academy of Ophthalmology website.

The most common ocular manifestation of shaking injury, identified in about 85% of cases, is retinal hemorrhage. However, the absence of retinal hemorrhages does not rule out abuse. Retinal hemorrhage without intracranial hemorrhage is rare.

For differential purposes, hemorrhages as a result of child abuse and those as a result of other injuries are often very different, the authors said.

“It really takes a forceful injury to cause retinal hemorrhages – not short falls, but rather crush injuries or motor vehicle accidents. I think by evaluating the patient’s history, you can nearly always tell if there’s an injury of that sort,” Forbes said.

Hemorrhages are typically identified in or near the posterior pole, but some are so severe that they cover almost the entire fundus.

According to the AAO statement, retinal hemorrhages from shaken baby syndrome normally resolve within several days to several months, depending on the location and severity of the injury. It is not possible to accurately date retinal hemorrhages.

Secondary vitreous hemorrhage may also develop, typically resulting from migration of intraretinal or preretinal blood. Vitrectomy may be considered if a hemorrhage does not resolve. Vitreous hemorrhage can result in the development of amblyopia or myopia.

Eyes of shaken infants also show evidence of tissue disruption, such as full-thickness perimacular folds in the neurosensory retina, retinoschisis, full-thickness retinal breaks and detachment.

“Although similar findings have been reported rarely in fatal crush injuries and fatal motor vehicle accidents, such histories are readily apparent and would allow rapid identification,” the authors said.

Comorbidities and sexual abuse

Non-accidental trauma may also be evident in extraocular structures such as the orbits and lids. Furthermore, some children are diagnosed with venereal diseases contracted through sexual abuse, Kerr said.

Some neonates develop conjunctivitis or other corneal diseases stemming from exposure to sexually transmitted diseases such as Chlamydia or gonococci in the birth canal; these children are typically not investigated for child abuse, Kerr said.

“But anytime after that and before a child is likely to be sexually active as a teenager, any kind of sexually transmitted infections that are found around the eye, such as gonococcal conjunctivitis and Chlamydia, are certainly red flags,” she said.

Documentation and reporting

Robert Sege, MD, PhD, a professor of pediatrics at Boston University, said some physicians do not recognize patterns of injury that suggest abuse or neglect. In addition, some may overestimate their ability to analyze the social dynamics of families.

“Sometimes, physicians will decide that a family is nice or that they know them well, and it couldn’t be abuse or, on the contrary, that families who are unpleasant or uneducated or have other issues are more likely to need an investigation,” he said in an interview. “Our belief is that physicians should be trained to look objectively and make our reporting decisions based on the medical evidence at hand.”

Kerr said that at LeBonheur Children’s Hospital in Memphis, the standard child abuse procedure includes documentation of all reported cases of retinal hemorrhage.

“We have a RetCam (Clarity Medical Systems), and the report is part of the medical record,” she said.

These test results have been used by the child protection team, she said, “particularly if they have to place the child into custody, which often happens, and if a suspected perpetrator is prosecuted.”

Kerr said that although emergency room physicians at her hospital are keenly aware of the signs of child abuse and proper reporting procedures, ER physicians and pediatricians in general are in need of more training in ophthalmic disease recognition.

Legal liability and protection

Reporting child abuse is a vital community service, although it can be somewhat complex. Strict protocols are designed to streamline the process and expedite treatment.

“It’s not only a moral obligation, it is a legal obligation that you report any suspicion of ocular child abuse,” Buzzelli said. “I emphasize the term ‘suspicion,’ because it’s not the optometrist’s job to interview, decide or to make a definitive diagnosis.

“If you suspect child abuse, you must call authorities, either local police or child protective services, and they will be the prime authority,” he added.

According to Sege, all 50 states have laws that mandate the reporting of suspected child abuse. Individuals who fail to report abuse are subject to civil or criminal penalties.

“And there’s extensive protection against reporting cases that don’t turn out to have been the result of maltreatment,” he said. “Unless, of course, the physician did it maliciously.”

State investigations often uncover patterns of abuse or factors that contribute to abuse, Sege said.

“In those cases, the injuries that occurred or the negligence that was apparent may just be a marker for more serious family problems,” he said. “I think it’s important for us to be aware of that and of the role the state has in investigating the situations of these children.”

Levin said there is a conundrum surrounding physician reporting of suspected child abuse. Physicians are considered the most reliable reporters of suspected child abuse but are actually the worst reporters.

“They often don’t report because they don’t want to become involved and they don’t want to take time away from their practice or they’re afraid to go to court, etc.,” Levin said.

However, eye care practitioners rarely need to testify in court, he said.

“Therefore, some of the concerns that eye care practitioners have about reporting are not justified and, more importantly, run against the legal obligation to report suspicion,” Levin said.

Furthermore, physicians are protected from legal action if they report in good faith, he added.

“What’s important is that doctors must report their suspicion and are protected by law as long as that suspicion is reasonable,” he said. “Eye care practitioners who miss a diagnosis and fail to report may be held liable for criminal action for failing to report, particularly when it leads to further harm.”

The American Optometric Association’s guide to clinical ethics states that it is essential for the optometrist to stay current on the signs and symptoms of abuse and neglect and to know how to document relevant observations and physical findings accurately in the patient’s record. It also notes that optometrists must be responsible for knowing their state’s reporting laws and the legal authorities responsible for investigating suspected abuse, as well as making sure their staffs are well educated on the subject.

It is important for optometrists to report only verifiable physical signs and events, rather than speculating on the causes of specific findings, the document added.

According to Forbes, the largest difficulty with reporting suspected child abuse is having clear, surefire channels to go through.

“For people in private practice, especially, who may suspect abuse, the biggest pitfall is the reliability of services in their particular area. People say, ‘I told this person, who told this person and then they didn’t do anything or don’t know anything about it,’” he said.

“The Division of Youth and Family Services covers nearly all areas in the United States,” Forbes continued. “It’s the service most people have available to them, so that’s probably your first choice. There are certainly in-hospital services like mine, the Suspected Child Abuse and Neglect Team; that’s usually the channel I take. And also, physicians need to approach the situation delicately, but law enforcement should be involved too.” – by Matthew Hasson and Daniel R. Morgan