A causative link between retinal haemorrhages and abusive head trauma is not universally accepted, but the identification, and documentation, of ocular abnormalities is a standard component of the examination of the injured child in life and in death.
Fundoscopy is a vital component of the medical evaluation of a living child suspected of having abusive head injury, whilst a gross, and microscopic, examination of the eyes at autopsy remains the current 'gold standard' for the evaluation of the dead child suspected of having been abused.
Could fundoscopy be used more frequently by pathologists, as well as opthalmologists, in the evaluation of the dead infant or child?
what is the significance of retinal haemorrhages in the eyes of infants and children?
Having identified, and documented, retinal haemorrhages, what can safely be said about their cause?
In addition to physical abuse - in which the specificity of retinal haemorrhages is controversial - retinal haemorrhages have been recognised in the setting of many natural disorders, including clotting disorders, childbirth, seizures, and infection (central nervous system and respiratory).
Some commentators, such as Tang et al (2008), consider the coexistence of retinal haemorrhages with subdural haemorrhage and cerebral oedema (in a setting of minimal external head trauma) - the so-called 'triad' - to 'virtually assure' a diagnosis of 'shaken baby syndrome'.
Gilliland and uthert (2003), however, consider it '... premature to consider that the eyes are in some way an independent arbiter of the mechanism or severity of injury'.
Bechtel et al (2004) suggested that retinal haemorrhages which were numerous, bilateral, multi-layered, and extended to the periphery/ ora serrata - or which were accompanied by perimacular folds - were more likely to be abusive in origin, although the specificity of these features has been questioned.
The cause of retinal haemorrhages in abusive head trauma is also controversial, and there are conflicting views as to whether they reflect local trauma, meningeal bleeding, or raised venous pressure.
The Royal College of Opthalmologists (UK), through its Child Abuse Working Party, advised that, 'in a child with retinal haemorrhages and subdural haemorrhages who has not sustained a high velocity injury and in whom other recognised causes of such haemorrhages have been excluded, child abuse is much the most likely explanation'.
systematic review of the literature
A systematic review of the literature was performed by researchers at Cardiff University, Wales, UK (and was published in 2013).
The key findings from this review were:
- The Odds Ratio that a child with retinal haemorrhages has suffered abusive head trauma (non-accidental injury) is 14.7 (confidence interval 6.39, 33.62), and the probability of abuse is 91%.
- Retinal haemorrhages in abusive head trauma are predominantly bilateral, numerous, and extend to the periphery.
- Retinal haemorrhages are rare in non-abusive head trauma and are usually few in number, in the posterior pole, and only 10% extend to the periphery.
- No one retinal finding is unique to abusive head trauma.
Having been a reviewer for that project, it was evident that much of the literature is based on single case reports, or groups of cases, and is of 'low quality'.
Additional potential limitations in the literature include a reliance on animal models and conflicting biomechanical data, and a lack of detail in the descriptions of the retinal findings.
At the very least, the presence of retinal haemorrhages must be considered an indicator for a thorough multi-disciplinary investigation into the circumstances of the child's injuries/ death.
A detailed medical examination must take place, including opthalomological examination, radiology (with 'skeletal surveys', and special views of long-bone metaphyses, and ribs), and pathology (including neuropathology, bone pathology, and opthalmic pathology).
The significance of the presence of retinal haemorrhages must then be considered together with all other investigations, in order to draw conclusions about the likelihood of abusive head injury in that particular case.
As to whether pathologists should be using fundoscopy in the mortuary, that would require some revision from days spent in clinical medicine but, if it is found to be a valuable screening technique, it might catch on.
Perhaps it might be safer, however, for opthalmologists to examine the eyes of all dead infants and children - where the cause of death is unknown, or suspicious - as soon as possible after death, as part of a standard protocol before that child is taken to the mortuary?
Articles to read:
- Development and validation of a standardised tool for reporting retinal findings in abusive head trauma
- Susceptibility weighted imaging depicts retinal haemorrhages in abusive head trauma
- Prevalence of retinal haemorrhages in critically ill children
- Clinical and radiographic characteristics associated with abusive and nonabusive head trauma
- A systematic review of the diagnostic accuracy of occular signs in pediatric abusive head trauma
- Retinal hemorrhage in abusive head trauma
- The occular pathology of Terson's syndrome
- Optical coherence tomography findings in Shaken Baby Syndrome
- Guidelines for postmortem protocol for occular investigation of sudden unexplained infant death and suspected physical child abuse
- Occular autopsy and histopathologic features of child abuse
- Unilateral retinal hemorrhages in shaken baby syndrome
- When a funduscopic examination is the clue of maltreatment diagnostic
- Nonophthalmologist accuracy in diagnosing retinal hemorrhages in the shaken baby syndrome
- Ophthalmologic findings in suspected child abuse victims with subdural hematomas
- Opthalmology of shaken baby syndrome
- Improved documentation of retinal hemorrhages using a wide-field digital ophthalmic camera in patients who experienced abusive head trauma
- Retinal hemorrhages caused by accidental household trauma
- Prevalence of retinal hemorrhages and child abuse in children who present with an apparent life-threatening event
- Morphometric analysis of retinal haemorrhages in the shaken baby syndrome
- Retinal findings after head trauma in infants and young children
- Head injury in very young children: mechanisms, injury types, and ophthalmologic findings in 100 hospitalized patients younger than 2 years of age
- Retinal haemorrhage in accidental head trauma in childhood
- Shaken baby syndrome diagnosed by MRI
- Optic nerve sheath and retinal hemorrhages associated with the shaken baby syndrome
- Ophthalmoscopic findings in occult child abuse
- A histopathologist's guide to occular pathology
Anatomy of the eye
- gross anatomy of the eye
- Occular anatomy and cross-sectional imaging of the eye
- Microscopic anatomy of the eye (interactive)
- Layers of the retina (interactive)
- Layers of the retina (microscopic)
- Forensic microscopy of the eye
- Neuropathology of non-accidental head injury