All forms of child abuse may have ocular manifestations. It has been estimated that 4% to 6% of cases of child abuse present first to the ophthalmologist. (For a general discussion of child maltreatment, including abuse, see Chapter 36.)
Any injury to the eye can be the result of child abuse. Some ocular findings are highly suggestive, if not diagnostic, for trauma (Table 577-1), but this does not inform the clinician as to the etiology of the trauma: abusive versus accidental. Appropriate attention to history, laboratory values, and diagnostic testing and the careful search for other signs of abusive injury are necessary to differentiate abusive from accidental injury.
++ Table Graphic Jump Location TABLE 577-1OCULAR SIGNS OF TRAUMA ||Download (.pdf) TABLE 577-1OCULAR SIGNS OF TRAUMA
| ||Possible Trauma ||Certain Trauma |
|Lid laceration || ||× |
|Periocular ecchymosis ||× || |
|Corneal/scleral laceration || ||× |
|Subconjunctival hemorrhage ||× || |
|Hyphema ||× || |
|Unilateral cataract ||× || |
|Acquired iris deformity ||× || |
|Unilateral optic atrophy ||× || |
|Retinal bruise (commotio) || ||× |
|Retinal detachment ||× || |
|Retinal scar ||× || |
|Retinal hemorrhages ||× || |
|Avulsion of vitreous base || ||× |
|Vitreous hemorrhage ||× || |
Perhaps the most common reason that an ophthalmologist is involved in child abuse cases is to search for retinal hemorrhage when there is a concern that an infant has been injured through repetitive acceleration-deceleration mechanisms. Intraocular hemorrhages are the most common ocular finding in shaken baby syndrome (SBS), occurring in approximately 85% of victims. Less common findings include traumatic retinoschisis (splitting of the retinal layers), perimacular folds, vitreous hemorrhage, retinal detachment, or total disruption of the ocular contents. In contrast, nonabusive blunt head impact causes retinal hemorrhage in less than 3% of cases unless the injury is from a severe motor vehicle accident, when the prevalence may rise to 17%. Occipital impact or children with accidental epidural hemorrhage may also result in a higher incidence of retinal hemorrhages. Numerous medical conditions can result in retinal hemorrhage. In SBS, two-thirds of the hemorrhagic retinopathies are severe, with hemorrhages in front of (preretinal), within (intraretinal), and under (subretinal) the retina (Fig. 577-1). The hemorrhages may be too numerous to count and extend throughout the retina to its edge (ora serrata).
Severe hemorrhagic retinopathy in a victim of abusive head injury (shaken baby syndrome). The optic nerve is seen in the center of the photo surrounded by severe preretinal (*) and intraretinal hemorrhage, so much so that barely any normal retina is visible. Hemorrhages of this severity covered virtually the entire retina in this patient. Compare to Figure 577-2.
Hemorrhage extending to the ora is statistically correlated with abuse. The hemorrhages may be unilateral or asymmetric between the 2 eyes. ...