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All forms of child abuse may have ocular manifestations. It has been estimated that 4% to 6% of cases of child abuse presents first to the ophthalmologist.

Although any injury to the eye can be the result of child abuse, appropriate attention to history and the careful search for other signs of abusive injury is necessary to differentiate abusive from accidental injury. Some ocular findings are highly suggestive, if not diagnostic, for trauma (Table 587-1). Abuse should be considered even when there is no history of trauma. A misclassification of physical findings as abuse may also occur. For example, a blunt impact to the forehead can result in uni- or bilateral periocular ecchymosis (“raccoon eyes”) as blood tracts down from the forehead. Bilateral periocular ecchymosis can also be a presenting sign of neuroblastoma with orbital involvement. Thrombocytopenia or strong repetitive Valsalva maneuvers can result in petechiae around the eyes or on the conjunctiva.

Table 587-1. Ocular Signs of Physical Abuse

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 (ie, abusive head injury, or shaken baby syndrome). Blunt impact, nonabusive injury to the head causes retinal hemorrhage in less than 3% of cases;1 however, if the injury is from a severe motor vehicle accident, the prevalence may rise to 17%.2 Numerous medical conditions can also result in retinal hemorrhage.1 Yet, in abusive head injury with or without impact, the prevalence rises to 85%; two thirds of these hemorrhagic retinopathies are severe and may be hemorrhages in front of (preretinal), within (intraretinal), and under (subretinal) the retina3,4 (Fig. 587-1). The hemorrhages may be too numerous to count and may extend throughout the retina to its edge (ora serrata).

Figure 587-1.

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 cover virtually the entire retina. Compare to Figure 587-2.

Hemorrhage extending to the ora is statistically correlated with abuse. The hemorrhages may be unilateral or asymmetric between the two eyes.3 With the exception of fatal crush injury to the head5,6 and severe ...

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