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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.
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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.
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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).
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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...