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The presence of retinal hemorrhages is an exception to most of
the other problems included in the symptoms section of this book.
It is a sign, rather than a symptom, and therefore it is not an
abnormality reported by parents or children. Pediatricians usually
identify retinal hemorrhages because they are specifically looking
for them due to associated problems. They are almost never noted during
routine examinations due to their rarity and the difficulty of examining
the retina in young children. Children with retinal hemorrhages
should be referred to a pediatric ophthalmologist.
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What Shouldn’t
Be Missed
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The presence of diffuse retinal hemorrhages in a previously healthy
infant or toddler should raise the strong suspicion of child abuse.
If there is no other identifiable etiology, the patient will require
an evaluation for occult systemic diseases and other evidence of
child abuse.
+
- 1. Normal birth. Retinal
hemorrhages are quite common after normal births. They are more
common following vaginal deliveries, but also can occur after caesarean
section. These usually resolve within the first few weeks of life
and do not cause visual problems.
- 2. Child abuse. Retinal hemorrhages
are an important finding in children who are victims of nonaccidental trauma.
They are frequently associated with intracranial hemorrhages and
other signs of trauma, such as bone fractures. They are not a universal
finding, however, and other disorders may cause mild hemorrhages.
Therefore, the presence of no or a few hemorrhages does not assist
in the diagnosis of child abuse. The presence of diffuse multilayered
hemorrhages (Figure 20–1) without another explanation
is strong evidence for abuse, and the presence of perimacular folds
and retinoschisis cavities is almost pathognomonic for abuse (Figure 20–2).
- 3. Major trauma. Even severe
trauma rarely results in more than mild retinal hemorrhages. A rare
exception is a severe crush head injury, which may mimic the finding
of abuse.
- 4. Systemic disease. A number
of systemic diseases may be associated with retinal hemorrhages
(Table 20-1). The findings are variable and depend on the underlying
disorder. These diseases include bleeding disorders, sepsis, hypertension,
and hematological malignancies. Infectious diseases, such as congenital
cytomegalovirus, may cause retinitis with retinal hemorrhage ...