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Retinal haemorrhages and related findings in abusive and non-abusive head trauma: a systematic review
S A Maguire1, P O Watts, A D Shaw
1Department of Child Health, School of Medicine, University Hospital of Wales, Cardiff University, Cardiff, UK. sabinemaguire@gmail.com
Insights
Retinal hemorrhages (RH) are strongly associated with abusive head trauma (AHT) in children. While not unique, specific patterns of RH significantly increase the likelihood of AHT over accidental injury.
Area of Science:
- Ophthalmology
- Pediatrics
- Forensic Medicine
Background:
- Distinguishing abusive head trauma (AHT) from non-abusive head trauma (nAHT) is critical in child protection.
- Retinal signs are key indicators in diagnosing AHT.
Purpose of the Study:
- To identify and characterize retinal signs differentiating AHT from nAHT.
- To establish the diagnostic value of specific retinal findings in suspected child abuse.
Main Methods:
- Systematic literature review (1950-2009) of studies with confirmed etiology in children under 11.
- Inclusion of ophthalmologist examinations; exclusion of post-mortem data, organic eye disease, and inadequate exams.
- Multivariate logistic regression analysis to determine odds ratios (OR) for AHT.
Main Results:
- Retinal hemorrhages (RH) were present in 78% of AHT cases versus 5% of nAHT.
- Head trauma with RH yielded an OR of 14.7 for AHT, indicating a 91% probability of abuse.
- RH were bilateral in 83% of AHT cases, numerous, and often involved all retinal layers and the periphery.
Conclusions:
- Specific patterns of RH (numerous, bilateral, peripheral) are highly suggestive of AHT.
- No single retinal sign is pathognomonic for abusive injury.
- RH are uncommon in accidental trauma, typically being unilateral, few, and posterior.
Aim:
To report the retinal signs that distinguish abusive head trauma (AHT) from non-abusive head trauma (nAHT).
Methods:
A systematic review of literature, 1950-2009, was conducted with standardised critical appraisal. Inclusion criteria were a strict confirmation of the aetiology, children aged <11 years and details of an examination conducted by an ophthalmologist. Post mortem data, organic disease of eye, and inadequate examinations were excluded. A multivariate logistic regression analysis was conducted to determine odds ratios (OR) and probabilities for AHT.
Results:
Of the 62 included studies, 13 provided prevalence data (998 children, 504 AHT). Overall, retinal haemorrhages (RH) were found in 78% of AHT vs 5% of nAHT. In a child with head trauma and RH, the OR that this is AHT is 14.7 (95% confidence intervals 6.39, 33.62) and the probability of abuse is 91%. Where recorded, RH were bilateral in 83% of AHT compared with 8.3% in nAHT. RH were numerous in AHT, and few in nAHT located in the posterior pole, with only 10% extending to periphery. True prevalence of additional features, for example, retinal folds, could not be determined.
Conclusions:
Our systematic review confirms that although certain patterns of RH were far commoner in AHT, namely large numbers of RH in both the eyes, present in all layers of the retina, and extension into the periphery, there was no retinal sign that was unique to abusive injury. RH are rare in accidental trauma and, when present, are predominantly unilateral, few in number and in the posterior pole.
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