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Published on: December 31, 2015
Appearance and location of retinal haemorrhages in critically ill children
G G W Adams1, Shruti Agrawal, Rajnish Sekhri
1Department of Strabismus and Paediatrics, Moorfields Eye Hospital, London, UK. gill.adams@blueyonder.co.uk
Insights
Retinal hemorrhages occur in critically ill children, but are usually mild and located peripherally. Extensive bleeding suggests underlying conditions like coagulopathy or leukemia, not abusive head trauma.
Area of Science:
- Ophthalmology
- Pediatric Critical Care
- Medical Imaging
Background:
- Limited high-quality studies exist on retinal hemorrhages in critically ill children.
- Excludes causes like birth trauma or abusive head trauma.
- Focuses on non-traumatic, non-birth-related critical illness.
Purpose of the Study:
- To describe the appearance and location of retinal hemorrhages in critically ill children.
- To differentiate findings from abusive head trauma.
- To identify associated conditions.
Main Methods:
- Prospective study of pediatric intensive care unit admissions (Feb 2008-Dec 2009).
- Exclusion criteria: penetrating eye injury, suspected/proven abusive head injury.
- Diagnostic tools: dilated funduscopy by ophthalmologist, RetCam imaging.
Main Results:
- Retinal hemorrhages found in 15% (24/159) of patients.
- 50% were bilateral; 75% were mild/moderate.
- Predominantly located in peripheral retina (Zone 1/2).
- Rare findings: schisis cavities, perimacular folds, pseudohypopyon, hemorrhagic retinal detachments, CMV-related changes.
Conclusions:
- Retinal hemorrhages are present in some critically ill children but typically not extensive.
- Extensive hemorrhages linked to severe coagulopathy, leukemia, or significant trauma (e.g., RTA, fall).
- Findings can be distinguished from abusive head trauma through history and lab tests.
Background:
There are few high-quality studies describing the appearance and location of retinal haemorrhages in critically ill children not due to birth or abusive head trauma.
Methods:
Prospective study from February 2008 to December 2009 of emergency admissions to a paediatric intensive care unit aged over 6 weeks. Children with a penetrating eye injury or suspected or proven abusive head injury were excluded. The children underwent either dilated funduscopy performed by a paediatric ophthalmologist or RetCam imaging.
Results:
Retinal haemorrhages were identified in 24/159 (15%) patients. 50% of the haemorrhages were bilateral. The severity was mild (<5 retinal haemorrhages) or moderate (5-20 retinal haemorrhages) in 75%. The location was in zone 1 in 45.8%, zones 1 and 2 in 33.3%, zone 2 alone in 8.3% and not described in 8.3%. Schisis cavities and perimacular folds were identified in two patients with one having a pseudohypopyon appearance; a further one patient had bilateral haemorrhagic retinal detachments. Three patients had exudates or scarring consistent with cytomegalovirus infection.
Conclusions:
Retinal haemorrhages are seen in a proportion of critically ill children, however most retinal bleeding is not extensive as indicated by location within the retina or layer of bleeding. Higher numbers and extent of retinal haemorrhages were only observed in the presence of severe coagulopathy, leukaemia, one victim of a road traffic accident, and one child who sustained a fatal witnessed fall down the stairs; all circumstances that would be readily distinguished by history and laboratory testing from abusive head injury.
