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Ocular and cerebral trauma in non-accidental injury in infancy: underlying mechanisms and implications for paediatric
M A Green1, G Lieberman, C M Milroy
1Department of Forensic Pathology, University of Sheffield.
Insights
Childhood head trauma, particularly non-accidental injuries, often causes severe eye damage like retinal detachment and hemorrhages. Early indirect ophthalmoscopy is crucial for detecting subtle eye injuries that may indicate brain trauma.
Area of Science:
- Forensic pathology
- Ophthalmology
- Pediatric neurology
Background:
- Non-accidental head injuries in children are a significant cause of mortality and morbidity.
- Ocular injuries are frequently associated with abusive head trauma, but their full spectrum and significance are not always recognized.
- Understanding the relationship between the severity of brain injury and specific eye findings is critical for diagnosis and child protection.
Purpose of the Study:
- To investigate the correlation between the severity of brain trauma and ocular injuries in children subjected to non-accidental trauma.
- To identify the specific sites and mechanisms of eye injuries in relation to the level of head trauma.
- To determine the clinical significance of these findings for diagnosing abusive head trauma.
Main Methods:
- A forensic pathological analysis was conducted on 23 children who died from non-accidental injuries over a four-year period.
- Detailed examination of ocular and cerebral injuries was performed.
- Statistical analysis, including correlation coefficients, was used to assess the relationship between central nervous system (CNS) trauma and eye trauma.
Main Results:
- Children who died from CNS injuries showed high incidences of retinal detachment (63%) and various intraocular hemorrhages (subhyaloid 75%, intraretinal 75%, perineural 68%).
- A strong correlation (r = 0.7551, p < 0.0001) was observed between CNS and eye trauma severity scores.
- More severe trauma was associated with subdural hemorrhage, intraocular hemorrhages, retinal detachment, and at the highest levels, choroidal/vitreous hemorrhages with cerebral lacerations.
Conclusions:
- Subtle early eye injuries, such as those coinciding with subdural hemorrhage, may be missed without indirect ophthalmoscopy in non-accidental head injuries.
- Retinal detachment and multiple hemorrhages, especially choroidal and vitreous, can signify additional cerebral damage.
- Vitreous traction is implicated as a primary cause of intraocular pathology in these cases.
Aims:
To determine the sites, mechanisms, and clinical significance of injuries to the eyes and brains of children with non-accidental injuries in relation to differing levels of trauma.
Methods:
A forensic pathological study of injuries in the eyes and brains of 23 consecutive children dying of non-accidental injuries over a 4 year period (1988-92) under the jurisdiction of Yorkshire and Humberside coroners.
Results:
Sixteen children died from cerebral injuries and seven died from non-cerebral causes. There were high incidences of retinal detachment (63%) and subhyaloid (75%), intraretinal (75%), and perineural (68%) haemorrhages in CNS deaths. Local subhyaloid haemorrhages and retinal detachment were more common at the periphery and optic disc than at the equator. There was a strong correlation between CNS and eye trauma scores in all 23 children (r = 0.7551, p < 0.0001). Ranking of injuries by severity suggests progressively more trauma required for (a) subdural haemorrhage, (b) subhyaloid, intraretinal, perineural haemorrhages, and (c) retinal detachment. At highest trauma levels choroidal and vitreous haemorrhages were associated with additional cerebral lacerations, intracerebral and subarachnoid haemorrhages.
Conclusions:
In non-accidental (and probably accidental) infantile head injury the earliest eye injuries (coinciding with subdural haemorrhage) could be missed if indirect ophthalmoscopy is not performed. Retinal detachment and multiple (particularly choroidal/vitreous) haemorrhages may indicate additional cerebral lacerations and/or intracerebral haemorrhage. Vitreous traction is the likely cause of intraocular pathology.