Evidence-Based Screening to Optimize the Yield of Positive Ophthalmologic Examinations in Children Evaluated for Suspected Child Abuse

Abstract

Purpose: To determine nonocular findings associated with significant retinal hemorrhage on dilated fundus examination in cases of suspected child abuse. Methods: This was a retrospective chart review from May 2014 to August 2021 at a level-1 trauma center. Two hundred seventy-four patients met the following inclusion criteria: (1) children 36 months and younger; (2) concern for child abuse; and (3) had an ophthalmology consultation. Through univariate and multivariate logistic regression, the study produced a screening algorithm for ophthalmic work-up in child abuse. Results: One or more abnormal neuroimaging findings had a statistically significant association with retinal hemorrhages and produced the strongest association with a univariate odds ratio of 170 (confidence interval: 10.245 to > 999.999). The multivariate model ( P < .0001 with a c-statistic of 0.980) proposes using the following variables for predicting retinal hemorrhage on examination: abnormal neuroimaging, Glasgow Coma Scale score less than 15, altered mental status on examination, seizure activity, vomiting, bruising, scalp hematoma/swelling, and skull fractures. Conclusions: This study elucidates clinical and imaging factors that correlate to retinal findings, validating previously studied variables and introducing new variables to be considered. The authors propose an evidence-based screening algorithm to increase the yield of positive dilated examinations and decrease the burden of potentially unnecessary child abuse ophthalmologic examinations. [ J Pediatr Ophthalmol Strabismus . 2022;59(5):310–319.]

An Update to Biomechanical and Biochemical Principles of Retinal Injury in Child Abuse

“…While studies have proposed a number of predictive factors for retinal hemorrhage, traumatic signs on the skin or fractures in areas other than the skull does not stand among them, hence the prerequisite for further examinations. However, subdural hemorrhage, injury to the posterior region of the head or occipital lobe, a Glasgow coma score (GCS) below 15, convulsive episodes and vomiting have been suggested to be fairly reliable predictors of retinal hemorrhage [4,5]. Nevertheless, clinicians are expected to be wary of pitfalls with regard to this delicate issue, as the co-occurrence of subdural and retinal hemorrhage cannot irrefutably indicate AHT, when there is precedent that such clinical picture might be suggestive of life-threatening conditions such as cerebral venous sinus thrombosis, which falls within the category of coagulopathies [6].…”