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Curcoy AI, Serra A, Morales M, Luaces C, Trenchs V. Retinal hemorrhages due to intracranial hypertension, is it possible to differentiate them from those associated with abuse? CHILD ABUSE & NEGLECT 2023; 144:106387. [PMID: 37549636 DOI: 10.1016/j.chiabu.2023.106387] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Revised: 07/21/2023] [Accepted: 07/25/2023] [Indexed: 08/09/2023]
Abstract
BACKGROUND Retinal hemorrhages (RHs) are suggestive of abusive head trauma (AHT). Even so, controversy persists about other possible causes, a fact that hinders the diagnosis of abuse. OBJECTIVE To determine the prevalence and patterns of RHs associated with increased intracranial pressure (ICP) in young children. PARTICIPANTS AND METHODS Prospective, single center study of children aged 29 days-3 years undergoing a lumbar puncture with opening pressure (OP) measured during routine clinical care in the emergency department, over a 4-year period. Children with known causes of RHs were excluded. All the children underwent a detailed ophthalmological examination within 72 h of admission. For children with RHs, an in-depth investigation was carried out to rule out AHT. RESULTS Thirty-four patients were included: 20(58.8 %) were boys, median age 11.7 months (range 1-33 months). Overall, 29(85.3 %) had clinical findings of increased ICP. The duration of symptoms was ≤4 days in all patients except one, in whom it was 1.5 months. The median OP was 27cmH2O (range 20-60cmH2O). One of the children was found to have RHs, with evaluation resulting in a diagnosis of AHT. No RHs were found in any of the others studied. Using the Wilson method, we can be confident to an upper limit of 95 % that the probability of RHs occurring secondary to increased ICP alone is at most 0.1. CONCLUSIONS RHs were not detected in patients with isolated nontraumatic increased ICP, measured via OP and diagnosed in the ED. Therefore, if RHs are detected, investigation into the possibility of AHT is warranted.
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Affiliation(s)
- Ana I Curcoy
- Pediatric Emergency Department, Hospital Sant Joan de Déu, Barcelona, Spain; University of Barcelona, Barcelona, Spain; Environment Effects on Child/Adolescent Well-being, Institut de Recerca Sant Joan de Déu (IRSJD), Barcelona, Spain
| | - Alicia Serra
- Ophthalmology Department, Hospital Sant Joan de Déu, Barcelona, Spain
| | - Marta Morales
- Ophthalmology Department, Hospital Sant Joan de Déu, Barcelona, Spain
| | - Carles Luaces
- Pediatric Emergency Department, Hospital Sant Joan de Déu, Barcelona, Spain; University of Barcelona, Barcelona, Spain; Environment Effects on Child/Adolescent Well-being, Institut de Recerca Sant Joan de Déu (IRSJD), Barcelona, Spain
| | - Victoria Trenchs
- Pediatric Emergency Department, Hospital Sant Joan de Déu, Barcelona, Spain; University of Barcelona, Barcelona, Spain; Environment Effects on Child/Adolescent Well-being, Institut de Recerca Sant Joan de Déu (IRSJD), Barcelona, Spain.
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Lam MR, Yang CD, Colmenarez JA, Dong P, Gu L, Suh DW. The role of intrapartum fetal head compression in neonatal retinal hemorrhage. J AAPOS 2023; 27:267.e1-267.e7. [PMID: 37722620 DOI: 10.1016/j.jaapos.2023.07.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Revised: 07/20/2023] [Accepted: 07/22/2023] [Indexed: 09/20/2023]
Abstract
PURPOSE Neonatal retinal hemorrhage is a common finding in newborns, but the underlying mechanisms are not fully understood. A computational simulation was designed to study the events taking place in the eye and orbit when the head is compressed as the neonate passes through the birth canal. METHODS A finite element model of the eye, optic nerve sheath, and orbit was simulated and subjected to forces mimicking rises in intracranial pressure (ICP) associated with maternal contractions during normal vaginal delivery. Resulting changes in intraocular pressure (IOP), pressure in the optic nerve sheath, and stress within the sclera and retina were measured. RESULTS During contractions, increased ICP was transmitted to the orbit, globe, and optic nerve sheath. IOP rose by 2.71 kPa near the posterior pole. Pressure at the center of the optic nerve sheath rose by 7.31 kPa and up to 9.30 kPa at its interface with the sclera. Stress in the retina was highest near the optic disk and reached 10.93, 10.99, and 13.28 kPa in the preretinal, intraretinal, and subretinal layers, respectively. Stress in the sclera peaked at 12.76 kPa. CONCLUSIONS Increasing ICP associated with natural vaginal delivery increases intraorbital pressure, which applies stress to the retina. Associated retinal deformation may cause tearing of the retinal vasculature. Increased pressure within the optic nerve sheath may occlude the central retinal vein, resulting in outflow obstruction and subsequent rupture. Forces accumulated near the optic disk, likely accounting for the tendency of neonatal retinal hemorrhage to occur posteriorly.
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Affiliation(s)
- Matthew R Lam
- Creighton University School of Medicine, Phoenix, Arizona.
| | - Christopher D Yang
- Department of Ophthalmology and Visual Sciences, University of California, Irvine School of Medicine, Irvine, California; Gavin Herbert Eye Institute, University of California, Irvine, Irvine, California
| | - Jose A Colmenarez
- Department of Biomedical Engineering and Science, Florida Institute of Technology, Melbourne, Florida
| | - Pengfei Dong
- Department of Biomedical Engineering and Science, Florida Institute of Technology, Melbourne, Florida
| | - Linxia Gu
- Department of Biomedical Engineering and Science, Florida Institute of Technology, Melbourne, Florida
| | - Donny W Suh
- Department of Ophthalmology and Visual Sciences, University of California, Irvine School of Medicine, Irvine, California; Gavin Herbert Eye Institute, University of California, Irvine, Irvine, California
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Doswell A, Killough E, Zinkus TP, Sherman A, Anderst J. Examining diagnostic variability among pediatric subspecialists using case examples of infant head injury. CHILD ABUSE & NEGLECT 2023; 144:106371. [PMID: 37536244 DOI: 10.1016/j.chiabu.2023.106371] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/15/2023] [Revised: 07/16/2023] [Accepted: 07/18/2023] [Indexed: 08/05/2023]
Abstract
BACKGROUND Although there is research regarding the diagnosis and timing of abusive head trauma, there remains practice variation among pediatric subspecialists. OBJECTIVES To examine diagnostic variability among pediatric subspecialists using case examples of infant head injury. Secondary objectives were timing variability among subspecialists, and diagnostic and timing variability among Child Abuse Pediatricians (CAPs). PARTICIPANTS AND SETTING Pediatric subspecialists were recruited from Child Abuse Pediatrics, Hospital Medicine, Emergency Medicine, Critical Care, and Neurosurgery to complete a research instrument. Participants qualified for the study if they evaluated at least 1 case of possible abusive head trauma during their career. METHODS This multi-institutional, mixed-methods study used a research instrument with 4 case examples of infant head injury: severe retinal hemorrhages (RH), mass-effect subdural hemorrhage (SDH), SDH membrane formation, and sepsis. The response selected by most CAPs was reference and compared across subspecialties and among CAPs using Chi-square or Fisher's exact tests. A Bonferroni correction (p < 0.01) was used for subspecialty comparisons. RESULTS There were 288 participants who completed at least 1 case example. Diagnostic variability was observed in all case examples. Significantly fewer Hospital Medicine (34.9 % vs. 57.9 %, p < 0.01), Emergency Medicine (28.0 % vs. 57.9 %, p < 0.0001), and Neurosurgery (24.0 % vs. 57.9 %, p < 0.01) participants selected the reference response for the mass-effect SDH case example. Timing variability was statistically significant for all case examples (p < 0.01). Significantly fewer CAPs aged 44-64 years selected the reference response for timing (p < 0.01) for the severe RH case example. CONCLUSIONS Additional peer review processes and consensus guidelines for challenging issues in abusive head trauma may be beneficial.
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Affiliation(s)
- Angela Doswell
- Division of Child Abuse and Neglect, Department of Pediatrics, Connecticut Children's Medical Center, University of Connecticut School of Medicine, 282 Washington Street, Hartford, CT 06106, United States of America.
| | - Emily Killough
- Division of Child Adversity and Resilience, Department of Pediatrics, Children's Mercy Kansas City, University of Missouri-Kansas City, 2401 Gillham Road, Kansas City, MO 64108, United States of America.
| | - Timothy P Zinkus
- Division of Pediatric Radiology, Department of Pediatrics, Children's Mercy Kansas City, University of Missouri-Kansas City, University of Kansas School of Medicine, Saint Louis University School of Medicine, 2401 Gillham Road, Kansas City, MO 64108, United States of America.
| | - Ashley Sherman
- Division of Health Services and Outcomes Research, Children's Mercy Kansas City, 2401 Gillham Road, Kansas City, MO 64108, United States of America.
| | - James Anderst
- Division of Child Adversity and Resilience, Department of Pediatrics, Children's Mercy Kansas City, University of Missouri-Kansas City, 2401 Gillham Road, Kansas City, MO 64108, United States of America
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Dasgupta D, Elhusseiny AM, Phillips PH, Jayappa S, Hill SEM, Tanaka T, Glasier CM, Vilanilam GK, Purushothaman R, Clingenpeel R, Murray L, Choudhary A, Ramakrishnaiah R. Utility of balanced steady-state field precession sequence in the evaluation of retinal and subdural hemorrhages in patients with abusive head trauma. Pediatr Radiol 2023; 53:1842-1853. [PMID: 37079040 DOI: 10.1007/s00247-023-05614-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Revised: 01/17/2023] [Accepted: 01/23/2023] [Indexed: 04/21/2023]
Abstract
Abusive head trauma is the leading cause of physical child abuse deaths in children under 5 years of age in the United States. To evaluate suspected child abuse, radiologic studies are typically the first to identify hallmark findings of abusive head trauma including intracranial hemorrhage, cerebral edema, and ischemic injury. Prompt evaluation and diagnosis are necessary as findings may change rapidly. Current imaging recommendations include brain magnetic resonance imaging with the addition of a susceptibility weighted imaging (SWI) sequence which can detect additional findings that suggest abusive head trauma including cortical venous injury and retinal hemorrhages. However, SWI is limited due to blooming artifacts and artifacts from the adjacent skull vault or retroorbital fat, which can affect the evaluation of retinal, subdural, and subarachnoid hemorrhages. This work explores the utility of the high-resolution, heavily T2 weighted balanced steady-state field precession (bSSFP) sequence to identify and characterize retinal hemorrhage and cerebral cortical venous injury in children with abusive head trauma. The bSSFP sequence provides distinct anatomical images to improve the identification of retinal hemorrhage and cortical venous injury.
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Affiliation(s)
- Dhruba Dasgupta
- College of Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, 72205, USA.
| | | | - Paul H Phillips
- Jones Eye Institute, University of Arkansas for Medical Sciences, Little Rock, AR, 72205, USA
| | - Sateesh Jayappa
- Department of Radiology, University of Arkansas for Medical Sciences, 4301 W. Markham St., Slot 556, Little Rock, AR, 72205, USA
| | | | - Tomoko Tanaka
- Department of Neurosurgery, Division of Pediatric Neurosurgery, University of Arkansas for Medical Sciences, Little Rock, AR, 72205, USA
| | - Charles M Glasier
- Department of Radiology, University of Arkansas for Medical Sciences, 4301 W. Markham St., Slot 556, Little Rock, AR, 72205, USA
| | - George Koshy Vilanilam
- Department of Radiology, University of Arkansas for Medical Sciences, 4301 W. Markham St., Slot 556, Little Rock, AR, 72205, USA
| | - Rangarajan Purushothaman
- Department of Radiology, University of Arkansas for Medical Sciences, 4301 W. Markham St., Slot 556, Little Rock, AR, 72205, USA
| | - Rachel Clingenpeel
- Department of Pediatrics, University of Arkansas for Medical Sciences, Clark Center, 1210 Wolfe St., Mail Slot # 512-24A, Little Rock, AR, 72202, USA
| | - Liza Murray
- Department of Pediatrics, University of Arkansas for Medical Sciences, Clark Center, 1210 Wolfe St., Mail Slot # 512-24A, Little Rock, AR, 72202, USA
| | - Arabinda Choudhary
- Department of Radiology, University of Arkansas for Medical Sciences, 4301 W. Markham St., Slot 556, Little Rock, AR, 72205, USA
| | - Raghu Ramakrishnaiah
- Department of Radiology, University of Arkansas for Medical Sciences, 4301 W. Markham St., Slot 556, Little Rock, AR, 72205, USA
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Di Fazio N, Delogu G, Morena D, Cipolloni L, Scopetti M, Mazzilli S, Frati P, Fineschi V. New Insights into the Diagnosis and Age Determination of Retinal Hemorrhages from Abusive Head Trauma: A Systematic Review. Diagnostics (Basel) 2023; 13:1722. [PMID: 37238204 PMCID: PMC10217069 DOI: 10.3390/diagnostics13101722] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Revised: 04/29/2023] [Accepted: 05/02/2023] [Indexed: 05/28/2023] Open
Abstract
(1) Background: Head trauma represents the first cause of death in abused children, but diagnostic knowledge is still limited. The characteristic findings of abusive head trauma (AHT) are retinal hemorrhages (RH) and additional ocular findings, including optic nerve hemorrhages (ONH). However, etiological diagnosis must be cautious. (2) Methods: The Preferred Reporting Items for Systematic Review (PRISMA) standards were employed, and the research focus was the current gold standard in the diagnosis and timing of abusive RH. (3) Results: Sixteen articles were included for qualitative synthesis. The importance of an early instrumental ophthalmological assessment emerged in subjects with a high suspicion of AHT, with attention to the localization, laterality, and morphology of the findings. Sometimes it is possible to observe the fundus even in deceased subjects, but the current techniques of choice consist of Magnetic Resonance Imaging and Computed Tomography, also useful for the timing of the lesion, the autopsy, and the histological investigation, especially if performed with the use of immunohistochemical reactants against erythrocytes, leukocytes, and ischemic nerve cells. (4) Conclusions: The present review has made it possible to build an operational framework for the diagnosis and timing of cases of abusive retinal damage, but further research in the field is needed.
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Affiliation(s)
- Nicola Di Fazio
- Department of Anatomical, Histological, Forensic and Orthopaedic Science, Sapienza University of Rome, 00185 Rome, Italy; (N.D.F.); (G.D.); (D.M.); (S.M.); (P.F.)
| | - Giuseppe Delogu
- Department of Anatomical, Histological, Forensic and Orthopaedic Science, Sapienza University of Rome, 00185 Rome, Italy; (N.D.F.); (G.D.); (D.M.); (S.M.); (P.F.)
| | - Donato Morena
- Department of Anatomical, Histological, Forensic and Orthopaedic Science, Sapienza University of Rome, 00185 Rome, Italy; (N.D.F.); (G.D.); (D.M.); (S.M.); (P.F.)
| | - Luigi Cipolloni
- Department of Clinical and Experimental Medicine, Section of Legal Medicine, University of Foggia, 71100 Foggia, Italy;
| | - Matteo Scopetti
- Department of Medical Surgical Sciences and Translational Medicine, Sapienza University of Rome, 00189 Rome, Italy;
| | - Sara Mazzilli
- Department of Anatomical, Histological, Forensic and Orthopaedic Science, Sapienza University of Rome, 00185 Rome, Italy; (N.D.F.); (G.D.); (D.M.); (S.M.); (P.F.)
| | - Paola Frati
- Department of Anatomical, Histological, Forensic and Orthopaedic Science, Sapienza University of Rome, 00185 Rome, Italy; (N.D.F.); (G.D.); (D.M.); (S.M.); (P.F.)
| | - Vittorio Fineschi
- Department of Anatomical, Histological, Forensic and Orthopaedic Science, Sapienza University of Rome, 00185 Rome, Italy; (N.D.F.); (G.D.); (D.M.); (S.M.); (P.F.)
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Kato M, Nonaka M, Akutsu N, Narisawa A, Harada A, Park YS. Correlations of intracranial pathology and cause of head injury with retinal hemorrhage in infants and toddlers: A multicenter, retrospective study by the J-HITs (Japanese Head injury of Infants and Toddlers study) group. PLoS One 2023; 18:e0283297. [PMID: 36930676 PMCID: PMC10022784 DOI: 10.1371/journal.pone.0283297] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Accepted: 03/05/2023] [Indexed: 03/18/2023] Open
Abstract
INTRODUCTION In infants who have suffered head trauma there are two possible explanations for retinal hemorrhage (RH): direct vitreous shaking and occurrence in association with intracranial lesions. Which possibility is more plausible was examined. MATERIAL AND METHODS This multicenter, retrospective study reviewed the clinical records of children younger than four years with head trauma who had been diagnosed with any findings on head computed tomography (CT) and/or magnetic resonance imaging (MRI). Of 452 cases, 239 underwent an ophthalmological examination and were included in this study. The relationships of RH with intracranial findings and the cause of injury were examined. RESULT Odds ratios for RH were significant for subdural hematoma (OR 23.41, p = 0.0004), brain edema (OR 5.46, p = 0.0095), nonaccidental (OR 11.26, p<0.0001), and self-inflicted falls (OR 6.22, p = 0.0041). CONCLUSION Although nonaccidental, brain edema and self-inflicted falls were associated with RH, subdural hematoma was most strongly associated with RH.
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Affiliation(s)
- Mihoko Kato
- Department of Neurosurgery, Aichi Children’s Health and Medical Center, Aichi, Japan
| | - Masahiro Nonaka
- Department of Neurosurgery, Kansai Medical University, Osaka, Japan
- * E-mail:
| | - Nobuyuki Akutsu
- Department of Neurosurgery, Hyogo Prefectural Kobe Children’s Hospital, Hyogo, Japan
| | - Ayumi Narisawa
- Department of Neurosurgery, Sendai City Hospital, Miyagi, Japan
| | - Atsuko Harada
- Department of Pediatric Neurosurgery, Takatsuki General Hospital, Osaka, Japan
| | - Young-Soo Park
- Department of Neurosurgery, Nara Medical University, Nara, Japan
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Harris CK, Stagner AM. The Eyes Have It: How Critical are Ophthalmic Findings to the Diagnosis of Pediatric Abusive Head Trauma? Semin Ophthalmol 2023; 38:3-8. [PMID: 36524752 DOI: 10.1080/08820538.2022.2152712] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Pediatric abusive head trauma (AHT), still colloquially known as shaken baby syndrome, is a leading cause of morbidity and mortality among infants. Controversy has grown surrounding this diagnosis, and the specificity of the clinical findings-subdural hemorrhage, cerebral edema, and retinal hemorrhages-has been challenged. A literature search of peer reviewed publications on PubMed pertaining to the history, clinical, and pathologic features of AHT was conducted using the terms "shaken baby syndrome," "non-accidental trauma," "abusive head trauma," "inflicted traumatic brain injury," "shaken impact syndrome," and "whiplash shaken infant syndrome." Focus was placed on articles discussing ophthalmic findings in AHT. Retinal hemorrhages-particularly those that are too numerous to count, occurring in all layers of the retina (preretinal, intraretinal, subretinal), covering the peripheral pole and extending to the ora serrata, and accompanied by retinoschisis and other ocular/periocular hemorrhages-are highly suggestive of AHT, particularly in the absence of otherwise explained massive accidental trauma. Although the diagnosis has grown in controversy in recent years, AHT has well-documented clinical and pathologic findings across a large number of studies.
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Affiliation(s)
- Cynthia K Harris
- Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.,Department of Ophthalmology, David G. Cogan Laboratory of Ophthalmic Pathology, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, MA, USA
| | - Anna M Stagner
- Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.,Department of Ophthalmology, David G. Cogan Laboratory of Ophthalmic Pathology, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, MA, USA
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8
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Christian CW, Binenbaum G. The eye in child abuse. Childs Nerv Syst 2022; 38:2335-2344. [PMID: 35871261 DOI: 10.1007/s00381-022-05610-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Accepted: 07/11/2022] [Indexed: 11/30/2022]
Abstract
Child physical abuse may result in a range of injuries to the globe and surrounding tissues. These injuries have varying degrees of specificity for abuse, and no pattern of injury is unique to abuse. Easily overlooked eye injuries in non-ambulatory infants often portend more severe abuse and require careful evaluation for occult injury when they are unexplained. Retinal hemorrhages are most often a sign of significant trauma and the severity of the hemorrhages generally parallels the severity of neurological trauma. Ophthalmologists contribute important data that more easily distinguish medical disease from trauma, but caution is needed in differentiating accidental from inflicted trauma. This distinction requires careful consideration of the complete clinical data and occasionally on additional law enforcement or child welfare investigation.
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Affiliation(s)
- Cindy W Christian
- The Children's Hospital of Philadelphia, 3500 Civic Center Blvd, Philadelphia, PA, 19104, USA.
- Department of Pediatrics, The Perelman School of Medicine at The University of Pennsylvania, Philadelphia, USA.
| | - Gil Binenbaum
- The Children's Hospital of Philadelphia, 3500 Civic Center Blvd, Philadelphia, PA, 19104, USA
- Department of Ophthalmology, The Perelman School of Medicine at The University of Pennsylvania, Philadelphia, USA
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9
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The eyes have it: when skin findings prompt referral to ophthalmology. Curr Opin Pediatr 2022; 34:381-389. [PMID: 35836396 DOI: 10.1097/mop.0000000000001143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
PURPOSE OF REVIEW Co-presentation of ocular and cutaneous conditions is common and prompt recognition of known associations may be imperative to sight-saving intervention. There are currently limited reviews in the pediatric literature addressing comorbid ocular and dermatologic presentations. Recent diagnostic and therapeutic advances have drastically altered the prognostic landscape for several disease states when recognition and referral are timely. The aim of this report is to examine important oculocutaneous disease associations with emphasis on management of ocular complications and appropriate referral practices to ophthalmology specialists. RECENT FINDINGS Oculocutaneous associations can be broadly classified into four etiologic categories: infectious, inflammatory, genetic, and medication/nutrition induced pathology. Several conditions in all four categories have had recent advances in their etiologic understanding, diagnostic evaluation, and therapeutic approach. Thematically, these advances highlight increasing disease prevalence of certain conditions, previously unrecognized pediatric relevance of others, updated diagnostic criteria, and newer categories of iatrogenic illness induced by advances in medical therapy. SUMMARY This review is designed to provide the pediatric practitioner a vignette-based high-level overview of both common and sight threatening associations that should prompt consideration for ophthalmology consultation. Conditions were selected based on relevance, relative urgency, and recent advances in their etiologic/therapeutic understanding.
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Chung CW, Levin AV, Forbes BJ, Binenbaum G. Retinal hemorrhage after pediatric neurosurgical procedures. J AAPOS 2022; 26:74.e1-74.e5. [PMID: 35304320 DOI: 10.1016/j.jaapos.2021.11.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2021] [Revised: 11/26/2021] [Accepted: 11/30/2021] [Indexed: 11/24/2022]
Abstract
BACKGROUND Neurosurgical procedures may occur prior to eye examination in children with suspected abusive head trauma and raise questions by child abuse physicians and ophthalmologists regarding the contribution of neurosurgery to retinal hemorrhage found postoperatively. The purpose of this study was to determine the prevalence and patterns of retinal hemorrhage attributable to neurosurgical intervention in children. METHODS We conducted a retrospective cohort study of children undergoing neurosurgery who had postoperative ophthalmoscopy. Some children were also examined preoperatively. Primary outcome measures were the prevalence and patterns of retinal hemorrhage attributable to neurosurgical intervention. Medical records were reviewed to identify confounding coexistent diseases. RESULTS Among 267 children undergoing 289 neurosurgical procedures, there were no cases in which children had post-procedural retinal hemorrhage that could be attributed to neurosurgery. Retinal hemorrhage was seen in 32 (12%) cases, but in every case they were either already present on preoperative examination (13 cases) or matched the pattern of a coexistent known cause of retinal hemorrhage, including head trauma with unambiguous history and/or nonocular signs (13), hydrocephalus-related increased intracranial pressure with papilledema-associated peripapillary retinal hemorrhage (5), and retinopathy of prematurity ridge-associated retinal hemorrhage (1). No retinal hemorrhage could be attributed only to neurosurgery. CONCLUSIONS Although children undergoing child abuse evaluations may have intracranial hemorrhage requiring neurosurgery that occurs before a dilated retinal examination can be performed, our data suggest that neurosurgery independently is unlikely to produce retinal hemorrhage and therefore is not a significant confounding factor in the interpretation of retinal hemorrhage patterns in child abuse evaluations.
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Affiliation(s)
- Caroline W Chung
- The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Alex V Levin
- Flaum Eye Institute and Golisano Children's Hospital, Rochester, New York
| | - Brian J Forbes
- The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Gil Binenbaum
- The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.
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11
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Scheller J, Wester K. Is external hydrocephalus a possible differential diagnosis when child abuse is suspected? Acta Neurochir (Wien) 2022; 164:1161-1172. [PMID: 33710381 PMCID: PMC8967805 DOI: 10.1007/s00701-021-04786-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2019] [Accepted: 02/22/2021] [Indexed: 11/07/2022]
Abstract
Background Criteria for diagnosing abusive head trauma (AHT) or “shaken baby syndrome” are not well defined; consequently, these conditions might be diagnosed on failing premises. Methods The authors have collected a total of 28 infants, from the US (20) and Norway (8), suspected of having been violently shaken, and their caregivers had been suspected, investigated, prosecuted or convicted of having performed this action. Among 26 symptomatic infants, there were 18 boys (69%) and 8 girls (31%)—mean age 5.1 month, without age difference between genders. Results Twenty-one of 26 symptomatic children (81%) had a head circumference at or above the 90 percentile, and 18 had a head circumference at or above the 97 percentile. After macrocephaly, seizure was the most frequent initial symptom in 13 (50%) of the symptomatic infants. Seventeen (65%) of the symptomatic infants had bilateral retinal haemorrhages, and two had unilateral retinal haemorrhages. All infants had neuroimaging compatible with chronic subdural haematomas/hygromas as well as radiological characteristics compatible with benign external hydrocephalus (BEH). Conclusions BEH with subdural haematomas/hygromas in infants may sometimes be misdiagnosed as abusive head trauma. Based on the authors’ experience and findings of the study, the following measures are suggested to avoid this diagnostic pitfall: medical experts in infant abuse cases should be trained in recognising clinical and radiological BEH features, clinicians with neuro-paediatric experience should always be included in the expert teams and reliable information about the head circumference development from birth should always be available.
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12
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Patterns of retinal hemorrhage associated with cardiac arrest and cardiopulmonary resuscitation. J AAPOS 2021; 25:324.e1-324.e4. [PMID: 34728383 DOI: 10.1016/j.jaapos.2021.06.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Revised: 05/28/2021] [Accepted: 06/06/2021] [Indexed: 11/22/2022]
Abstract
BACKGROUND Hypoxia and cardiopulmonary resuscitation (CPR) have been proposed as causes of retinal hemorrhage (RH) in children evaluated for abusive head trauma (AHT). We sought to determine the prevalence and characteristics of RH in children who underwent CPR after cardiac arrest. METHODS This was a prospective, single-center, consecutive observational study of 38 children (<18 years of age). Indirect ophthalmoscopic examination was completed by an ophthalmologist within 48 hours of CPR. Extensive medical records data were collected to assess for potential confounding factors. Outcomes included the presence and pattern of RH. RESULTS Of the 38 children, 20 had in-hospital arrest; 18 had out-of-hospital arrest. The median duration of CPR was 10 minutes. Seven children had RH, of whom 6 had an RH pattern consistent with coexistent medical conditions: 4 AHT diagnosable with nonocular findings, including subdural and subarachnoid hemorrhage, rib fractures, abdominal injury (RH pattern: diffuse, numerous, intraretinal and/or multilayered RH); 1 septic shock (RH pattern: 1-2 posterior pole RH); 1 ruptured arteriovenous malformation (RH pattern: 4-8 peripapillary RH). The seventh child had unwitnessed cardiac arrest due to nonfatal drowning and a single superficial intraretinal peripapillary hemorrhage. CONCLUSIONS CPR for cardiac arrest is rarely associated with RH, which, absent coexisting conditions causing retinal hemorrhage, are intraretinal, few in number, and located in the posterior pole. In children who have undergone CPR, when RH are multilayered, or are more than a few in number, or extend outside the posterior pole, another etiology for the RH should be sought.
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13
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Zhu X, Cai X, Zhou X, Li Y, Yang C. Retinal vein occlusion with cerebral infarction in a preterm neonate: a case report. BMC Pediatr 2021; 21:511. [PMID: 34784915 PMCID: PMC8594150 DOI: 10.1186/s12887-021-02989-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Accepted: 11/03/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Retinal vein occlusion (RVO) is a common disease that causes blindness in elderly patients, and cerebral infarction is also a severe disorder impairing the health of individuals. Both diseases are not common in neonates and are related to thrombosis. To date, only one case of simultaneous occurrence of RVO with intracranial haemorrhage in a full-term neonate has been reported. CASE PRESENTATION A preterm neonate was diagnosed with cerebral infarction and RVO. Retinal haemorrhage and macular oedema were detected in the left eye after the onset of ipsilateral stroke. Although the retinal conditions in this case resolved spontaneously without ocular treatment, the long-term effect on visual function is still unknown. CONCLUSIONS Given that ocular fundus examinations are rarely performed in paediatric stroke patients, a screening fundus examination in these newborns with stroke might be worth considering.
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Affiliation(s)
- Xiuyu Zhu
- Department of Ophthalmology, Children's Hospital of Fudan University, National Children's Medical Center, Wanyuan Road No.399, Shanghai, 201102, China
| | - Xiaojing Cai
- Department of Ophthalmology, Children's Hospital of Fudan University, National Children's Medical Center, Wanyuan Road No.399, Shanghai, 201102, China
| | - Xiaohong Zhou
- Department of Ophthalmology, Children's Hospital of Fudan University, National Children's Medical Center, Wanyuan Road No.399, Shanghai, 201102, China
| | - Yian Li
- Department of Ophthalmology, Children's Hospital of Fudan University, National Children's Medical Center, Wanyuan Road No.399, Shanghai, 201102, China
| | - Chenhao Yang
- Department of Ophthalmology, Children's Hospital of Fudan University, National Children's Medical Center, Wanyuan Road No.399, Shanghai, 201102, China.
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14
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Cho IH, Kim MS, Heo NH, Kim SY. Birth-related retinal hemorrhages: The Soonchunhyang University Cheonan Hospital universal newborn eye screening (SUCH-NES) study. PLoS One 2021; 16:e0259378. [PMID: 34752467 PMCID: PMC8577753 DOI: 10.1371/journal.pone.0259378] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2021] [Accepted: 10/19/2021] [Indexed: 11/18/2022] Open
Abstract
Purpose To report the prevalence, related factors, and characteristics of birth-related retinal hemorrhages (RHs) according to their severity in healthy newborns using a telemedicine network and wide-field digital retinal imaging (WFDRI). Methods Newborns who underwent WFDRI at 61 obstetrics/gynecology hospitals between January 2017 and December 2019 were enrolled. Demographics and related factors were compared among newborns with and without RHs. The newborns’ eyes were divided into the minimal, mild, moderate, and severe groups according to the number of RHs, and characteristics like bilaterality, laterality, involved retinal layer, involved zone, macular and/or optic nerve (ON) involvement were compared. Results Among 56247 newborns, 13026 had birth-related RHs (23.2%). Normal spontaneous vaginal delivery (NSVD) showed the highest association with RHs (odds ratio, 19.774; 95% confidence interval, 18.277–21.393; P < 0.001) on multivariate analysis. Bilateral RHs (8414/13026; 64.59%) were more common than unilateral RHs (4612/13026; 35.41%); however, unilateral RHs (2383/4217; 56.51%) were more common than bilateral RHs (1834/4217; 43.49%) in the minimal group. RHs showed no laterality differences between the two eyes (P = 0.493). Most RHs were intraretinal (18678/21440; 87.12%), and 2328 (31.65%) eyes with preretinal hemorrhage were observed in the severe group. Zone I RHs were common in the minimal (7072/7090; 99.75%), mild (4953/4960; 99.86%), and moderate (2013/2035; 98.92%) groups; zone I and II RHs were common in the severe group (4843/7355; 65.85%); and RHs in zone III were rare (7/21440; 0.03%). Most RHs showed no macular and/or ON involvement in the minimal and mild group; however, this was common in the severe group (7111/7355; 96.68%). Conclusions Birth-related RHs were common in healthy newborns and were significantly associated with NSVD. RHs were usually bilateral, intraretinal, and distributed posterior to the retina, but severe RHs had unique characteristics. Future long-term and longitudinal studies are required to elucidate the prognosis of severe RHs.
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Affiliation(s)
- In Hwan Cho
- Department of Ophthalmology, College of Medicine, Soonchunhyang University, Cheonan, Korea
| | - Min Seong Kim
- Department of Ophthalmology, College of Medicine, Soonchunhyang University, Cheonan, Korea
| | - Nam Hun Heo
- Clinical Trial Center, Soonchunhyang University, Cheonan, Korea
| | - So Young Kim
- Department of Ophthalmology, College of Medicine, Soonchunhyang University, Cheonan, Korea
- * E-mail:
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15
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Maiese A, Iannaccone F, Scatena A, Del Fante Z, Oliva A, Frati P, Fineschi V. Pediatric Abusive Head Trauma: A Systematic Review. Diagnostics (Basel) 2021; 11:diagnostics11040734. [PMID: 33924220 PMCID: PMC8074611 DOI: 10.3390/diagnostics11040734] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Revised: 04/16/2021] [Accepted: 04/19/2021] [Indexed: 02/03/2023] Open
Abstract
Abusive head trauma (AHT) represents a commonly misdiagnosed condition. In fact, there is no pathognomonic sign that allows the diagnosis in children. Therefore, it is such an important medico-legal challenge to evaluate reliable diagnostic tools. The aim of this review is to evaluate the current scientific evidence to assess what the best practice is in order to diagnose AHT. We have focused particularly on evaluating the importance of circumstantial evidence, clinical history, the use of postmortem radiological examinations (such as CT and MRI), and the performance of the autopsy. After autopsy, histological examination of the eye and brain play an important role, with attention paid to correlation with symptoms found in vivo.
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Affiliation(s)
- Aniello Maiese
- Department of Surgical Pathology, Medical, Molecular and Critical Area, Institute of Legal Medicine, University of Pisa, 56126 Pisa, Italy; (A.M.); (F.I.); (A.S.)
- IRCSS Neuromed Mediterranean Neurological Institute, Via Atinense 18, 86077 Pozzilli, Italy;
| | - Francesca Iannaccone
- Department of Surgical Pathology, Medical, Molecular and Critical Area, Institute of Legal Medicine, University of Pisa, 56126 Pisa, Italy; (A.M.); (F.I.); (A.S.)
| | - Andrea Scatena
- Department of Surgical Pathology, Medical, Molecular and Critical Area, Institute of Legal Medicine, University of Pisa, 56126 Pisa, Italy; (A.M.); (F.I.); (A.S.)
| | - Zoe Del Fante
- Department of Anatomical, Histological, Forensic and Orthopaedic Sciences, Sapienza University of Rome, Viale Regina Elena 336, 00161 Rome, Italy;
| | - Antonio Oliva
- Department of Health Surveillance and Bioethics, Section of Legal Medicine, Catholic University, Fondazione Policlinico A. Gemelli IRCCS, 00100 Rome, Italy;
| | - Paola Frati
- IRCSS Neuromed Mediterranean Neurological Institute, Via Atinense 18, 86077 Pozzilli, Italy;
- Department of Anatomical, Histological, Forensic and Orthopaedic Sciences, Sapienza University of Rome, Viale Regina Elena 336, 00161 Rome, Italy;
| | - Vittorio Fineschi
- IRCSS Neuromed Mediterranean Neurological Institute, Via Atinense 18, 86077 Pozzilli, Italy;
- Department of Anatomical, Histological, Forensic and Orthopaedic Sciences, Sapienza University of Rome, Viale Regina Elena 336, 00161 Rome, Italy;
- Correspondence: ; Tel.: +39-064-991-2722
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16
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Bloemen EM, Rosen T, Lindberg DM, Krugman RD. How Experiences of Child Abuse Pediatricians and Lessons Learned May Inform Health Care Providers Focused on Improving Elder Abuse Geriatrics Clinical Practice and Research. JOURNAL OF FAMILY VIOLENCE 2021; 36:389-398. [PMID: 34121804 PMCID: PMC8189565 DOI: 10.1007/s10896-020-00143-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
The experience of physicians and other health care providers in child abuse pediatrics in the last six decades includes successes and failures, which can offer critical insights to inform the growing field of health care providers focusing on elder abuse clinical practice and research. We identify and describe in detail relevant lessons learned, including balancing an urgent call to action with a need for robust evidence to support clinical conclusions. We discuss solutions to research challenges, including the lack of a uniform gold standard for abuse diagnosis and how to ethically recruit subjects who may have cognitive impairment and also be crime victims. We offer recommendations on recruiting and training a specialized health care workforce. We make suggestions for health care providers about how to navigate the legal world including issues with expert testimony and also how to participate in policymaking and development of rational systems. We emphasize the importance of developing and supporting partnerships within the field, with allied fields inside and outside medicine, and internationally. We also highlight the value of connecting researchers and clinicians focused on different types of family violence.
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Affiliation(s)
- Elizabeth M. Bloemen
- University of Colorado School of Medicine, 13001 E 17th Pl, Aurora, CO 80045, New York, NY 10065, USA
| | - Tony Rosen
- Department of Emergency Medicine, Weill Cornell Medicine / NewYork-Presbyterian Hospital, 525 E. 68 St., Room M130, New York, NY 10065, USA
| | - Daniel M. Lindberg
- The Kempe Center for the Prevention & Treatment of Child Abuse & Neglect, University of Colorado School of Medicine, 12401 E. 17th Ave. Mailstop B-215, Aurora, CO 80045, USA
| | - Richard D. Krugman
- The Kempe Center for the Prevention & Treatment of Child Abuse & Neglect, University of Colorado School of Medicine, 12401 E. 17th Ave. Mailstop B-215, Aurora, CO 80045, USA
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17
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Serlin Y, Ben-Arie G, Lublinsky S, Flusser H, Friedman A, Shelef I. Distorted Optic Nerve Portends Neurological Complications in Infants With External Hydrocephalus. Front Neurol 2021; 12:596294. [PMID: 33597915 PMCID: PMC7882497 DOI: 10.3389/fneur.2021.596294] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Accepted: 01/08/2021] [Indexed: 11/13/2022] Open
Abstract
Background: Benign external hydrocephalus (BEH) is defined by rapid increase in head circumference in infancy, with neuroimaging evidence of enlarged cerebrospinal fluid (CSF) spaces. BEH was postulated to predispose to subdural hematoma, neurocognitive impairments, and autism. There is currently no consensus on BEH diagnostic criteria and no biomarkers to predict neurological sequalae. Methods: MRI-based quantitative approach was used for measurement of potential imaging markers related to external hydrocephalus and their association with neurological outcomes. We scanned 23 infants diagnosed with BEH and 11 age-similar controls. Using anatomical measurements from a large sample of healthy infants (n = 150), Z-scores were calculated to classify subject's CSF spaces as enlarged (≥1.96SD of mean values) or normal. Results: Subjects with abnormally enlarged CSF spaces had a significantly wider and longer ON (p = 0.017 and p = 0.020, respectively), and a significantly less tortuous ON (p = 0.006). ON deformity demonstrated a high diagnostic accuracy for abnormally enlarged frontal subarachnoid space (AUC = 0.826) and interhemispheric fissure (AUC = 0.833). No significant association found between enlarged CSF spaces and neurological complications (OR = 0.330, 95%CI 0.070-1.553, p = 0.161). However, cluster analysis identified a distinct subgroup of children (23/34, 67.6%) with enlarged CSF spaces and a wider, longer and less tortuous ON, to have an increased risk for neurological complications (RR = 7.28, 95%CI 1.07-49.40). Discussion: This is the first report on the association between external hydrocephalus, ON deformity and neurological complications. Our findings challenge the current view of external hydrocephalus as a benign condition. ON deformity is a potential auxiliary marker for risk stratification in patients with enlarged CSF spaces.
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Affiliation(s)
- Yonatan Serlin
- Neurology Residency Training Program, McGill University, Montreal, QC, Canada
| | - Gal Ben-Arie
- Department of Medical Imaging, Soroka Medical Center, Faculty of Health Sciences, Ben-Gurion University of the Negev, Be'er Sheva, Israel
| | - Svetlana Lublinsky
- Departments of Physiology and Cell Biology, Brain and Cognitive Sciences, Zlotowski Center for Neuroscience, Ben-Gurion University of the Negev, Be'er Sheva, Israel
| | - Hagit Flusser
- Zussman Child Development Center, Division of Pediatrics, Soroka Medical Center, Faculty of Health Sciences, Ben-Gurion University of the Negev, Be'er Sheva, Israel
| | - Alon Friedman
- Departments of Physiology and Cell Biology, Brain and Cognitive Sciences, Zlotowski Center for Neuroscience, Ben-Gurion University of the Negev, Be'er Sheva, Israel.,Department of Medical Neuroscience, Brain Repair Center, Faculty of Medicine, Dalhousie University, Halifax, NS, Canada
| | - Ilan Shelef
- Department of Medical Imaging, Soroka Medical Center, Faculty of Health Sciences, Ben-Gurion University of the Negev, Be'er Sheva, Israel
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18
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Raevis J, Elmalem VI. Pseudotumor cerebri syndrome causing a terson like syndrome. Am J Ophthalmol Case Rep 2020; 20:100993. [PMID: 33305067 PMCID: PMC7710506 DOI: 10.1016/j.ajoc.2020.100993] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2020] [Revised: 11/02/2020] [Accepted: 11/16/2020] [Indexed: 11/18/2022] Open
Abstract
Purpose Terson syndrome presents with retinal and vitreous hemorrhages in patients with a subarachnoid hemorrhage or after acutely elevated intracranial pressure. The source of this hemorrhage has been debated and may originate either from direct extension of intracranial hemorrhage or more likely from the peripapillary retinal vessels. Observations A 39-year-old woman presenting with nausea, vomiting, floaters and papilledema with normal neuroimaging was diagnosed ultimately with pseudotumor cerebri syndrome. She had a right vitreous hemorrhage and bilateral subretinal and intraretinal hemorrhages which were consistent with Terson like syndrome. Her symptoms resolved with acetazolamide over one month and the retinal and vitreous hemorrhages significantly improved over two months. Conclusions and importance This case with initial presentation of pseudotumor cerebri syndrome causing a Terson like syndrome may help elucidate the mechanism behind the etiology of these hemorrhages from leaking peripapillary vessels.
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Affiliation(s)
- Joseph Raevis
- State University of New York Downstate Medical Center, 450 Clarkson Ave, Brooklyn, NY, 11203, United States
- Corresponding author.
| | - Valerie I. Elmalem
- New York Eye and Ear Infirmary of Mount Sinai, 310 E 14th Street, New York, NY, 10003, United States
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19
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Influence of Optic Nerve Appearance on Visual Outcome in Pediatric Idiopathic Intracranial Hypertension. Can J Neurol Sci 2020; 47:661-665. [PMID: 32362301 DOI: 10.1017/cjn.2020.89] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVES To determine whether optic disc hemorrhages (ODH) and cotton wool spots (CWS) at presentation are associated with worse visual outcomes in pediatric patients with idiopathic intracranial hypertension (IIH). METHODS Retrospective institutional review of 100 eyes of 50 consecutive pediatric IIH patients (aged 16 years or less) who had baseline optic disc photographs before or within 30 days of their diagnostic lumbar puncture and initiation of medical treatment. Optic disc photographs were independently graded by three ophthalmologists in a standardized manner. Visual function was assessed using visual acuity (VA) and visual field grade (VFG). RESULTS At least one ODH was found in 41% of eyes, at least one CWS was found in 27% of eyes, and 20% of eyes had both ODH and CWS. At presentation, Frisén grade was associated with the presence of CWS (p = 0.013) and showed no association with ODH (p = 0.060). When controlling for Frisén grade, ODH and CWS were not associated with worse VA or VFG at final follow-up. Severe ODH were associated with worse VA and VFG at presentation (p < 0.03), but not at final follow-up. Severe CWS at presentation was strongly associated with a worse Humphrey mean deviation of 5.0 dB (95% confidence interval 1.6-8.3) at final follow-up (p = 0.002). CONCLUSION When controlling for the severity of papilledema, ODH do not provide any additional prognostic value in pediatric IIH patients. Frisén grade and severe CWS at presentation were independently associated with worse visual outcomes at the final follow-up.
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20
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Wester K. Two Infant Boys Misdiagnosed as "Shaken Baby" and Their Twin Sisters: A Cautionary Tale. Pediatr Neurol 2019; 97:3-11. [PMID: 31147228 DOI: 10.1016/j.pediatrneurol.2019.02.024] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2018] [Revised: 02/06/2019] [Accepted: 02/27/2019] [Indexed: 12/13/2022]
Affiliation(s)
- Knut Wester
- Department of Clinical Medicine K1, University of Bergen, Bergen, Norway; Department of Neurosurgery, Haukeland University Hospital, Bergen, Norway.
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21
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Kelly P, Vincent A, Nolan M, Bastin S. Retinal haemorrhage in a child with optic neuritis and acute disseminated encephalomyelitis. BMJ Case Rep 2019; 12:12/5/e227211. [PMID: 31061175 DOI: 10.1136/bcr-2018-227211] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
A 2-year-old presented with lethargy, acute visual loss, fixed dilated pupils and severe bilateral retinal haemorrhages. The retinal findings raised concerns about abusive head trauma, but subsequent investigations confirmed the diagnosis of bilateral optic neuritis associated with acute disseminated encephalomyelitis.
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Affiliation(s)
- Patrick Kelly
- Te Puaruruhau (Child Protection Team), Starship Children's Health, Auckland, New Zealand.,Department of Paediatrics: Child and Youth Health; Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Andrea Vincent
- Department of Paediatrics: Child and Youth Health; Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand.,Department of Ophthalmology, Auckland City Hospital, Auckland, New Zealand
| | - Melinda Nolan
- Department of Paediatric Neurology, Starship Children's Health, Auckland, New Zealand
| | - Sonja Bastin
- Department of Paediatric Radiology, Starship Children's Health, Auckland, New Zealand
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22
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Shi A, Kulkarni A, Feldman KW, Weiss A, McCourt EA, Schloff S, Partington M, Forbes B, Geddie BE, Bierbrauer K, Phillips PH, Rogers DL, Abed Alnabi W, Binenbaum G, Levin AV. Retinal Findings in Young Children With Increased Intracranial Pressure From Nontraumatic Causes. Pediatrics 2019; 143:peds.2018-1182. [PMID: 30630868 PMCID: PMC6361344 DOI: 10.1542/peds.2018-1182] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/14/2018] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES Increased intracranial pressure (ICP) has been suggested in legal settings as an alternative cause of retinal hemorrhages (RHs) in young children who may have sustained abusive head trauma. We assessed the prevalence and characteristics of RHs in children with increased ICP. METHODS We conducted a prospective, multicenter study of children <4 years old with newly diagnosed increased ICP as determined by using direct measurement and/or clinical criteria. Infants who were premature, neonates, and suspected survivors of abusive head trauma were excluded on the basis of nonocular findings. Fundus examinations were performed; extent, number, and type of RH in each of 4 distinct retinal zones were recorded. RESULTS Fifty-six children (27 boys) were studied (mean age 15.4 months; range 1-43 months). All of the children had elevated ICP that required intervention. One child had papilledema. No child (0%; 95% confidence interval: 0%-6.4%) or eye (0%; 95% confidence interval: 0%-3.3%) was found to have an RH. Causes of increased ICP included hydrocephalus, intraventricular hemorrhage, congenital malformations, malfunctioning shunts, and the presence of intracranial space-occupying lesions. CONCLUSIONS Although acute increased ICP can present in children with a pattern of peripapillary superficial RHs in the presence of papilledema, our study supports the conclusion that RHs rarely occur in the absence of optic disc swelling and do not present beyond the peripapillary area in the entities we have studied.
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Affiliation(s)
- Angell Shi
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Abhaya Kulkarni
- Division of Neurosurgery, The Hospital for Sick Children, Toronto, Ontario, Canada
| | | | - Avery Weiss
- Ophthalmology, Seattle Children’s Hospital and School of Medicine, University of Washington, Seattle, Washington
| | - Emily A. McCourt
- Department of Ophthalmology, Children’s Hospital Colorado and School of Medicine, University of Colorado, Aurora, Colorado
| | - Susan Schloff
- Associated Eye Care, St Paul, Minnesota;,Department of Ophthalmology and Visual Neurosciences, Children’s Minnesota St Paul Hospital, St Paul, Minnesota
| | - Michael Partington
- Department of Neurosurgery, Gillette Children’s Specialty Healthcare, St Paul, Minnesota
| | - Brian Forbes
- Division of Ophthalmology, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Brooke E. Geddie
- Division of Pediatric Ophthalmology, Helen DeVos Children’s Hospital, Grand Rapids, Michigan
| | - Karin Bierbrauer
- Division of Pediatric Neurosurgery, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Paul H. Phillips
- Harvey and Bernice Jones Eye Institute, University of Arkansas for Medical Sciences, Little Rock, Arkansas;,Department of Ophthalmology, Arkansas Children’s Hospital, Little Rock, Arkansas
| | - David L. Rogers
- Department of Ophthalmology, Nationwide Children’s Hospital, Columbus, Ohio
| | - Waleed Abed Alnabi
- Department of Pediatric Ophthalmology and Ocular Genetics, Wills Eye Hospital, Philadelphia, Pennsylvania; and,Médecins Sans Frontieres, Amman, Jordan
| | - Gil Binenbaum
- Division of Ophthalmology, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Alex V. Levin
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania;,Department of Pediatric Ophthalmology and Ocular Genetics, Wills Eye Hospital, Philadelphia, Pennsylvania; and
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23
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Abstract
Abusive head trauma is an important cause of morbidity and mortality in infants and young children. Retinal hemorrhages (RHs) are frequently seen, particularly during dilated eye examination of these children. This review focuses on the evaluation of children with RH, with emphasis on the differential diagnosis, pathophysiology, and distinguishing features of RHs due to abusive head trauma. Many causes exist for RHs in infants and children. Most medical and accidental traumatic causes result in a pattern of RH that is nonspecific and not typical of the pattern and distribution of RHs seen in children with abusive head trauma. In children with intracranial hemorrhage and concerns for abuse, the finding of severe, multilayered RHs extending to the periphery of the retina is very specific for abuse as the cause of the findings, especially if retinoschisis is present. There are few other accidental traumatic mechanisms associated with retinoschisis, and the history of such a traumatic event is readily apparent. The indications for ophthalmologic consult, optimal timing of the eye examination, and significance of the findings are specifically discussed.
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24
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Christian CW, Levin AV, Flaherty EG, Sirotnak AP, Budzak AE, Gavril AR, Haney SB, Idzerda SM, Laskey A, Legano LA, Messner SA, Moles RL, Palusci VJ, Karr DJ, Bradford GE, Nischal K, Roarty JD, Rubin SE, Suh DW. The Eye Examination in the Evaluation of Child Abuse. Pediatrics 2018; 142:peds.2018-1411. [PMID: 30037976 DOI: 10.1542/peds.2018-1411] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Child abuse can cause injury to any part of the eye. The most common manifestations are retinal hemorrhages (RHs) in infants and young children with abusive head trauma (AHT). Although RHs are an important indicator of possible AHT, they are also found in other conditions. Distinguishing the number, type, location, and pattern of RHs is important in evaluating a differential diagnosis. Eye trauma can be seen in cases of physical abuse or AHT and may prompt referral for ophthalmologic assessment. Physicians have a responsibility to consider abuse in the differential diagnosis of pediatric eye trauma. Identification and documentation of inflicted ocular trauma requires a thorough examination by an ophthalmologist, including indirect ophthalmoscopy, most optimally through a dilated pupil, especially for the evaluation of possible RHs. An eye examination is helpful in detecting abnormalities that can help identify a medical or traumatic etiology for previously well young children who experience unexpected and unexplained mental status changes with no obvious cause, children with head trauma that results in significant intracranial hemorrhage and brain injury, and children with unexplained death.
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Affiliation(s)
- Cindy W. Christian
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania and Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania; and
| | - Alex V. Levin
- Departments of Pediatric Ophthalmology and Ocular Genetics, Wills Eye Hospital and Departments of Ophthalmology and Pediatrics, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania
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25
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Minns RA, Jones PA, Tandon A, Fleck BW, Mulvihill AO, Minns FC. Raised intracranial pressure and retinal haemorrhages in childhood encephalopathies. Dev Med Child Neurol 2017; 59:597-604. [PMID: 28369828 DOI: 10.1111/dmcn.13419] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/25/2017] [Indexed: 11/28/2022]
Abstract
AIM To explore the relationship between raised intracranial pressure (RICP) and retinal haemorrhages in traumatic and non-traumatic childhood encephalopathies. METHOD A prospective study of 112 children (35 females and 77 males, age range 0.01mo-17y 8.3mo; mean 5y 8.6mo, median 4y 5.6mo) included 57 accidental traumatic brain injuries (ATBIs), 21 inflicted traumatic brain injuries (ITBIs), and 34 non-traumatic encephalopathy cases. Measurements included intracranial pressure (ICP), cerebral perfusion pressure, pressure-time index of ICP, and number, zone, and layer of retinal haemorrhages on retinal imaging. RESULTS Group I had measured elevated ICP (n=42), Group II had clinical and/or radiological signs of RICP (n=21), and Group III had normal ICP (n=49). In the combined Groups I and II, 38% had retinal haemorrhages. Multiple logistic regression confirmed that the presence of retinal haemorrhages was significantly related to the presence of RICP independent of age and aetiology; however, the occurrence and overall numbers were not significantly related to the specific ICP level. The numbers of intraretinal (nerve-fibre layer and dot blot) retinal haemorrhages were significantly greater in those with RICP. The ITBI population was significantly different from the other combined aetiological categories. INTERPRETATION The study results indicate a complex RICP/retinal haemorrhage relationship. There was no evidence of existing retinal haemorrhages being exacerbated or new retinal haemorrhages developing during periods of confirmed RICP.
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Affiliation(s)
- Robert A Minns
- Department Child Life and Health, College of Medicine and Veterinary Medicine, University of Edinburgh, Edinburgh, UK
| | - Patricia A Jones
- Department Child Life and Health, College of Medicine and Veterinary Medicine, University of Edinburgh, Edinburgh, UK
| | | | - Brian W Fleck
- Princess Alexandra Eye Pavilion, Edinburgh, UK.,Royal Hospital for Sick Children, Edinburgh, UK
| | - Alan O Mulvihill
- Princess Alexandra Eye Pavilion, Edinburgh, UK.,Royal Hospital for Sick Children, Edinburgh, UK
| | - Fiona C Minns
- Department of Radiology, New Royal Infirmary, Edinburgh, UK
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26
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Razeghinejad MR, Nowroozzadeh MH. Optic disk hemorrhage in health and disease. Surv Ophthalmol 2017; 62:784-802. [PMID: 28400276 DOI: 10.1016/j.survophthal.2017.04.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2016] [Revised: 03/31/2017] [Accepted: 04/03/2017] [Indexed: 12/19/2022]
Abstract
Optic disk hemorrhage occurs in all age groups from neonates to the elderly. Optic disk hemorrhage is best known for its association with visual field loss and progression in patients with glaucoma; however, it may occur in conjunction with other ocular or systemic conditions as well as in healthy individuals. It may also be the first sign of a sight-threatening condition. Variations in the shape, location, and size of the optic disk hemorrhage, as well as associated ocular and systemic signs or symptoms, may help determine the underlying pathology. We address the epidemiology, demographics, pathophysiology, clinical presentations and implications, differential diagnoses, and management of eyes with optic disk hemorrhage in diseased and healthy subjects.
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Affiliation(s)
- M Reza Razeghinejad
- Glaucoma Service, Wills Eye Institute, Philadelphia, PA, USA; Poostchi Eye Research Center, Shiraz University of Medical Sciences, Shiraz, Iran.
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Binenbaum G, Reid JE, Rogers DL, Jensen AK, Billinghurst LL, Forbes BJ. Patterns of retinal hemorrhage associated with pediatric cerebral sinovenous thrombosis. J AAPOS 2017; 21:23-27. [PMID: 28087346 DOI: 10.1016/j.jaapos.2016.10.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2016] [Revised: 10/01/2016] [Accepted: 10/06/2016] [Indexed: 01/06/2023]
Abstract
BACKGROUND Cerebral sinovenous thrombosis (CSVT) has been proposed as an alternative cause of retinal hemorrhage (RH) in children being evaluated for abusive head trauma. This study investigated the prevalence and characteristics of RH in children with CSVT. METHODS The medical records of children >6 weeks of age with newly diagnosed CSVT and fundus examination by an ophthalmologist were examined retrospectively. Primary outcomes were presence and patterns of RH. RESULTS A total of 29 children (median age, 9 years; range, 7 weeks to 17 years) were studied. Of these, 5 (17%) had RH, in 4 of whom RH were peripapillary, superficial, intraretinal, and adjacent to a swollen optic disk. In the fifth child, who had meningitis, sepsis, and multiple cerebral infarcts, there were a moderate number of posterior pole intraretinal hemorrhages. Eighteen children (62%) had optic disk swelling. In 13 children, cerebrospinal fluid opening pressure was recorded (range, 27-59 cm H2O). CSVT risk factors included meningitis, mastoiditis, and hypercoagulability. CONCLUSIONS RH in pediatric CSVT was uncommon. When RHs were present, the appearance matched RH patterns known to be caused by medical conditions, such as raised intracranial pressure and sepsis, also present in these children. These findings suggest that the RHs are due to these other causes and not directly to CSVT itself. In children with CSVT, if RHs are multilayered, extend beyond the peripapillary region into the rest of the posterior pole or retinal periphery, or occur in the absence of optic disk swelling, another etiology for the RH should be sought.
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Affiliation(s)
- Gil Binenbaum
- Division of Ophthalmology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.
| | - Julia E Reid
- Division of Ophthalmology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - David L Rogers
- Department of Ophthalmology, Nationwide Children's Hospital, Columbus, Ohio
| | - Anne K Jensen
- Division of Ophthalmology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Lori L Billinghurst
- Division of Neurology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Brian J Forbes
- Division of Ophthalmology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
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Wall M, Thurtell MJ. Optic disc haemorrhages at baseline as a risk factor for poor outcome in the Idiopathic Intracranial Hypertension Treatment Trial. Br J Ophthalmol 2017; 101:1256-1260. [PMID: 28130349 DOI: 10.1136/bjophthalmol-2016-309852] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2016] [Revised: 01/03/2017] [Accepted: 01/07/2017] [Indexed: 11/03/2022]
Abstract
BACKGROUND The risk of optic disc haemorrhages on visual outcome in idiopathic intracranial hypertension (IIH) is unknown. We report the type and frequency of optic disc haemorrhages and other funduscopic abnormalities at baseline in the study eye of the 133 subjects enrolled in the Idiopathic Intracranial Hypertension Treatment Trial completing 6 months of follow-up. METHODS We reviewed optic disc photographs to tabulate the frequency and type of optic disc haemorrhages, other funduscopic abnormalities and papilloedema grades of the study eye at baseline and analyse if their presence is associated with a poor visual outcome. RESULTS 27.2% of subjects had nerve fibre layer haemorrhages in at least one eye. Five of seven, 71% of subjects that met criteria for treatment failure, had nerve fibre layer haemorrhages in at least one eye (Fisher's exact test: p=0.02). There was a good correlation between presence of nerve fibre layer haemorrhages and Frisén grade (Spearman's correlation, p=0.002; r=0.271). Subjects with nerve fibre layer haemorrhages had a higher cerebrospinal fluid pressure (40.0 mm water, p=0.04). There was poor correlation between nerve fibre layer haemorrhages at baseline and the perimetric mean deviation change at 6 months. Cotton wool spots were present in 4% of subjects, exudates in 3% and pseudodrusen in 4%. CONCLUSIONS Nerve fibre layer haemorrhages are common in patients with IIH with mild visual loss and correlate with the severity of the papilloedema. They occur more frequently in treatment failure subjects and therefore may be associated with poor visual outcomes. TRIAL REGISTRATION NUMBER NCT01003639, Post-results.
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Affiliation(s)
- Michael Wall
- Departments of Neurology and Ophthalmology, University of Iowa College of Medicine, Iowa City, Iowa, USA
| | - Matthew J Thurtell
- Department of Ophthalmology, University of Iowa College of Medicine, Iowa City, Iowa, USA
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Edwards GA. Response to Edwards GA. Mimics of child abuse: Can choking explain abusive head trauma? J Forensic Leg Med 2016; 39:135-7. [DOI: 10.1016/j.jflm.2016.01.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Callaway NF, Ludwig CA, Blumenkranz MS, Jones JM, Fredrick DR, Moshfeghi DM. Retinal and Optic Nerve Hemorrhages in the Newborn Infant: One-Year Results of the Newborn Eye Screen Test Study. Ophthalmology 2016; 123:1043-52. [PMID: 26875004 DOI: 10.1016/j.ophtha.2016.01.004] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2015] [Revised: 01/01/2016] [Accepted: 01/05/2016] [Indexed: 12/31/2022] Open
Abstract
PURPOSE To report the birth prevalence, risk factors, characteristics, and location of fundus hemorrhages (FHs) of the retina and optic nerve present in newborns at birth. DESIGN Prospective cohort study at Stanford University School of Medicine. PARTICIPANTS All infants who were 37 weeks postmenstrual age or older and stable were eligible for screening. Infants with known or suspected infectious conjunctivitis were excluded. METHODS Infants born at Lucile Packard Children's Hospital (LPCH) from July 25, 2013, through July 25, 2014, were offered universal newborn screening via wide-angle digital retinal photography in the Newborn Eye Screen Test study. Maternal, obstetric, and neonatal factors were obtained from hospital records. The location, retinal layer, and laterality of FH were recorded by 1 pediatric vitreoretinal specialist. MAIN OUTCOME MEASURES Birth prevalence of FH. Secondary outcomes included rate of adverse events, risk factors for FH, hemorrhage characteristics, and adverse events. RESULTS The birth prevalence of FH in this study was 20.3% (41/202 infants). Ninety-five percent of FHs involved the periphery, 83% involved the macula, and 71% involved multiple layers of the retina. The fovea was involved in 15% of FH cases (birth prevalence, 3.0%). No cases of bilateral foveal hemorrhage were found. Fundus hemorrhages were more common in the left eye than the right. Fundus hemorrhages were most commonly optic nerve flame hemorrhages (48%) and white-centered retinal hemorrhages (30%). Retinal hemorrhages were found most frequently in all 4 quadrants (35%) and more often were multiple than solitary. Macular hemorrhages most often were intraretinal (40%). Among the risk factors examined in this study, vaginal delivery compared with cesarean section (odds ratio [OR], 9.34; 95% confidence interval [CI], 2.57-33.97) showed the greatest level of association with FH. Self-identified ethnicity as Hispanic or Latino showed a protective effect (OR, 0.43; 95% CI, 0.20-0.94). Other study factors were not significant. CONCLUSIONS Fundus hemorrhages are common among newborns. They often involve multiple areas and layers of the retina. Vaginal delivery was associated with a significantly increased risk of FH, whereas self-identified Hispanic or Latino ethnicity was protective against FH in this study. The long-term consequences of FH on visual development remain unknown.
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Affiliation(s)
- Natalia F Callaway
- Department of Ophthalmology, Byers Eye Institute, Stanford University School of Medicine, Palo Alto, California
| | - Cassie A Ludwig
- Department of Ophthalmology, Byers Eye Institute, Stanford University School of Medicine, Palo Alto, California
| | - Mark S Blumenkranz
- Department of Ophthalmology, Byers Eye Institute, Stanford University School of Medicine, Palo Alto, California
| | - Jennifer Michelle Jones
- Department of Ophthalmology, Byers Eye Institute, Stanford University School of Medicine, Palo Alto, California
| | - Douglas R Fredrick
- Department of Ophthalmology, Byers Eye Institute, Stanford University School of Medicine, Palo Alto, California
| | - Darius M Moshfeghi
- Department of Ophthalmology, Byers Eye Institute, Stanford University School of Medicine, Palo Alto, California.
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Abstract
OBJECTIVE The purpose of this article is to review the constellation of findings of abusive head trauma, which may be accompanied by injuries to the appendicular and axial skeleton, brain and spinal cord, and retina. Additional common features include skin and soft-tissue injury, visceral findings, and evidence of oral trauma. CONCLUSION The evidence base for abusive head trauma encompasses diverse disciplines, including diagnostic imaging, pathology, pediatrics, biomechanics, ophthalmology, epidemiology, and orthopedics. When the varied sources of evidence are pieced together and taken in toto, abusive head trauma is often readily differentiated from alternative explanations of an infant's injuries.
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Abstract
PURPOSES OF REVIEW This article provides an update on abusive head trauma (AHT), focusing on new developments most salient to the emergency medicine clinician, including epidemiology, clinical recognition, diagnostic work-up, management of neurologic injury, and public health implications. RECENT FINDINGS The recent literature has focused on honing the clinician's ability to recognize AHT and its immediate sequelae, to more accurately distinguish between abusive and accidental head injuries by patterns of neuroimaging and retinal hemorrhages, and to appreciate the long-term impacts. Specifically, both a clinical prediction rule and biomarker show promise, and new research advocates for the early identification of subclinical seizures as well as cervical spine injuries. SUMMARY The emergency medicine provider must be able to recognize and manage children who may have AHT and to appreciate when the diagnostic findings warrant consultation with a child protection team. These authors summarize the recent and notable advances in our understanding of AHT.
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The eye in child abuse: key points on retinal hemorrhages and abusive head trauma. Pediatr Radiol 2014; 44 Suppl 4:S571-7. [PMID: 25501729 DOI: 10.1007/s00247-014-3107-9] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2014] [Accepted: 06/18/2014] [Indexed: 10/24/2022]
Abstract
This review presents an up-to-date overview of ocular injuries resulting from child abuse, with a spotlight on abusive head trauma. Retinal hemorrhage is a principle finding of inflicted head trauma. The specific pattern of hemorrhages holds valuable diagnostic information, which can help to guide multidisciplinary assessments of the likelihood of abuse. Indirect ophthalmoscopy through dilated pupils by an ophthalmologist is necessary for adequate examination and documentation of retinal findings. Initial pediatrician evaluation of the eye and indications for ophthalmological consultation are reviewed. Focus is then placed upon understanding retinal hemorrhage patterns, their diagnostic significance and likely pathophysiological mechanisms. The differential diagnosis of retinal hemorrhage in young children is discussed, highlighting key distinctions among retinal hemorrhage patterns, severity and frequencies, as well as other ocular findings. The most common cause of retinal hemorrhage in an infant is trauma, and most other causes can be identified by considering the hemorrhage pattern, ocular or systemic signs and the results of laboratory and imaging tests, when indicated.
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Hwang JF, Lin CJ. Multilayered optic disc hemorrhages in adolescents. J Pediatr Ophthalmol Strabismus 2014; 51:313-8. [PMID: 25036104 DOI: 10.3928/01913913-20140715-01] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2014] [Accepted: 05/27/2014] [Indexed: 11/20/2022]
Abstract
PURPOSE To describe the clinical characteristics of multilayered optic disc hemorrhages, which are defined as subretinal, superficial retinal, and subhyaloid or vitreous hemorrhages in adolescents. METHODS Case records of adolescents with acute multilayered optic disc hemorrhages were identified and evaluated retrospectively from 1994 to 2012. The appearance of the hemorrhages including the size, location, extension, and disc anatomy was recorded. Fluorescein angiography, visual field examination, and spectral-domain optical coherence tomography were performed in select cases. RESULTS Nine boys and 7 girls were included, with a mean age of 15.0 ± 2.6 years. No precipitating factor, such as involuntary Valsalva maneuver, was identified in the majority of patients (93.75%). All eyes were myopic with an average refraction of -4.64 ± 1.88 diopters. Fifteen (93.75%) of the affected optic discs were crowded and tilted with small cups. Peripapillary subretinal hemorrhages were all crescent in shape and located at the nasal disc. Eight (50%) eyes had marked subretinal blood extension exceeding 1 disc diameter away from the disc edge. Superficial flame hemorrhages were predominantly located in the superotemporal part of the disc. Spectral-domain optical coherence tomography of the disc showed vitreopapillary traction and obvious subretinal hemorrhage with increased thickness. All multilayered optic disc hemorrhages resolved spontaneously. CONCLUSIONS Multilayered optic disc hemorrhages in adolescents more commonly affect myopic eyes with crowded and tilted discs. The visual outcome is excellent.
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Abstract
PURPOSES OF REVIEW This review summarizes new findings in the field of maltreatment, addressing epidemiology, physical abuse, abusive head trauma, sexual abuse, sequelae, and prevention. RECENT FINDINGS Many articles this year focus on establishing a framework for thinking about how to evaluate a child for maltreatment, the consequences of maltreatment, and the current understanding of prevention efforts. Interestingly, some research has helped to reinforce some concepts that were clinically appreciated, especially related to retinal hemorrhages. SUMMARY The volume, quality, and breadth of research relating to child maltreatment continue to improve and expand our understanding of child abuse pediatrics. These authors summarize notable advances in our understanding of child maltreatment over the past year.
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Bansal L, Niccoli L, Bailey A, Zuccoli G. Imaging the Eye in Idiopathic Intracranial Hypertension. Headache 2014; 54:1046-7. [DOI: 10.1111/head.12380] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Lalit Bansal
- Division of Child Neurology; Children's Hospital of Pittsburgh; University of Pittsburgh Medical Center; Pittsburgh PA USA
| | - Laura Niccoli
- Division of Radiology; University of Bari; Bari Italy
| | - Ariel Bailey
- Department of Pediatric Radiology; Children's Hospital of Pittsburgh; University of Pittsburgh Medical Center; Pittsburgh PA USA
| | - Giulio Zuccoli
- Department of Pediatric Radiology; Children's Hospital of Pittsburgh; University of Pittsburgh Medical Center; Pittsburgh PA USA
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Holmgren BK. Ethical Issues in Forensic Testimony Involving Abusive Head Trauma. Acad Forensic Pathol 2013. [DOI: 10.23907/2013.042] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Medical examiners provide critical diagnostic and testimonial information in abusive head trauma cases. Courtroom challenges to these diagnostic criteria and contested expert testimony have raised concerns about ethical and professional conduct of practitioners. Legal evidentiary standards for expert testimony, ethical guidelines established by medical organizations, and proposed standards for ethical practice provide a background for examination of several common challenges and testimonial claims in these cases.
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