Elsevier

Ophthalmology

Volume 117, Issue 5, May 2010, Pages 983-992.e17
Ophthalmology

Original article
A Systematic Review of the Diagnostic Accuracy of Ocular Signs in Pediatric Abusive Head Trauma

https://doi.org/10.1016/j.ophtha.2009.09.040Get rights and content

Topic

To review systematically the diagnostic accuracy of various ocular signs for pediatric abusive head trauma (AHT).

Clinical Relevance

Intraocular hemorrhages (IOH), perimacular retinal folds, traumatic retinoschisis and optic nerve sheath hemorrhages have been reported as cardinal signs of AHT. The evidence base supporting the accuracy of this interpretation, however, has not been systematically reviewed.

Methods

A systematic keyword search of MEDLINE, EMBASE, and Evidence-Based Medicine Reviews was conducted for original studies reporting ocular findings in AHT. Articles were graded using a checklist for systematic reviews of diagnostic accuracy.

Results

The initial search yielded 971 articles, of which 55 relevant studies were graded, and 20 studies met inclusion criteria and were included in the review. The overall sensitivity of IOH for AHT was 75% and their specificity was 94%. Intraretinal hemorrhage at the posterior pole was the most common finding, although extensive, bilateral, and multilayered IOH were the most specific for AHT. Optic nerve sheath hemorrhages had a sensitivity and specificity for AHT of 72% and 71%, respectively. Traumatic retinoschisis and perimacular retinal folds were reported in 8% and 14% of AHT, respectively, but were not reported in other conditions.

Conclusions

Prospective, consecutive studies confirm that IOH in infants—particularly bilateral, extensive, and multilayered—are highly specific for AHT. Optic nerve sheath hemorrhages are significantly more common in AHT than in other conditions, in autopsy studies. Traumatic retinoschisis and perimacular folds are present in a minority of AHT, but rarely seen in other conditions.

Financial Disclosure(s)

Proprietary or commercial disclosure may be found after the references.

Section snippets

Types of Studies

Studies were included that allowed conclusions to be made regarding sensitivity or specificity of ocular findings for AHT. Sensitivity can be calculated from the frequency of ocular findings in a consecutive series of patients with AHT. Specificity can be calculated from the frequency of ocular findings in consecutively recruited control groups. Thus, the types of studies eligible for inclusion were case-control studies, cohort studies, or consecutive case series.

Population

Eligible studies included

Results

The varied search terms for AHT combined with retinal hemorrhage, retinal folds, retinoschisis and optic nerve sheath hemorrhage returned a total of 971 unique articles. A total of 79 relevant articles from all search sets were reviewed in full. A further 9 articles were added from reference lists of relevant articles, making a total of 88 articles. Of these, 33 articles were excluded for various reasons (Fig 1), leaving 55 studies.

Grading was performed on all 55 eligible studies. Because we

Discussion

Since the first case report2 of retinal trauma in an abused infant, level III retrospective studies14, 17 have confirmed that a significant proportion of infants with AHT have IOH. These studies have several potential drawbacks, including incomplete data and interobserver bias. The largest retrospective series14 found that fatal cases had more severe and diffuse retinal findings extending to the periphery, whereas nonfatal cases had fewer IOH that were confined to the posterior pole.

Numerous

Clinical Recommendations

The significance of ocular findings in AHT has been the subject of great controversy. Previously identified8 weaknesses in the evidence base were the lack of prospective, controlled studies, frequency of circular logic, and inconsistency in definition of cases. Currently, there is level II evidence from prospective controlled studies, supporting a significant relationship between IOH and AHT. Accurate classification of trauma as being from abuse remains difficult, because the trauma is

References (40)

  • Y.M. Buys et al.

    Retinal findings after head trauma in infants and young children

    Ophthalmology

    (1992)
  • G. Binenbaum et al.

    Odds of abuse associated with retinal hemorrhages in children suspected of child abuse

    J AAPOS

    (2009)
  • N. Rao et al.

    Autopsy findings in the eyes of fourteen fatally abused children

    Forensic Sci Int

    (1988)
  • D.L. Budenz et al.

    Ocular and optic nerve hemorrhages in abused infants with intracranial injuries

    Ophthalmology

    (1994)
  • M. Mills

    Funduscopic lesions associated with mortality in shaken baby syndrome

    J AAPOS

    (1998)
  • R.S. Riffenburgh et al.

    Ocular findings at autopsy of child abuse victims

    Ophthalmology

    (1991)
  • M.A. Keithahn et al.

    Retinal folds in Terson syndrome

    Ophthalmology

    (1993)
  • A. Ganesh et al.

    Retinal hemorrhages in type I osteogenesis imperfecta after minor trauma

    Ophthalmology

    (2004)
  • H.T. Keenan et al.

    A population-based study of inflicted traumatic brain injury in young children

    JAMA

    (2003)
  • G.T. Kiffney

    The eye of the “battered child”

    Arch Ophthalmol

    (1964)
  • Cited by (0)

    Manuscript no. 2009-103.

    Financial Disclosure(s): The authors have made the following disclosures:

    A/Prof Frank J. Martin – Alcon Advisory Board

    This was not related to the preparation of this manuscript, and there was no conflict of interest.

    Minas T. Coroneo, Gaurav Bhardwaj, Vivek Chowdhury and Mark B. Jacobs received research funding from the Sydney Children's Hospital Foundation, Randwick, NSW. No funds however were directly utilized in producing this article. The sponsor or funding organization had no role in the design or conduct of this research.

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