title: Dedicated retinal examination in children evaluated for physical abuse without radiographically identified traumatic brain injury.
abstract: OBJECTIVE
  To determine the rate of retinal hemorrhages in children evaluated for physical abuse without traumatic brain injury (TBI) by diagnostic imaging.
  
  
  METHODS
  This study was a prospectively planned, secondary analysis of the Examining Siblings to Recognize Abuse (ExSTRA) research network, and included only index children who presented with concerns for abuse. Subjects were eligible for the parent study if they were less than 10 years old and evaluated by a Child Abuse Physician for concerns of physical abuse. Child Abuse Physicians recorded results of all screening testing and determination of the likelihood of abuse in each case. For this analysis, we examined the results of dedicated retinal examinations for children with neuroimaging that showed no TBI. Isolated skull fractures were not considered to be TBI.
  
  
  RESULTS
  The original ExSTRA sample included 2890 index children evaluated for physical abuse. Of this group, 1692 underwent neuroimaging and 1122 had no TBI. Of these 1122 children, 352 had a dedicated retinal examination. Retinal hemorrhages were identified in 2 (0.6%) children. In both cases, there were few (defined as 3-10) hemorrhages isolated to the posterior poles; neither was diagnosed with physical abuse. The presence of facial bruising, altered mental status, or complex skull fractures was neither sensitive nor specific for retinal hemorrhage identification.
  
  
  CONCLUSIONS
  Forensically significant retinal hemorrhages are unlikely to be found in children evaluated for physical abuse without TBI on neuroimaging, and such children may not require routine dedicated retinal examination.
authors.affiliation: Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229, USA. mary.greiner@cchmc.org
authors.forename: Mary V
authors.initials: MV
authors.lastname: Greiner
authors.forename: Rachel P
authors.initials: RP
authors.lastname: Berger
authors.forename: Jonathan D
authors.initials: JD
authors.lastname: Thackeray
authors.forename: Daniel M
authors.initials: DM
authors.lastname: Lindberg
mesh_terms: D001930:Brain Injuries / Q000000981:diagnostic imaging; D002648:Child; D002649:Child Abuse / Q000175:diagnosis*; D002675:Child, Preschool; D003941:Diagnostic Techniques, Ophthalmological; D005260:Female; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D008297:Male; D011446:Prospective Studies; D011859:Radiography; D012166:Retinal Hemorrhage / Q000175:diagnosis* / Q000209:etiology*
keywords: AHT; Abusive head trauma; CAP; CT; Child Abuse Physician; Computed tomography; ExSTRA; Examining Siblings to Recognize Abuse research network; TBI; Traumatic brain injury