title: Grading system for retinal hemorrhages in abusive head trauma: clinical description and reliability study.
abstract: OBJECTIVE
  There is currently no universally accepted grading system for describing retinal hemorrhages (RH) in abusive head trauma (AHT). The purpose of this study was to devise and evaluate a novel grading system and descriptive nomenclature for RH in AHT for clinical and research purposes.
  
  
  METHODS
  A traumatic hemorrhagic retinopathy (THR) grading system was developed for assessing and quantitatively analyzing retinal findings in abusive head trauma. The criteria for the THR grade included the extent, spread, and morphology of RH. Extent was classified as region 1 (posterior pole) or region 2 (peripheral). Spread, based on number of retinal hemorrhages, was classified as mild (10 or fewer RH), moderate (more than 10 RH) and severe (more than half of involved regions covered by RH). Morphology was classified by its intraretinal or extraretinal involvement. Two independent graders calculated the THR grade from RetCam images of 38 eyes of 19 patients <3 years of age with retinal hemorrhages associated with head injury. Grading was performed on two separate occasions. Intra- and interobserver reliability was assessed with Spearman correlation coefficient (r) and intraclass correlation coefficient (ICC).
  
  
  RESULTS
  There was a high level of intraobserver agreement across both assessments (97% agreement [Spearman r = 0.997; P < 0.0001] and 100% agreement [Spearman r = 1.0; P < 0.0000]). Intraclass correlation (ICC, 0.995; 95% CI, 0.991-0.997; P < 0.0001) confirmed a very high level of agreement overall.
  
  
  CONCLUSIONS
  The traumatic hemorrhagic retinopathy grading system demonstrated excellent intraobserver and interobserver reliability. The nomenclature is easily understood and may be useful in medical records and medicolegal reports.
authors.affiliation: Faculty of Medicine, University of New South Wales (UNSW), Sydney, NSW, Australia. Electronic address: gauravb23@gmail.com.
authors.forename: Gaurav
authors.initials: G
authors.lastname: Bhardwaj
authors.affiliation: Faculty of Medicine, University of New South Wales (UNSW), Sydney, NSW, Australia; Department of Ophthalmology, Prince of Wales and Sydney Children's Hospital, Randwick, NSW.
authors.forename: Mark B
authors.initials: MB
authors.lastname: Jacobs
authors.affiliation: Department of Ophthalmology, Prince of Wales and Sydney Children's Hospital, Randwick, NSW; Department of Ophthalmology, The Children's Hospital at Westmead, Westmead, NSW; Faculty of Medicine, University of Sydney, NSW.
authors.forename: Frank J
authors.initials: FJ
authors.lastname: Martin
authors.affiliation: Department of Ophthalmology, Prince of Wales and Sydney Children's Hospital, Randwick, NSW; Department of Ophthalmology, The Children's Hospital at Westmead, Westmead, NSW.
authors.forename: Craig
authors.initials: C
authors.lastname: Donaldson
authors.affiliation: Faculty of Medicine, University of New South Wales (UNSW), Sydney, NSW, Australia; Child Protection Unit, Sydney Children's Hospital, Randwick, NSW.
authors.forename: Kieran T
authors.initials: KT
authors.lastname: Moran
authors.affiliation: School of Psychiatry, Faculty of Medicine, University of New South Wales (UNSW), Randwick, NSW.
authors.forename: Ute
authors.initials: U
authors.lastname: Vollmer-Conna
authors.affiliation: Centre for Vision Research, Westmead Millennium Institute, University of Sydney, NSW.
authors.forename: Paul
authors.initials: P
authors.lastname: Mitchell
authors.affiliation: Faculty of Medicine, University of New South Wales (UNSW), Sydney, NSW, Australia; Department of Ophthalmology, Prince of Wales and Sydney Children's Hospital, Randwick, NSW.
authors.forename: Minas T
authors.initials: MT
authors.lastname: Coroneo
mesh_terms: D002649:Child Abuse / Q000175:diagnosis*; D002675:Child, Preschool; D016489:Head Injuries, Closed / Q000145:classification* / Q000150:complications; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D015588:Observer Variation; D010781:Photography; D011446:Prospective Studies; D015203:Reproducibility of Results; D012166:Retinal Hemorrhage / Q000145:classification* / Q000209:etiology