Evaluation of Temporal Association Between Vaccinations and Retinal Hemorrhage in Children.
OBJECTIVE
Vaccinations have been proposed as a cause of retinal hemorrhage in children, primarily as part of a defense strategy in high-stakes abusive head trauma cases. If vaccination injections cause retinal hemorrhage, this consideration would affect the evaluation of children for suspected child abuse.


OBJECTIVE
To describe the prevalence and causes of retinal hemorrhage among infants and young children in an outpatient ophthalmology clinic and to test the hypothesis that, if vaccination injections cause retinal hemorrhage, then retinal hemorrhage would be seen frequently and be temporally associated with immunization.


METHODS
Retrospective cohort study between June 1, 2009, and August 30, 2012, at The Children's Hospital of Philadelphia pediatric ophthalmology clinics among 5177 children 1 to 23 months old undergoing a dilated fundus examination as an outpatient for any reason. Children with intraocular surgery or active retinal neovascularization were excluded from the study.


METHODS
The prevalence and causes of retinal hemorrhage, as well as the temporal association between vaccination injection within 7, 14, or 21 days preceding examination and retinal hemorrhage.


RESULTS
Among 7675 outpatient fundus examinations, 9 of 5177 children had retinal hemorrhage for a prevalence of 0.17% (95% CI, 0.09%-0.33%). All 9 had abusive head trauma diagnosable with nonocular findings. Among a subset of 2210 children who had complete immunization records and underwent 3425 fundoscopic examinations, 163 children had an eye examination within 7 days of vaccination, 323 within 14 days, and 494 within 21 days. No children had retinal hemorrhage within 7 days of vaccination, 1 child had hemorrhage within 14 days, and no additional child had hemorrhage within 21 days. There was no temporal association between vaccination injection and retinal hemorrhage in the prior 7 days (P > .99), 14 days (P = .33), or 21 days (P = .46).


CONCLUSIONS
Retinal hemorrhage was rare among outpatients younger than 2 years. Considering both immediate and delayed effects, no temporal association existed between vaccination injection and retinal hemorrhage. Vaccination injections should not be considered a potential cause of retinal hemorrhage in children, and this unsupported theory should not be accepted clinically or in legal proceedings. Ophthalmologists noting incidental retinal hemorrhage on an outpatient examination should consider a child abuse evaluation in the absence of other known ocular or medical disease.
Department of Ophthalmology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania2Department of Ophthalmology, The Scheie Eye Institute, Philadelphia, Pennsylvania.
Gil
G
Binenbaum
Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania4Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia.
Cindy W
CW
Christian
Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.
Katy
K
Guttmann
Department of Ophthalmology, The Scheie Eye Institute, Philadelphia, Pennsylvania.
Jiayan
J
Huang
Department of Ophthalmology, The Scheie Eye Institute, Philadelphia, Pennsylvania.
Gui-Shuang
GS
Ying
Department of Ophthalmology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania2Department of Ophthalmology, The Scheie Eye Institute, Philadelphia, Pennsylvania.
Brian J
BJ
Forbes
D000553:Ambulatory Care; D006259:Craniocerebral Trauma / Q000175:diagnosis / Q000453:epidemiology; D005260:Female; D006776:Hospitals, Pediatric; D006801:Humans; D007223:Infant; D008297:Male; D015143:Philadelphia / Q000453:epidemiology; D010808:Physical Examination; D015995:Prevalence; D012166:Retinal Hemorrhage / Q000175:diagnosis / Q000453:epidemiology* / Q000209:etiology; D012189:Retrospective Studies; D018570:Risk Assessment; D014611:Vaccination / Q000009:adverse effects / Q000706:statistics & numerical data*; D014612:Vaccines / Q000008:administration & dosage*; D014787:Vision Tests
D014612:Vaccines