The Use of Ophthalmic Ultrasonography to Identify Retinal Injuries Associated With Abusive Head Trauma.
Abusive head trauma includes any nonaccidental injury inflicted to a child's head and body. It is often characterized by, but not limited to, the repetitive acceleration-deceleration forces with or without blunt head impact. It has a mortality rate of 30%, and 80% of survivors experience permanent neurologic damage. In this case series, we hypothesize that bedside ultrasonography can be useful in the identification of retinal injuries that are consistent with abusive head trauma. Ocular manifestations of abusive head trauma are identified by dilated ophthalmic examination showing retinal hemorrhages that are too numerous to count, multilayered, and extending to the periphery. Traumatic retinoschisis, splitting of the retinal layers with or without blood accumulating in the intervening space, is exclusive for abusive head trauma in infants without a history of significant cerebral crush injury. Direct visualization of intraocular structures is difficult when the eyelids are swollen shut or when dilatation must be delayed. We present a series of 11 patients with brain injuries who underwent ophthalmic point-of-care ultrasonography that revealed traumatic retinoschisis on average 60 hours earlier than direct ophthalmic visualization. Dilated ophthalmic examinations and autopsy reports confirmed retinoschisis and other forms of retinal hemorrhages that were too numerous to count, multilayered, and extending to the periphery in all 11 patients. One patient did not have a dilated ophthalmic examination; however, traumatic retinoschisis and retinal hemorrhages were confirmed on autopsy. Ocular point-of-care ultrasonography is a promising tool to investigate abusive head trauma through the identification of traumatic retinoschisis and retinal hemorrhages when pupillary dilatation and direct ophthalmic examination is delayed.
Division of Critical Care Medicine, Children's National Health System, Washington, DC; Division of Pediatric Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, MD. Electronic address: rriggs6@jhmi.edu.
Becky J
BJ
Riggs
Division of Ophthalmology, Children's National Health System, Washington, DC.
Carmelina
C
Trimboli-Heidler
Division of Critical Care Medicine, Children's National Health System, Washington, DC; Department of Pediatrics, George Washington University School of Medicine and Health Sciences, Washington, DC.
Michael C
MC
Spaeder
Division of Ophthalmology, Children's National Health System, Washington, DC; Department of Pediatrics, George Washington University School of Medicine and Health Sciences, Washington, DC.
Marijean M
MM
Miller
Division of Critical Care Medicine, Children's National Health System, Washington, DC; Department of Pediatrics, George Washington University School of Medicine and Health Sciences, Washington, DC.
Nathan P
NP
Dean
Division of Emergency Medicine, Children's National Health System, Washington, DC; Department of Pediatrics, George Washington University School of Medicine and Health Sciences, Washington, DC.
Joanna S
JS
Cohen
D002675:Child, Preschool; D006259:Craniocerebral Trauma / Q000150:complications / Q000175:diagnosis* / Q000000981:diagnostic imaging; D003937:Diagnosis, Differential; D005260:Female; D006801:Humans; D007091:Image Processing, Computer-Assisted; D007223:Infant; D008297:Male; D009885:Ophthalmology; D019095:Point-of-Care Systems; D012166:Retinal Hemorrhage / Q000150:complications / Q000175:diagnosis* / Q000000981:diagnostic imaging; D038642:Shaken Baby Syndrome / Q000175:diagnosis / Q000000981:diagnostic imaging; D014463:Ultrasonography