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J AAPOS. Author manuscript; available in PMC 2017 April 01. Published in final edited form as: J AAPOS. 2016 April ; 20(2): 131–135. doi:10.1016/j.jaapos.2015.12.008.
The natural history of retinal hemorrhage in pediatric head trauma Gil Binenbaum, MD, MSCEa,b, Wendy Chen, MD, PhDc, Jiayan Huang, MSb, Gui-shuang Ying, PhDb, and Brian J. Forbes, MD, PhDa
Author Manuscript
aDivision
of Ophthalmology, The Children’s Hospital of Philadelphia, Philadelphia bScheie Eye Institute, Department of Ophthalmology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia cDivision of Ophthalmology, Alpert Medical School at Brown University, Providence, Rhode Island
Abstract BACKGROUND—Ophthalmologists are commonly asked to interpret appearance of retinal hemorrhages (RH) in children with suspected traumatic head injury. We sought to determine the natural history of RH in young children with head trauma and to identify patterns suggestive of chronicity in order to help establish timing of suspected traumatic injury.
Author Manuscript
METHODS—The medical records of children 20, too numerous to count [TNTC]). RESULTS—A total of 91 eyes of 52 children were studied. All eyes had IRH (62 eyes with TNTC). In all but one eye, IRH resolved to none or mild within 1–2 weeks. TNTC IRH did not persist beyond a few days. The longest an isolated IRH persisted was 32 days. Preretinal hemorrhage (PRH) was present in 68 eyes, persisting 5–111 days. On initial examination, 25% of eyes had only IRH, 75% both PRH and IRH; no eyes had only PRH. At 2 weeks, 3% had only IRH, 18% both, and 45% only PRH. In no eyes did RH worsen.
Author Manuscript
CONCLUSIONS—IRH clears rapidly, whereas PRH may persist for many weeks. The presence of TNTC IRHs indicates that trauma occurred within a few days prior to examination, whereas the presence of PRH with no or few IRHs suggests days to weeks since trauma. To accurately identify these patterns, eye examinations should be completed as soon as possible after admission, preferably within 24–48 hours. Retinal hemorrhage (RH) is an important diagnostic sign of inflicted head trauma in infants and young children.1–9 Ophthalmologists are often asked to interpret the appearance of RH
Correspondence: Gil Binenbaum, MD, MSCE, Children’s Hospital of Philadelphia, 34th Street and Civic Center Blvd., 9-MAIN, Philadelphia, PA 19104 ([email protected]). Presented in part at the 39th Annual Meeting of the American Association for Pediatric Ophthalmology and Strabismus in Boston, Massachusetts, April 3–7, 2013, and at the Annual Meeting of the Pediatric Academic Societies, Washington, DC, May 4–7, 2013.
Binenbaum et al.
Page 2
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in an effort to provide clues about the timing of a suspected injury. The diagnostic specificity of the severity, location, and type of RH for inflicted versus accidental injury are well established,1,2,5–11 but there are limited published data to guide an assessment of injury timing based on RH findings. The time to resolution of birth-trauma related RH has been reported, with intraretinal hemorrhage (IRH) clearing much faster than preretinal hemorrhage (PRH),12,13 but the overall patterns of RH at varying postnatal ages following birth have not been explicitly described. Further, the time course and patterns of resolution of RH in pediatric head trauma have not been formally investigated. A reported case of abusive head trauma has suggested the potential for limited progression of RH during the initial 24 hours of medical care,14 but this possibility has not been formally evaluated. The purpose of this study was to determine the natural history of RH in infants and young children with suspected abusive or accidental head trauma and to identify patterns of RH that might suggest chronicity or aid in establishing the timing of a suspected traumatic injury.
Subjects and Methods
Author Manuscript
The medical records of children
J AAPOS. Author manuscript; available in PMC 2017 April 01. Published in final edited form as: J AAPOS. 2016 April ; 20(2): 131–135. doi:10.1016/j.jaapos.2015.12.008.
The natural history of retinal hemorrhage in pediatric head trauma Gil Binenbaum, MD, MSCEa,b, Wendy Chen, MD, PhDc, Jiayan Huang, MSb, Gui-shuang Ying, PhDb, and Brian J. Forbes, MD, PhDa
Author Manuscript
aDivision
of Ophthalmology, The Children’s Hospital of Philadelphia, Philadelphia bScheie Eye Institute, Department of Ophthalmology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia cDivision of Ophthalmology, Alpert Medical School at Brown University, Providence, Rhode Island
Abstract BACKGROUND—Ophthalmologists are commonly asked to interpret appearance of retinal hemorrhages (RH) in children with suspected traumatic head injury. We sought to determine the natural history of RH in young children with head trauma and to identify patterns suggestive of chronicity in order to help establish timing of suspected traumatic injury.
Author Manuscript
METHODS—The medical records of children 20, too numerous to count [TNTC]). RESULTS—A total of 91 eyes of 52 children were studied. All eyes had IRH (62 eyes with TNTC). In all but one eye, IRH resolved to none or mild within 1–2 weeks. TNTC IRH did not persist beyond a few days. The longest an isolated IRH persisted was 32 days. Preretinal hemorrhage (PRH) was present in 68 eyes, persisting 5–111 days. On initial examination, 25% of eyes had only IRH, 75% both PRH and IRH; no eyes had only PRH. At 2 weeks, 3% had only IRH, 18% both, and 45% only PRH. In no eyes did RH worsen.
Author Manuscript
CONCLUSIONS—IRH clears rapidly, whereas PRH may persist for many weeks. The presence of TNTC IRHs indicates that trauma occurred within a few days prior to examination, whereas the presence of PRH with no or few IRHs suggests days to weeks since trauma. To accurately identify these patterns, eye examinations should be completed as soon as possible after admission, preferably within 24–48 hours. Retinal hemorrhage (RH) is an important diagnostic sign of inflicted head trauma in infants and young children.1–9 Ophthalmologists are often asked to interpret the appearance of RH
Correspondence: Gil Binenbaum, MD, MSCE, Children’s Hospital of Philadelphia, 34th Street and Civic Center Blvd., 9-MAIN, Philadelphia, PA 19104 ([email protected]). Presented in part at the 39th Annual Meeting of the American Association for Pediatric Ophthalmology and Strabismus in Boston, Massachusetts, April 3–7, 2013, and at the Annual Meeting of the Pediatric Academic Societies, Washington, DC, May 4–7, 2013.
Binenbaum et al.
Page 2
Author Manuscript Author Manuscript
in an effort to provide clues about the timing of a suspected injury. The diagnostic specificity of the severity, location, and type of RH for inflicted versus accidental injury are well established,1,2,5–11 but there are limited published data to guide an assessment of injury timing based on RH findings. The time to resolution of birth-trauma related RH has been reported, with intraretinal hemorrhage (IRH) clearing much faster than preretinal hemorrhage (PRH),12,13 but the overall patterns of RH at varying postnatal ages following birth have not been explicitly described. Further, the time course and patterns of resolution of RH in pediatric head trauma have not been formally investigated. A reported case of abusive head trauma has suggested the potential for limited progression of RH during the initial 24 hours of medical care,14 but this possibility has not been formally evaluated. The purpose of this study was to determine the natural history of RH in infants and young children with suspected abusive or accidental head trauma and to identify patterns of RH that might suggest chronicity or aid in establishing the timing of a suspected traumatic injury.
Subjects and Methods
Author Manuscript
The medical records of children
