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Audrey Cinru Ko, Daniel Choi, Nathan Wayne Blessing, Sander R Dubovy, Audina M Berrocal; The Novel Use of Fluorescein Angiography to Evaluate Retinal Hemorrhages in Abusive Head Trauma. Invest. Ophthalmol. Vis. Sci. 2015;56(7 ):387.
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© ARVO (1962-2015); The Authors (2016-present)
The evaluation of retinal hemorrhages in the setting of suspected abusive head trauma (AHT) has important social and legal implications. However, many of these patients have a delayed presentation after trauma, resulting in partially or fully resolved retinal hemorrhages at the time of initial evaluation. This severely hampers the evaluation and attribution of the retinal hemorrhages to AHT. We report the novel use of fluorescein angiography (FA) to evaluate retinal pathology secondary to AHT.
Part A: Retrospective case series of initial and follow-up FA findings in three cases of suspected and proven AHT. Part B: IRB approved prospective study of initial and follow-up FA findings in cases of suspected and proven AHT.
Part A: Case 1. A 5 month old female born at full term presented with facial bruising, left subdural hematoma, seizure, and retinal hemorrhages secondary to proven abuse. Four days later, she underwent a bedside FA showing peripheral nonperfusion (Fig 1A,B). Repeat FA 4 months later showed persistence of findings. Case 2. An 8 month old male born at 38 weeks gestation presented with focal seizure and right subdural hemorrhage. Ophthalmic exam showed the presence of retinal hemorrhages. Three months after presentation, the patient underwent an exam under anesthesia with FA that did not show areas of peripheral retinal ischemia (Fig 2C,D). Due to this finding, it was eventually discovered that the patient had von Willebrand Disease and the etiology of the exam findings was more likely to be secondary to minor accidental head trauma in the setting of a bleeding disorder. Case 3. A 6 week old male born at full term presented with bilateral subdural hematomas, subarachnoid hemorrhage, ischemic infarct, new onset seizures, and retinal hemorrhage. Two days later, he underwent a bedside FA showing peripheral nonperfusion (Fig 3E,F). Repeat FA 3 months later showed persistence of findings. Part B: data collection ongoing and expected to be completed in Spring 2015.
Although retinal hemorrhages are found in the majority of children with AHT, these findings are not specific for abuse and can represent mimickers of AHT. Fluorescein angiography is useful for the evaluation of acute and remote retinal trauma, even after resolution of retinal hemorrhages. The finding of bilateral peripheral nonperfusion and remodeling in the setting of abuse may suggest AHT.
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