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Pavlina S Kemp, Susannah Q Longmuir, Bridget Zimmerman, Amy Walz, Resmiye Oral, Michael David Abramoff; Peripheral Retinal Hemorrhages on Fundus Photography in Patients with Suspected Abusive Head Trauma. Invest. Ophthalmol. Vis. Sci. 2014;55(13):5862.
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© ARVO (1962-2015); The Authors (2016-present)
To examine whether the number of retinal hemorrhages outside of the posterior pole present on fundus photography of children suspected of abusive head trauma predict death, presence of skull or skeletal fractures, abnormal brain findings on neuroimaging, or the diagnosis of definite abusive head trauma (AHT).
The images of all subjects suspected of AHT, less than 36 months of age, that had wide-field retinal images (RetCam) from June 2003 to June 2013 were collected. The best image for each eye was selected by an expert and divided into zones. The peripheral zone was defined as the area outside a 40 degree circle centered on the fovea. All retinal hemorrhages in this zone were counted, and each image was classified as mild (< 5 hemorrhages), moderate (5-20 hemorrhages) or severe (> 20 hemorrhages). Diagnoses of death, skull and skeletal fractures, abnormal brain findings on neuroimaging other than intracranial hemorrhage, and the diagnosis of definite abusive head trauma were recorded. Odds ratios (OR) were calculated using hemorrhage grades for both eyes, where the proportion with moderate/severe hemorrhage in the peripheral zone was compared between those with clinical finding present vs. clinical finding absent using a logistic regression model fitted by the Generalized Estimating Equations (GEE) method.
54 patients (100 eyes) were included. There were significant associations between moderate and severe classifications (> 5 hemorrhages) and skeletal fracture (OR 4.21, p=0.031) and abnormal findings on neuroimaging other than intracranial hemorrhage (OR 2.68, p=0.08). However, there was no correlation with the other diagnoses.
Hemorrhages outside of the posterior pole (outside of the central 40 degrees) on fundus photography of patients suspected of AHT predict presence of skeletal fracture, and abnormal neuroimaging findings, but not inflicted etiology or death, indicating that an absence of retinal hemorrhages does not rule out the diagnosis of AHT. This may improve the management of children with head trauma that is suspicious for abuse.
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