Review of Retinal Hemorrhages
Authored by Kathi Makoroff, M.D.
The Child Abuse and Neglect Team of The Mayerson Center for Safe and Healthy Children at Cincinnati Children's Hospital provides the following clinical update of literature on retinal hemorrhages resulting from shaken baby syndrome.
Does Accidental Injury Result in Retinal Hemorrhages?
Alario, et al., Johnson, et al. and Elder, et al. all performed prospective studies to determine if children who sustain accidental head injuries have retinal hemorrhages.
Combining the three studies, a total of 215 children were examined. Two children (0.93%) had retinal hemorrhages; both of these children were involved in fatal or serious motor vehicle accidents. Buys, et al. and Duhaime, et al. examined children who sustained traumatic head injury.
Buys found that 3/78 children had retinal hemorrhages; all three children were determined to have suffered non-accidental head injury after full multidisciplinary work-up. Duhaime found retinal hemorrhages in 10/100 patients <24 months who were admitted with head injury. Nine patients with retinal hemorrhages were felt by the authors to have suffered abusive head trauma. The other patient with retinal hemorrhages was involved in a motor vehicle accident.
Luerssen, et al. examined a database of 811 pediatric patients who were admitted to the hospital following traumatic brain injury. Retinal hemorrhages were detected in 27 patients. Twenty-two of these patients were felt by the authors to have suffered abusive head injury; one patient was involved in a motor vehicle accident and four patients suffered falls.
Christian, et al. reports three cases of retinal hemorrhages occurring after serious household accidental trauma. In the three patients, aged 13 months, 9 months and 7 months, the retinal hemorrhages were localized to the posterior pole.
Betz, et al. examined different groups of traumatic and non-traumatically head injured patients to compare a morphometrical analysis of the eyes. Two adult patients who suffered significant trauma (fall from stairs and a motor vehicle accident) had retinal hemorrhages, and all of the patients who were diagnosed with shaken baby syndrome had retinal hemorrhages. None of the patients with non-traumatic head injury had retinal hemorrhages.
Are Retinal Hemorrhages Caused by Cardiopulmonary Resuscitation?
Kanter, et al., Goetting, et al., and Odom, et al. all performed prospective studies to evaluate whether cardiopulmonary resuscitation (CPR) can cause retinal hemorrhages in children.
They studied a total of 117 patients. Nine patients had retinal hemorrhages: one patient had a single retinal hemorrhage following 75 minutes of CPR; another patient had multiple small punctate hemorrhages after 60 minutes of CPR.
Four patients were determined by the authors to have been abused based on additional findings. Another patient was involved in a motor vehicle accident, and one had significant hypertension. The final patient was a drowning victim; it is notable that no other reports of similar retinal hemorrhages following drowning can be found.
Weedn, et al., Kramer, et al., and Bacon, et al. each describe a single case report of an infant or child with retinal hemorrhages following cardiopulmonary resuscitation. The authors felt that these patients did not suffer non-accidental traumatic brain injury. In all three cases, however, the reviewer wonders if non-accidental traumatic brain injury was completely excluded.
Gilliland and Lukenbach performed a postmortem study on 169 infants and children to examine if resuscitation is associated with retinal hemorrhages. Seventy patients had retinal hemorrhages after receiving resuscitation attempts, and the majority of these patients had head injuries as the cause of death. Importantly, however, the nature and cause of the head injury was not specified.
Fackler et al. used an animal model to determine if CPR causes retinal hemorrhages in piglets. They performed CPR on six piglets for 50 minutes. No retinal hemorrhages were found following the resuscitation of these six piglets even with measurements of right atrial mean pressures of 74 ± 12 mm Hg and mean sagittal sinus pressures of 42 ± 6 mm Hg.
Are Retinal Hemorrhages Caused by Seizures?
Tyagi et al., and Sandramouli et al. performed similar studies to evaluate the likelihood that seizures alone will cause retinal hemorrhages in children. Combining the two studies, a total of 65 children who had recently had a seizure were examined with a dilated indirect fundiscopic examination. None of the children had retinal hemorrhages.
Do Retinal Hemorrhages Follow Meningitis?
Fraser et al. reports a case of a 12 year old with meningococcal meningitis who was found to have a large subretinal and vitreous hemorrhage of the left eye. The authors propose that obstruction of the central retinal vein caused retinal venous hypertension and the hemorrhage.
Kennedy describes a 4-month-old with meningococcal meningitis and disseminated intravascular coagulation. The infant had a small number of retinal nerve fiber hemorrhages in the posterior pole of both eyes. The author suggests that the hemorrhages were due to disseminated intravascular coagulation.
Are There Other Causes of Retinal Hemorrhages?
Clark et al. report a case of a 4 year old who had a spinal cord arteriovenous malformation and presented with bilateral retinal hemorrhages and papilledema. McLellan et al. present a case of a 6 week old with a ruptured intracranial arterial aneurism who also presented with bilateral retinal hemorrhages.
Pollack and Tychsen examined a random sample of infants and children after they had received extracorporeal membrane oxygenation. Five patients were found to have retinal hemorrhages; four of the five were neonates. The hemorrhages were all described as single or few dot or flame hemorrhages.
Shiono et al. describes two older patients with von Willebrand's syndrome. One patient (19 years old) had vitreous hemorrhages only, but the second patient (13 years old) had retinal, subretinal and vitreous hemorrhages.
What is the Significance of Unilateral Retinal Hemorrhages?
Drack et al. describes four cases of documented child abuse in which the children had extensive preretinal or retinal hemorrhages in one eye only.
All of the children had indirect ophthalmoscopy performed by an ophthalmologist. Tyagi et al. similarly describes three cases of unilateral retinal hemorrhages in children who the authors felt sustained non-accidental head injury.
Paviglianti and Donahue describe three infants who were found to have unilateral retinal hemorrhages and ipsilateral cranial hemorrhages. All three cases were "strongly suspicious of nonaccidental trauma".
Wilkinson et al. correlated retinal hemorrhages with neurological outcome in shaken baby syndrome. Three of fourteen patients (21%) in their series had unilateral retinal hemorrhages. Kivlin et al. examined the ophthalmologic findings with shaken baby syndrome at one medical center. Of the retinal hemorrhages that were identified by the ophthalmologists, 11/76 (14%) were unilateral.
Do Neonates Have Retinal Hemorrhages?
Sezen et al., Planten al., Baum et al., Levin et al., Schenker et al.., and Emerson et al. all performed studies looking at the incidence of retinal hemorrhages in neonates and also to see if the delivery technique influences the incidence of retinal hemorrhages.
In all of the studies that looked at delivery technique, the highest incidence was seen following delivery with vacuum extraction and the lowest incidence was seen following cesarean section. Sezen et al. and Baum et al. determined the incidence of retinal hemorrhages when neonates were examined within one week of birth.
The incidences were 14.3% and 15.5% respectively. Planten et al., Levin et al. and Schenker et al examined neonates within 24 hours of birth. The incidence of retinal hemorrhages in these studies ranged from 19.2% to 37.3%.
Sezen et al. additionally looked at the time to resolution of the hemorrhages. Hemorrhages identified as flame shaped resolved within five days. Round, red, deep hemorrhages usually disappeared within 21 days except in one case in which the hemorrhage did not resolve until 6 weeks after birth.
Emerson et al. examined neonates within 30 hours of birth and found the incidence of retinal hemorrhages to be 34%. Most of the hemorrhages were gone by 2 weeks of age; one subretinal hemorrhage persisted up to six weeks after birth.
Smith et al. randomly selected 46 neonates without perinatal problems for dilated retinal examination. Ten infants were found to have retinal hemorrhages. These ten infants also had a brain MRI looking for evidence of intracranial injury. Only eight of the scans were satisfactory but none of the neonates showed evidence of intracranial injury on MRI.
Skalina et al. examined the incidence of retinal hemorrhages in newborn infants with systemic hypertension (defined as mean arterial pressure >70mmHg on at least three separate days). Eight patients had retinal hemorrhages; one infant had splinter hemorrhages which were still visible 10 weeks later.
Beratis et al. investigated whether maternal smoking during pregnancy causes retinal abnormalities in the newborn. They used two groups of neonates matched for mode of delivery and gestational size; the neonates were grouped according to whether their mothers smoked during pregnancy or not (self-report).
There was an increased frequency of retinal hemorrhages seen in neonates of mothers who smoked during pregnancy when compared to infants of mothers who did not smoke during pregnancy.
Does Purtscher retinopathy occur in children?
Tomasi and Rosman report two cases of children who had ecchymosis of the chest and were also found to have retinal hemorrhages.
The authors define Purtscher retinopathy as following a sudden compression of the thoracic cage. The two children in these case reports did not have head imaging, so it is difficult to conclude that thoracic compression is the cause of the hemorrhages.
Does Terson syndrome occur in children?
Kuhn, et al. performed two studies examining vitreous hemorrhages and subarachnoid and subdural hemorrhages in adults and children.
The second study which examined the incidence of intraocular hemorrhages with subarachnoid hemorrhages did not include children. The incidence of Terson syndrome in children, therefore, could not be determined from this study. Interestingly, all of the children in the first study who underwent vitrectomy for vitreous hemorrhages had subdural hemorrhages.
What are the Outcomes of Infants and Children with Retinal Hemorrhages?
Matthews and Das examined the relationship of retinal and vitreous hemorrhages and neurological outcomes in five infants with shaken baby syndrome. Three of the five infants had a poor neurological outcome. Wilkinson et al. also looked at the relationship between retinal hemorrhages and neurological outcomes in fourteen infants and children with shaken infant syndrome. There was a borderline statistical significance between the presence of retinal hemorrhages and the neurological outcome.
Kivlin et al. examined clinical and ophthalmological findings in children who were diagnosed with shaken baby syndrome. They found that the presence and bilaterality of retinal hemorrhages indicated a worse prognosis for survival.
Han and Wilkinson examined six children 12 - 55 months following a shaking injury. There was significant visual morbidity seen in these six cases. In addition, three of the children had significant neurological disabilities. McCabe and Donahue performed a retrospective chart review of 30 patients who were diagnosed with shaken baby syndrome. They found that decreased vision in these patients was due to retinal scarring, optic atrophy and cortical visual impairment.
Article Summaries
Does Accidental Injury Result in Retinal Hemorrhages?
Christian CW, Taylor AA, Hertle R, Duhaime AC. Retinal hemorrhages due to accidental household trauma. J Pediatrics 1999;135:125-127.
Objectives:
To describe cases of retinal hemorrhages occurring after serious accidental trauma.
Methods:
3 case reports of unintentional household trauma resulting in retinal hemorrhages.
Case 1
- Mechanism: 13 month old fell down 13 concrete steps in a walker
- Symptoms: Immediate loss of consciousness
- Findings: Scalp and thigh bruise; nasal abrasion. Acute right parieto-temporal subdural and enlarged extra-axial space with minor mass effect. Skeletal survey normal
- Retinal Findings: Unilateral (right) pre-retinal and intra-retinal hemorrhage; localized retinal edema in the posterior pole
- Outcome: Normal findings on ophthalmology follow-up at 3, 11, 24 months
Case 2
- Mechanism: 9 month old was being supported and swung by father; fell back 1-2 feet hitting occiput
- Symptoms: Cried then transiently unresponsive with seizure activity. Glasgow Coma Score (GCS) = 4
- Findings: Acute subdural and/or subarachnoid hemorrhage over the left parieto-occipital area with midline shift; Skeletal survey normal
- Retinal Findings: Multiple intraretinal flame shaped hemorrhages and round intraretinal hemorrhages in the posterior pole of left eye. Also 2 small posterior vitreous hemorrhages along the posterior pole. Foveal edema.
- Outcome: Normal neurological exam at follow-up at 3, 6 months.
Case 3
- Mechanism: 7 month old fell through a stair rail onto concrete basement floor, landing on her head
- Symptoms: No LOC; Glasgow Coma Score (GCS) = 7
- Findings: Large right parieto-frontal subdural hemorrhage with midline shift. Diastatic fracture of coronal suture; linear fracture of temporal bone; right cerebral contusion also noted operatively. Skeletal survey normal
- Retinal Findings: Unilateral (right) subretinal and intraretinal hemorrhages in the posterior pole; also preseptal cellulitis
- Outcome: Normal neurological exam and ophthalmology exam at follow-up
Conclusions:
- Intracranial bleeding and retinal hemorrhage may occur secondary to household accidental trauma. Reports of this are infrequent.
- There were differences between retinal findings in these three patients compared to typical retinal findings seen in patients with non-accidental head injury. In these cases, the retinal hemorrhages were:
- Isolated to the posterior pole
- Had no peripheral involvement
- Not associated with retinal folds or retinal detachment
Alario A, Duhaime T. Do retinal hemorrhages occur with accidental head trauma in young children? AJDC 1990;144:445. (Abstract only)
Objectives:
To determine if retinal hemorrhages occur from common accidents.
Methods:
Prospective study of 50 children <24 months of age with well-documented accidental head trauma.
Ophthalmologists performed an ophthalmologic exam on patients within 24 hours of presentation of accidental head trauma to look for retinal hemorrhages.
Results:
Mean age of patients was 11.4 months. Retinal hemorrhages were not found in any of the 50 children.
| Mechanism of injury: | n (%) |
| Fall down stairs (19/26 in walkers) | 26 (52%) |
| Fall <= 4 feet | 15 (30%) |
| Fall >= 10 feet | 4 (8%) |
| Impact from moving object | 2 (4%) |
| MVA 3 | (6%) |
Outcomes:
All children recovered quickly without any neurologic sequelae.
Conclusion:
Retinal hemorrhages were not found in the young children who sustained mild to moderate head injury as a result of common accidental injury in this series.
Johnson DL, Braun D, Friendly D. Accidental head trauma and retinal hemorrhages. Neurosurgery. 1993;33(2):231-4.
Objective:
To determine if retinal hemorrhages occur with accidental injuries, including accidental injuries that cause skull fractures and/or intracranial hemorrhages.
Methods:
Head injured children who also had skull fractures and/or intracranial hemorrhages were examined by an ophthalmologist. Exclusion criteria included children with suspected child abuse and with gunshot wounds to the head.
Results:
Median age was 4.5 years (52 children were less than 2 years of age). Retinal hemorrhages were found in 2/140 children (1.4%) (hemorrhages are not described). Both children were involved in side-impact MVAs:
- One child died (no autopsy information)
- One child additionally had an ipsilateral cerebral concussion and sub-arachnoid hemorrhage
| Mechanisms of injury | n (%) |
| MVA | 55 (39%) |
| Assault | 13 (6%) |
| Other | 8 (5%) |
| Falls: | 70 (50%) |
| <5 feet | 17 (24%) |
| 5-10 feet | 11 (16%) |
| Stairs | 17 (24%) |
| Falls from buildings | 12 (17%) |
| Playground | 13 (19%) |
Conclusion:
Retinal hemorrhages were noted in <2% of accidental closed head injury and only following serious injury.
Elder JE, Taylor RG, Klug GL. Retinal hemorrhage in accidental head trauma in childhood. J Pediatr Child Health 1991;27:286-289.
Objective:
To study the incidence of retinal hemorrhages in children who sustained known accidental trauma.
Methods:
25 children admitted with significant head injury (defined as injury that resulted in loss of consciousness, confusion or obtunded mental state) had a dilated indirect fundoscopic examination by an ophthalmologist within 6 days of injury. (72% of patients were examined within 3 days of injury). Children with suspected non-accidental trauma were excluded.
Results:
Median age was 5.6 years (only 16% were <2 years of age). No children had evidence of retinal hemorrhages.
Conclusion:
Another study that shows that retinal hemorrhages are not a common finding following accidental closed head injury. These children, notably, were older, on average, than infants diagnosed with shaken baby syndrome.
Buys YM, et al. Retinal findings after head trauma in infants and young children. Ophthalmology 1992;99(11):1718-1723.
Objectives:
To see if retinal hemorrhages in children who sustained head injuries is pathognomonic for child abuse.
Methods:
Children between 4-36 months who sustained head trauma within the preceding 48 hours had a dilated indirect fundoscopic exam by an ophthalmologist. Patients with systemic diseases that are associated with retinal hemorrhages were excluded. Patients were assigned to accidental or non-accidental group after full multidisciplinary work-up:
- 75 were determined to be accidental
- 3 were determined to be non-accidental
- 1 was indeterminate (and was not included in the statistical analysis)
Results:
Mean age was 16.1 months (range 1.1-35.2 months). All children in the accidental head injury group had a normal fundoscopic examination. 3/3 children in the non-accidental group had retinal hemorrhages:
| Patient | Retinal Hemorrhage Description |
| 1: | single dot intraretinal hemorrhage in the posterior pole of right eye |
| 2: | extensive bilateral nerve fiber layer, subhyaloid and vitreous hemorrhages and a left retinal detachment |
| 3: | bilateral subhyaloid and nerve fiber layer hemorrhages |
Conclusion:
Retinal hemorrhages were found in all three children in the non-accidental head injury group but in none of the 75 children with accidental head injury.
Duhaime AC, Alario AJ, Lewander WJ, et al. Head injury in very young children: mechanisms, injury types, and ophthalmologic findings in 100 hospitalized patients younger than 2 years of age. Pediatrics 1992; 90:179-185.
Objectives:
To analyze the mechanism, injury type and ophthalmologic findings in young children who sustain head injury.
Methods:
100 consecutively admitted head-injured patients 24 months of age or younger (diagnosis as determined at discharge or autopsy) were prospectively studied. All patients underwent ophthalmologic exam by ophthalmologists or ED physicians. Radiologic evaluations were performed as clinically indicated.
Abuse was determined by an algorithm which the authors feel provides a conservative estimate: Determination is based on a combination of findings indicating the presence of either:
- unexplained or healing long bone fractures
- injuries unequivocally caused by mechanical trauma with no history of trauma,
- a history of forces considered by the authors to be mechanically insufficient to cause a particular injury, or
- changing or developmentally incompatible history
Results:
Retinal hemorrhages were found in 10/100 patients:
- 9/10 were in patients that were found to have inflicted injuries (abuse)
- One patient was involved in an MVA
| Reported Mechanism of Injury: |
| | Accidental | Abuse |
| Number | 76 | 24 |
| Mean Age (months) | 9.0 | 8.7 |
| Falls | | |
| <4 feet | 26 | 8 |
| >4 feet | 21 | 0 |
| Down stairs | 10 | 0 |
| Down stairs in walker | 8 | 0 |
| MVA | 9 | 0 |
| No history | 0 | 14 |
| Admitted assault | 0 | 2 |
| Impact by moving object | 2 | 0 |
Conclusion:
Retinal hemorrhages were not seen in trivial accidental head injuries in this study.
Betz P, Puschel K, et al. Morphometrical analysis of retinal hemorrhages in the shaken baby syndrome. Forensic Sci Internat 1996;78:71-80.
Objective:
To investigate whether a morphometrical analysis of eyes can differentiate between accidental and non-accidental head injury.
Methods:
Patient Groups:
- Accidental head injury; n=24 (ages 2 months-73 years)
- Non-traumatic intracranial bleeding; n=6
- Intravital brain death; n=2
- SIDS; n=10
- Shaken baby syndrome; n=7
Area of retinal hemorrhage was determined using a 100-square grid fitted on an eyepiece of a microscope.
Area fraction = number of squares covered by retinal hemorrhages/total number of squares covered by retinal layers
Results:
- Accidental head injury: Retinal hemorrhages were seen in 2/24 patients:
- 35 year old who fell from stairs; had skull fracture, SDH and DAH
- "spot-like hemorrhages in one eye, not in all layers"
- Retinal area = 3.33%
56 year old in a traffic accident; had skull fracture, SDH and DAH and brain contusion RH in one eye Retinal area = 1.18%Non-traumatic intracranial bleeding: No patients had retinal hemorrhages Intravital brain death: No patients had retinal hemorrhages SIDS: No patients had retinal hemorrhages; (all patients in this group received CPR) Shaken baby syndrome: All patients had retinal hemorrhages (7 patients) Six patients had massive retinal hemorrhages involving all layers of both eyes One patient had extensive retinal hemorrhages in one eye only Retinal area range: 19.2-73.2%Conclusions:
- Morphometrical analysis can contribute to the differentiation between shaken baby syndrome and accidental injuries
- The detection of extensive retinal bleeding can indicate a violent traumatic event
Objective:
To look at the relationship of retinal hemorrhages and seizures as clinical indicators of pediatric traumatic brain injury.
Methods:
Data was collected in cases of pediatric traumatic brain injury requiring admission to the hospital.
Results:
811 patients in database. Mean age was 4.4 years. Retinal hemorrhages were detected in 27 patients (but were not described):
| Mechanism of injury | n |
| MVA | 1 |
| Fall | 4 |
| Abuse | 22 |
Conclusion:
Retinal hemorrhages were more commonly seen in children who were found to have been abused in this study.
Are Retinal Hemorrhages Caused by Cardiopulmonary Resuscitation?
Kanter RK. Retinal hemorrhage after cardiopulmonary resuscitation or child abuse. J. Pediatr 1986;108:430-432.
Objective:
To determine the extent to which retinal hemorrhage is a complication of cardiopulmonary resuscitation (CPR).
Methods:
Direct fundiscopic examinations without use of mydriatics was performed in patients who had received cardiopulmonary resuscitation (CPR). Non-survivors were examined immediately after death. Survivors were examined within 2 days except for one patient who was not examined until 84 hours following CPR.
If retinal hemorrhages were detected, work up for occult trauma was done including CT, skeletal radiographs, physical examination and history.
Results:
54 total patients were examined:
- 20 patients were <12 months of age
- 10 patients were 12 - 23 months of age
- 24 patients were >24 months of age
6 patients had retinal hemorrhages:
- 4 patients also had bruising on head/face (4 patients) or subdural hematomas (2 patients) or brain edema (3 patients). (skeletal radiographs were all negative)
These patients were determined by the authors to have been abused (ages of these patients: 1 month, 5 months, 18 months, 2 years).
- 1 patient was hit by car.
- 1 patient (age 18 months) had no evidence of trauma but had arterial hypertension (190/120 mm Hg) and seizures.
Conclusion:
In this small patient sample, the majority of children with retinal hemorrhages following cardiopulmonary resuscitation were felt by the authors to have been abused based also on other physical findings. Another child suffered significant accidental trauma, and one child had no history of trauma but had significant hypertension. The retinal hemorrhages are not described.
Goetting MG, Sowa B. Retinal jhemorrhage after cardiopulmonary resuscitation in children: an etiologic reevaluation. Pediatrics 1990;85:585-588.
Objective:
Prospective study to evaluate whether CPR can cause retinal hemorrhages.
Methods:
Children who underwent CPR and met the following criteria:
- Had chest compressions
- Had no evidence of preceding trauma
- Had no history of conditions associated with RH (seizures, hypertension, bleeding disorders)
The children had direct fundiscopic examination performed by a pediatric neurologist. Positive findings were confirmed by two additional examiners. (Pharmacologic dilatation was used only "when necessary")
Results:20 children met the above criteria. Median age was 2 years (range: 2 weeks-17 years). Causes of cardiopulmonary arrest:
- sepsis (5 patients)
- SIDS (5 patients)
- near-drowning (3 patients)
- asthma (3 patients)
- poisoning (2 patients)
- asphyxia (1 patient)
- aspiration (1 patient)
Two children (10%) had retinal hemorrhages:
Patient 1 was a two year old drowning victim who had CPR for 40 minutes. Had multiple bilateral large retinal hemorrhages. Platelet number, coagulation studies, skeletal survey and autopsy were normal.
Patient 2 was a 6 week old admitted for 36 hours with possible sepsis (cause of death was SIDS). Had 75 minutes of CPR. Had a "single fresh retinal hemorrhage 0.3 disc diameters (dd) in size at 1.2 dd temporal to the right disc" Skeletal survey and autopsy were normal.
Additional case (detected after the study period):
9 year old with 2 episodes of arrest from asthma. Minutes before his third arrest had no retinal hemorrhages. Had CPR for 12 minutes then 2 retinal hemorrhages were seen in the left fundus.
Conclusions:
- This study illustrates that although retinal hemorrhages are frequently associated with head trauma in children, other causes must be excluded.
- The description of retinal hemorrhages in patient 1 may not be dissimilar to those seen in shaken infants. It is notable that we have found no other reports of retinal hemorrhages like these following drowning.
Gilliland MGF, Luckenbach MW. Are retinal hemorrhages found after resuscitation attempts? Am J Forensic Med Path 1993;14:187-192.
Objective:
To examine the hypothesis that resuscitation causes retinal hemorrhages.
Methods:
169 infants and children had a postmortem examination were included:
- 131 had resuscitation attempts lasting a minimum of 30 minutes
- 38 had not received such vigorous attempts or no resuscitation attempts.
90% of patients were <3 years; mean age was 17 months.
Results:
99 patients did not have retinal hemorrhages:
- 70 of these 99 had resuscitation attempts lasting a minimum of 30 minutes
70 patients had retinal hemorrhages:
- 61 of these 70 patients had resuscitation attempts lasting a minimum of 30 minutes:
- 56 patients had head injuries as the cause of death
- 3 patients had CNS disease as the cause of death
- 1 patient had sepsis as the cause of death
1 patient had an undetermined cause of death (came from household with two prior deaths and confirmed abuse) 9 had not received such vigorous attempts or no resuscitation attempts: 6 patients had head injuries as the cause of death 1 patient had CNS disease as the cause of death 2 patients had an undetermined cause of deathConclusion:
Most of the patients in this series who were found on postmortem examination to have retinal hemorrhages had head injuries as the cause of death. It is not discussed which of these patients were felt to have suffered non-accidental head injury.
Odom A, Christ E, Kerr N, et al. Prevalence of retinal hemorrhages in pediatric patients after in-hospital cardiopulmonary resuscitation: a prospective study. Pediatrics 1997;99(6).
Objective:
To determine the prevalence of retinal hemorrhages after inpatient cardiopulmonary resuscitation (CPR) in patients hospitalized for non-traumatic illnesses.
Methods:
43 patients (total of 45 resuscitation attempts) who received CPR > 1 minute and survived. Exclusion criteria:
- patients who had evidence of trauma
- patients with suspected child abuse
- patients with seizures or near-drowning
- patients who had retinal hemorrhages documented before CPR
- patients who had CPR performed out-of-hospital
Dilated fundus examinations that visualized the retina to the equator was performed by pediatric ophthalmolgists within 96 hours of CPR.
Age range: 1 month-15.8 years; mean 23.2 months
84% of patients were <2 years old
Results:
One patient (1 month old) had retinal hemorrhages:
- Had 60 minutes of chest compressions via open cardiac massage
- PT/PTT: 22.9/78; Plts=91,000
- Retinal findings: multiple small punctate hemorrhages bilaterally
Conclusion:
No patients with a normal platelet count and normal coagulation studies had retinal hemorrhages following cardiopulmonary resuscitation in this study.
Fackler JC, Berkowitz ID, Green WR. Retinal hemorrhages in newborn piglets following cardiopulmonary resuscitation. AJDC 1992;146:1294-1296.
Objective:
To determine whether conventional CPR causes retinal hemorrhages in piglets.
The pig is an appropriate model for ocular research because the retinal capillary networks of swine and humans are similar in size and distribution throughout the retinal layers. However the pig has no central retinal artery and major retinal vessels lie superficially.
Methods:
6 two week old piglets weighing 3.5-4.5 kg underwent CPR for 50 minutes with 20% displacement of AP chest diameter. Measurements of right atrial and sagital sinus pressures were obtained during CPR. Following CPR, the pigs were euthanized and the eyes were examined for gross and microscopic changes.
Results:
No retinal hemorrhages were found. Sagital sinus and right atrial pressures were elevated above baseline and remained elevated throughout CPR.
Conclusion:
There was no evidence of retinal hemorrhages in a piglet model of cardiopulmonary resuscitation in these six piglets.
Weedn VW, Mansour AM, Nichols MM. Retinal hemorrhage in an infant after cardiopulmonary resuscitation. Am J Forensic Med Path 1990;11:79-82.
Objectives:
To describe a case report with retinal hemorrhages following cardiopulmonary resuscitation in an infant who the authors felt was not abused.
Case report:
4 month old suffered scalding burns to upper body (face, neck, hands and back) and the oral airway. The history supplied by mother was that the 2 year old sibling turned on the hot water faucet. The patient had 45 minutes of CPR and died. The autopsy showed:
- Several large patches of retinal hemorrhages situated in the nerve fiber layer in the equator and posterior pole of both eyes.
- Marked edema of the brain without subdural or subarachnoid hemorrhages
- There was no report of skeletal radiographs
Conclusion:
This one case report suggests that retinal hemorrhages in the posterior poles could result from prolonged CPR, but the reviewer wonders if non-accidental trauma was completely excluded as a diagnosis in this case.
Kramer K, Goldstein B. Retinal hemorrhages following cardiopulmonary resuscitation. Clin Pediatr 1993;32:366-368.
Objective:
To report the occurrence of retinal hemorrhages following vigorous CPR in a 17 month old child.
Case Report:
17 month old presents with severe dehydration from vomiting, diarrhea and fever. Initial fundiscopic examination by the attending pediatrician (local hospital) was normal without retinal hemorrhages. Had respiratory arrest and underwent 60 minutes of CPR. Transferred to a children's hospital where another fundiscopic examination revealed: bilateral multiple scattered intraretinal and subhyaloid hemorrhages throughout the posterior poles and mid-periphery.
CT of the head showed diffuse cerebral edema without evidence of trauma. Skeletal survey was normal.
Conclusion:
This one case report suggests that retinal hemorrhages could occur as a consequence of vigorous and prolonged resuscitation attempts. The author found no evidence of shaking in this case although this reviewer recognizes that shaking can never be entirely eliminated as a possible cause.
Bacon CJ, Sayer GC, Howe JW. Extensive retinal hemorrhages in infancy-an innocent cause. BMJ 1978;1(6108):281.
Objective:
To report the existence of retinal hemorrhages in an infant who the authors felt was not abused.
Case Report:
2 month old was found pale and limp by father. Mother "slapped him repeatedly on the back to try and revive him". He survived and was found to have "extensive fresh haemorrhages in the nerve-fiber layer of both fundi". Coagulation studies and platelet count and CSF cytology were all normal. There was no report of skeletal radiographs or head CT.
Conclusion:
This one case report suggests that retinal hemorrhages could occur as a consequence of thoracic compression, but non-accidental trauma was never excluded in this patient.
Are Retinal Hemorrhages Caused by Seizures?
Tyagi AK, Scotcher S, Kozeis N, Willshaw HE. Can convulsions alone cause retinal hemorrhages in infants? Br J Ophthalmol 1998;82:659-660.
Objective:
To evaluate the likelihood that seizures alone will cause retinal hemorrhages in children under the age of 2 years.
Methods:
32 children <2 years of age who just had a seizure were evaluated with a dilated indirect fundiscopic exam by an ophthalmologist within 48 hours of presentation. Mean age of patients was 12.2 months; age range was 1 - 23.5 months.
Exclusion criteria: patients with a history of associated head trauma and who received cardiopulmonary resuscitation.
Results:
No children had retinal hemorrhages.
Conclusion:
Seizures alone are unlikely to cause retinal hemorrhages in children under the age of 2 years.
Sandramouli S, Robinson R, Tsaloumas M, Willshaw HE. Retinal hemorrhages and convulsions. Arch Dis Child 1997;76:449-451.
Objective:
To evaluate the likelihood that seizures alone will cause retinal hemorrhages in children.
Methods:
33 children who were admitted after having a seizure were evaluated with a dilated indirect fundiscopic exam by an ophthalmologist within 48 hours.
One child was excluded for having absence seizures only.
Age range was 4 months-14 years; mean age was 46.9 months.
Thirteen children (41%) were less than 2 years of age
Three children were admitted in status epilepticus.
Results:
No children had retinal hemorrhages.
Conclusion:
Seizures alone are unlikely to cause retinal hemorrhages in children.
Do Retinal Hemorrhages Follow Meningitis?
Fraser SG, Horgan SE, Bardavio J. Retinal hemorrhages in meningitis. Eye 1995;9:659-660.
Case report:
12 y.o. female admitted with Meningococcal meningitis. She complained of blurred vision and on day # 6 of illness was found to have a large subretinal and a vitreous hemorrhage of the left eye. Clotting studies were normal.
8 weeks later she had a small residual foveal hemorrhage. The authors propose that retinal venous hypertension brought on by obstruction of the central retinal vein may have been the source of the hemorrhage.
Kennedy CJ. Sectorial iris infarction caused by meningococcal septicaemia. Aust N Z J Ophthalmol 1995;23:149-151.
Case report:
4 month old with Meningococcal meningitis, sepsis and disseminated intravascular coagulation. Petechial and purpuric skin rash was present.
The posterior pole of both eyes had a small numder of retinal nerve fiber hemorrhages. There was a mild left uveitis and a small subconjunctival hemorrhage was present in the conjunctiva of the right eye.
The author proposes that the occular hemorrhages in this case are due to disseminated intravascular coagulation.
Are There Other Causes of Retinal Hemorrhages?
Clark RSB, Orr RA, Atkinson CS. Retinal hemorrhages associated with spinal cord arteriovenous malformation. Clin Pediatrics 1995;:281-283.
Objective:
To report a case of a ruptured arteriovenous malformation as a cause of retinal hemorrhages.
Case report:
4 y.o. presents with loss of consciousness and generalized tonic-clonic seizures. Had bilateral retinal hemorrhages and papilledema. Head CT showed acute subarachnoid and intracerebral hemorrhages. Cerebral angiogram was negative but spinal cord MRI showed a large spinal cord arteriovenous malformation at T9-L2.
The authors presume that the cause of retinal hemorrhages in this case is a sudden increases in intracranial pressure that is transmitted through the optic nerve sheath through the subarachnoid communication in the optic canal.
Pollack JS, Tychsen L. Prevalence of retinal hemorrhages in infants after extracorporeal membrane oxygenation. Am J Ophthalmol 1996;121:297-303.
Objective:
To determine the prevalence of retinal hemorrhages in infants and children after venoarterial ECMO.
Methods:
Thirty-seven (18% of 202 patients who underwent ECMO) patients were chosen randomly by a neonatologist for eye examination following ECMO. Patients were examined within 30 days (average 16 days) of ECMO.
Results:
Five patients were found to have (unilateral) retinal hemorrhages (13%):
- 4/5 were neonates examined an average of three weeks after birth:
- descriptions of retinal hemorrhages:
- Patient 1: "single dot hemorrhage located posterior to the equator"
- Patient 2: "two extamacular dot hemorrhages in the right eye"
- Patient 3: "three dot hemorrhages located outside the macula in the left eye"
- Patient 4: "single extrafoveal dot hemorrhage in the macula"
One patient was 21 months old: description of retinal hemorrhage: "small (<1 disc diamerter) intraretinal flame-shaped hemorrhage located near the optic disk in the left eye"Eight patients in the series had cerebral hemorrhages but none of these eight had retinal hemorrhages. Presence of retinal hemorrhages did not correlate with mortality.
Conclusion:
In this small series of patients, retinal hemorrhages were not seen commonly in patients following ECMO. It is notable that the majority of patients with retinal hemorrhages following ECMO (4/5) were neonates.
Shiono T, Abe S, Watabe T, et al. Vitreous, retinal and subretinal hemorrhages associated with von Willebrand's syndrome. Arch Clin Exp Ophthalmol 1992;230:496-497.
Objective:
To describe retinal hemorrhages in patients with von Willebrand's syndrome.
Two case repots:
Patient 1: 13 year old female presents with spotted vision OS. Opththalmoscopic examination revealed vitreous, peripapillary retinal and subretinal hemorrhages in right fundus. Found to have decreased activities of Factor VIII and von Willebrand's factor.
Patient 2: 19 year old with vitreous hemorrhages in both eyes and decreased activities of Factor VIII and von Willebrand's factor.
Conclusion:
These case reports demonstrate that retinal and vitreous hemorrhages can be seen in patients with von Willebrand's syndrome.
McLellan NJ, Prasad R, Punt J. Spontaneous subhyaloid and retinal hemorrhages in an infant. Arch DisChild 1986;61:1130-1132.
Objective:
To describe a case of retinal hemorrhages occuring with a ruptured intracranial arterial aneurism.
Case Report:
6 week old presented with left sided seizures, full fontanelle, extensive bilateral retinal hemorrhages and a large right subhyaloid hemorrhage.
Hb=8.5g/dL
PT/PTT, Plts, WBC normal
Skeletal survey normal
CT Scan showed a large right intracerebral hemorrhage
Angiography showed an aneurysm of the right middle cerebral artery
Conclusion:
Intracranial bleeding secondary to a ruptured cerebral aneurism can mimic the symptoms seen in shaken baby syndrome.
What is the Significance of Unilateral Retinal Hemorrhages?
Drack AV, Petronio J, et al. Unilateral retinal hemorrhages in documented cases of child abuse. Amer J Ophthalmol 1999; 128:340-344.
Objective:
To describe 4 cases of documented child abuse in which the children had extensive preretinal or retinal hemorrhages in one eye only.
Methods:
In all four cases " an adult caretaker was found responsible for shaking, choking or squeezing the child". Indirect ophthalmoscopy was performed by an ophthalmologist in all cases.
Case 1: 6 month old
- CT scan: Cerebral infarction
- Fundiscopic exam: "Multiple diffuse dot/blot retinal hemorrhages, some with white centers"; several preretinal hemorrhages" in the left fundus
- Other findings: Ecchymosis of the left upper eyelid and left side of neck
- Adult caretaker prosecuted for grabbing and shaking the infant by the neck
Case 2: 5 month old
- Brain MRI: Small right subdural hematoma
- Fundiscopic exam: "Diffuse intraretinal hemorrhages in the posterior pole in the right eye including white-centered hemorrhages, preretinal hemorrhages and hemorrhages into the vitreous near the optic nerve"
- Other findings: Old rib fracture
- Adult caretaker admitted to shaking the baby
Case 3: 17 month old
- Brain MRI: Bilateral subdurals, R>L
- Fundiscopic exam: "Diffuse intraretinal hemorrhages many with white centers throughout the posterior pole in the right fundus"
- Other findings: Ecchymosis around right eye and bruises on left face and right arm
- Adult caretaker had shaken the child
Case 4: 6 month old
- Brain MRI: Bilateral subdurals
- Fundiscopic exam: "Preretinal hemorrhage over left macula with several other intraretinal hemorrhages throughout the posterior pole"
- Other findings: Bilateral rib fractures and left tibia fracture
- Adult caretaker tried to calm infant during inconsolable crying and "perhaps did not know his own strength"
Conclusion:
Unilateral retinal hemorrhages occurred in these four cases where adult caretakers admitted to or were prosecuted for child abuse or shaking.
Tyagi AK, Willshaw HE, Ainsworth JR. Unilateral retinal hemorrhages in non-accidental injury. Lancet 1997;349:1224.
Objective:
To describe three cases of unilateral retinal hemorrhages in children sustaining non-accidental injury.
Case 1: 5 week old
- Retinal Findings: "Extensive retinal hemorrhage and a dense premacular hemorrhage in the right eye".
- CT Findings: Cerebral edema; subdural hemorrhages
Case 2: (No age reported)
- Retinal findings: Unilateral retinal hemorrhages (not described)
- CT findings: Cerebral edema; subdural hemorrhages Other findings: Fractures of differing ages
Case 3: (no age reported)
- Retinal findings: Unilateral retinal hemorrhages (not described)
- CT findings: Cerebral edema; subdural hemorrhages Other findings: Humerus metaphyseal fracture
Conclusion:
Unilateral retinal hemorrhages occurred in these three cases which the authors felt were consistent with non-accidental injury.
Paviglianti JC, Donahue SP. Unilateral retinal hemorrhages and ipsilateral cranial bleeds in nonaccidental trauma. JAAPOS 1999; 3:383-384.
Objective:
To describe three patients with unilateral retinal hemorrhages and ipsilateral cranial hemorrhages in which non-accidental trauma was "strongly suspicious"
Results:
| Case | 1 | 2 | 3 |
| Age/sex/race | 5mo/m/w | 4w/f/w | 10 mo/m/w |
| History To ED after sz. | Intermittent sz in ED | To ED multiple apneic episodes | To ED after fall from bed at home |
| Ocular findings | OD numerous intra and pre retinal hemorrhages near optic nerve, extending past the arcades. OS normal | OD numerous pre- and subretinal hemorrhages near optic nerve, extending past the arcades. OS normal | OS multiple intraretinal rh. OD normal |
| Neuroimaging | CT acute and subacute SDH near R frontal convexity, with mass effect and midline shift | CT SAH over the right frontal convexity and r sylvian fissure | CT small epidural heme underlying the left convexity |
| Skeletal imaging | normal | normal | normal |
Conclusion:
Unilateral retinal hemorrhages occurred in these three patients who the authors felt had sustained non-accidental trauma.
What are the Outcomes of Infants and Children with Retinal Hemorrhages?
Matthews GP, Das A. Dense vitreous hemorrhages predict poor visual and neurological prognosis in infants with shaken baby syndrome. J Pediatr Ophthalmol Strabismus 1996;33:260-265.
Objective:
To examine the relationship between the presence and extent of vitreous hemorrhages and neurological outcome findings in infants with shaken baby syndrome.
Methods:
5 patients with shaken baby syndrome (SBS) were examined. SBS was diagnosed when infants or children had evidence of intraocular hemorrhages, with subdural or subarachnoid hemorrhages and a history of suspected child abuse. All patients underwent pars plana vitrectomy for removal of vitreous hemorrhages.
Results:
| Patient | Age at Injury | Ocular findings | CT/MRI | Neurological outcome findings |
| 1 | 7 months | Dense vitreous hemorrhages (OU). Intraoperative findings (IO): large multiple retinal holes and ischemia (OU) | Occipital infarct; subarachnoid hemorrhage | Chronic vegetative state; hypertonic; expired 5 months after injury |
| 2 | 8 months | Dense vitreous hemorrhages (OU) IO: large multiple retinal holes (OU) | Right frontal, temporal, parietal subdural | Left hemiparesis; seizures; no neurologic improvement |
| 3 | 5 months | Dense vitreous hemorrhages (OU) IO: :macular holes (OU); giant retinal tear (OS) | Bilateral subdural hemorrhage; diffuse cerebral edema; atrophy | Spasticity; seizures; no neurologic improvement |
| 4 | 3 months | Intraretinal hemorrhages (OD); subhyaloid macular hemorrhage (OS) IO: retina attached; no holes | Right frontal intracranial hemorrhage with ischemia and edema; subdural hematoma | Neurologically improved |
| 5 | 4.5 months | Subhyaloid and intraretinal hemorrhage (OU) IO: retina attached; no holes | Bilateral frontal subdural hemorrhage | Neurologically improved |
Conclusion:
The presence of vitreous hemorrhages in these infants with shaken baby syndrome suggested a poor neurological outcome in three of the five infants.
Han DP, Wilkinnson WS. Late ophthalmic manifestations of the shaken baby syndrome. J Pediatr Ophthalmol Strabismus 1990;27:299-303.
Objective:
To describe the ophthalmologic findings and complications in children months after an initial shaking episode.
Methods:
Six children were examined 12-55 months following a shaking injury. Patients underwent a dilated direct and indirect fundiscopic exam as well as visual acuity testing and other tests by an ophthalmologist.
Results:
| Age at Injury | Age at F/U | CT findings | Intraoccular hemorrhage | Final Visual Acuity | Associated Findings | Causes of visual loss |
| 20 months | 6.2 yrs. | Right subdural hemorrhage | Bilateral subhyaloid hemorrhage | 20/50 OD
20/20 OS | | Macular fold |
| 8.5 months | 1.8 yrs. | Diffuse atrophy | Unilateral (OD) subhyaloid or vitreous hemorrhage | Unable to maintain gaze (OD) | | Macular folds |
| 4 months | 3.2 yrs. | Subarachnoid hemorrhage; diffuse edema | Bilateral subhyaloid or vitreous hemorrhage | Poor fixation (OU) | Severe MR | Bilateral occipital lobe infarction |
| 3 months | 2.4 yrs. | Right occipital hematoma; diffuse edema;subarachnoid hemorrhage | Unilateral subhyaloid or vitreous hemorrhage | No fixing/ following (OU) | Severe MR | Occipital lobe atrophy |
| 10 months | 4.0 yrs. | Bilateral occipital infarction; bilateral subarachnoidhemorrhage | Bilateral subhyaloid or vitreous hemorrhage | No fixing/ following (OU) | | Bilateral occipital lobe infarction |
| 9 months | 1.8 yrs. | Right subarachnoid; bilateral prefrontal subdural hemorrhage | Bilateral subhyaloid hemorrhage | Steady maintained gaze | Left hemiparesis | (not mentioned) |
Conclusion:
There was significant visual morbidity associated with these 6 cases of shaken baby syndrome.
McCabe CF, Donahue SP. Prognostic indicators for vision and mortality in shaken baby syndrome. Arch Ophthalmol 2000;118:373-377.
Objective:
To determine the prognostic indicators for vision and mortality in patients who were diagnosed with shaken baby syndrome.
Methods:
Retrospective chart review of 30 patients. Mean age of patients at injury was 9.3 months (range: 1-39 months)
Results:
Follow-up: 20/22 living children received follow-up examinations for a mean of 6.7 months (range 1-36 months).
- Retinal hemorrhages resolved in
- 7 patients 1 month following injury
- 5 patients 2 months following injury
- 4 patients 3 months following injury
- 2 patients 4 months following injury
- 1 patient at the 9 month visit
- 1 patient at the 11 month visit
- (not all patients had monthly visits, so this represents the maximum time)
- Twelve patients (40%) were able to fix and follow (fix and follow vision) initially.
- Ten (83%) retained fixed and follow vision
- Two (17%) lost this vision
- Eighteen patients (60%) presented without fix and follow vision in at least 1 eye:
- Eight died.
- Of the remaining 10 patients: 7 (70%) gained fix and follow vision, and 3 (30%) never had improvement in their vision
- After resolution of retinal hemorrhages, 6/22 patients had poor vision in at least one eye:
- Two patients had optic atrophy
- One patient had retinal fibrosis,
- One patient had retinal scaring/traumatic cataract
- Two patients had cortical visual impairment
Conclusion:
Decreased vision in these patients at follow-up was due to retinal scarring, optic atrophy and cortical visual impairment.
Kivlin JD, Simons KB, Lazoritz S, Ruttum MS. Shaken Baby Syndrome. Ophthalmology 2000;107:1246-1254.
Objective:
To examine clinical and autopsy ophthalmological findings and outcome results in children who were diagnosed with shaken baby syndrome.
Methods:
Retrospective review of the eye examinations or histological examination of patients <3 years of age with shaken baby syndrome (shaken baby syndrome was determined based on the presence of subdural hemorrhages, characteristic fractures and lack of supporting history).
Results:
Eighty three percent of 111 patients diagnosed as having SBS and who had an ophthalmology consult had retinal hemorrhages.
Thirty six (29%) patients died:
- Lack of visual response and poor pupillary response proved to be strongly associated with demise.
- The presence of retinal hemorrhages correlated with death
Visual outcome was assessed in 68 survivors:
Mean follow-up was 21 months (range: 1 month-7years)
| Causes of impairment | Number |
| Bilateral (19 patients) | |
| Cerebral alone | 11 |
| Cerebral + optic atrophy | 1 |
| Cerebral + retinal injury | 2 |
| Cerebral + high myopia | 1 |
| Retinal injury + homoonymous | 1 |
| Hemianopsia (HH) | |
| HH alone | 3 |
| | |
| Unilateral (2 patients) | |
| Retinal/optic nerve injury | 1 |
| Stabismic amblyopia | 1 |
Conclusions:
- Presence and bilaterality of retinal hemorrhages gave a worse prognosis for survival in patients with shaken baby syndrome.
- Most patients with visual impairment following shaken baby syndrome had cortical impairment.
Wilkinson WS, Han DP, Rappley MD, Owings CL. Retinal hemorrhage predicts neurologic injury in the shaken baby syndrome. Arch Ophthalmol 1989;107:1472-1474.
Objectives:
To find characteristics of retinal hemorrhages that will identify infants at risk for severe intracranial injury from the shaken baby syndrome.
Methods:
Fourteen cases of shaken baby syndrome were identified (shaken baby syndrome was defined by the presence of intraoccular hemorrhage and intracranial injuries in the absence of external signs of head trauma). Mean age was 5.5 months.
All patients had a head CT and a fundiscopic exam (fundiscopic exam was within 72 hours of injury and performed by an ophthalmologist).
- "Initial neurologic score" was determined from the clinical examination and CT findings.
- "Late neurologic score" was based on the presence of motor or cognitive delay, seizure activity or residual focal defect and the presence of hydrocephalus or substance loss on CT.
- "Retinopathy score" was determined from the type and extent of occular hemorrhage.
Results:
There was a significant correlation between retinopathy score and the initial neurologic injury score. There was a borderline statistical significance between retinopathy score and late neurologic injury score. Younger patients had higher retinopathy scores.
Conclusion:
The severity of retinal hemorrhages predicts the severity of initial neurological injury in this series of patients with shaken baby syndrome.
Do Neonates Have Retinal Hemorrhages?
Smith WL, Alexander RC, Judisch GF, et al. Magnetic Resonance Imaging Evaluation of Neonates with Retinal Hemorrhages. Pediatrics 1992;89: 332-333.
Objective:
To determine if there is a relationship between retinal hemorrhages acquired at birth and concurrent intracranial injuries.
Methods:
Full-term neonates without perinatal problems and normal Apgar scores were selected randomly and had dilated retinal examination by pediatric ophthalmologist (n=46).
Ten infants had retinal hemorrhages. All 10 infants had a brain MRI: 8/10 were satisfactory scans.
Results:
None of the neonates showed evidence of intracranial injury on MRI.
Conclusion:
In this group of full-term neonates without perinatal complications and with normal Apgar scores, retinal hemorrhages were not associated with intracranial bleeding.
Sezen F. Retinal hemorrhages in newborn infants. Brit J Ophthalmol 1970;55:248-253.
Objective:
To determine the incidence and causes of retinal hemorrhages (RH) in newborn infants.
Methods:
1238 newborn infants were examined for retinal hemorrhages with dilated direct ophthalmoscopy:
- 709 infants were examined within the first 24 hours
- 304 infants were examined within 25-48 hours
- 225 infants were examined between 72-120 days
Results:
178 infants had retinal hemorrhages (14.3%)
| Hours after birth | Percentage of infants with Retinal Hemorrhages |
| 1-24 | 18.9 |
| 24-48 | 12.5 |
| 72-120 | 2.6 |
| Delivery technique | Number | Number with RH (%) |
| Vacuum extraction | 62 | 25 (40.3) |
| Forceps | 9 | 3 (33.3%) |
| Cesarean section | 125 | 1 (0.8%) |
| Spontaneous | 1042 | 147 (14.2) |
15/61 of infants born premature had retinal hemorrhages (24.6%).
Types of hemorrhages seen:
- Flame shaped hemorrhage: occasionally disappeared within 24 hours; usually within 3 days and sometimes remained as long as 5 days.
- Round, red, deep hemorrhages: usually disappeared after 14-21 days; in one case, the retinal hemorrhages disappeared 6 weeks after birth.
Conclusions:
- Mode of delivery influences the incidence of retinal hemorrhages in newborn infants with the highest incidence seen in infants following vaccum extraction delivery and the lowest following cesarean sections.
- Retinal hemorrhages secondary to birth usually resolve within 5 days of life if they are flame shaped and within 21 days if they are deep hemorrhages.
Planten JT, v d Schaaf PC. Retinal hemorrhage in the newborn. Ophthalmologica 1971;162:213-222.
Objective:
To see if there is a relationship between the course of labor and retinal hemorrhages in neonates.
Methods:
Study 1. Once a week all infants born within that week were examined with direct dilated ophthalmoscopy (n=329 infants)
Study 2: All infants born within 24 hours were examined with direct dilated ophthalmoscopy (n=222 infants)
(examiners were blinded to the mode of delivery)
Results:
Study 1: Twenty-four infants had retinal hemorrhage (7%)
| Type of delivery | Number of neonates | Number with RH (%) |
| Spontaneous | 244 | 19 (8%) |
| Vacuum extraction | 22 | 3 (14%) |
| Forceps | 25 | 1 (4%) |
| Cesarean section | 36 | 1 (3%) |
| Version and extraction | 2 | 0 |
(13 patients were examined on the first day of life, 4 patients were examined on the second day of life, 2 patients were examined on the third day of life, 3 patients were examined on the forth day of life, 1 patient was examined on the fifth day of life, 1 patient was examined on the sixth day of life)
Study 2: Fifty infants had retinal hemorrhages (23%).
| Type of delivery | Number of neonates | Number with RH (%) |
| Spontaneous | 154 | 34 (22%) |
| Vacuum extraction | 23 | 5 (21%) |
| Forceps | 20 | 8 (40%) |
| Cesarean section | 36 | 2 (6%) |
| Breech presentation | 13 | 1 (7.6%) |
Conclusion:
The incidence of retinal hemorrhages in newborn infants is influenced by mode of delivery with the highest incidence following forceps assisted delivery and the lowest incidence following cesarean section.
Baum JD, Bulpitt CJ. Retinal and conjunctival hemorrhage in the newborn. Arch Dis Child 1970;45:344-349.
Objective:
To study the incidence of retinal and conjunctival hemorrhages in the newborn in relation to etiologic factors.
Methods:
230 infants were examined within a few days of birth with dilated indirect ophthalmoscopy.
Results:
Thirty-three infants had retinal hemorrhages (15.5%) when all infants examined within the first week of life were included.
Retinal hemorrhages were bilateral in 20/33 of cases. In the 13 unilateral cases the hemorrhages were "smaller and less extensive".
| Age at examination | Number of infants seen | %with retinal hemorrhages |
| 0-12 hours | 39 | 31% |
| 0-24 hours | 100 | 20% |
| 0-48 hours | 152 | 17% |
| 0-120 hours | 210 | 15.5% |
| Type of delivery | Number | Number with retinal hemorrhages (%) |
| Spontaneous vertex | 109 | 24 (22%) |
| Breech | 8 | 1 (13%) |
| Cesarian section | 23 | 3 (13%) |
| Forceps | 12 | 4 (33%) |
| Vacuum extraction | 1 | 1 (100%) |
There was no significant difference between infants with retinal hemorrhages and without retinal hemorrhages when infants were compared according to:
- sex distribution
- race
- birthweight
- relation to gestational age
- mode of delivery
- need for positive pressure ventilation during resuscitation
- maternal parity
No relation was established between retinal hemorrhages and asphyxia.
Conclusion:
Retinal hemorrhages were found in 15.5% of infants who were examined in the first week of life. No factor was found to be significantly associated with retinal hemorrhages in neonates.
Levin S, Janive J, Mintz M, et al. Diagnostic and prognostic value of retinal hemorrhages in the neonate. Obstretics and Gynecology 1980;55:309-314.
Objective:
To investigate whether the course of pregnancy and management of delivery influences the incidence of retinal hemorrhages in neonates.
Methods:
410 infants were examined within 24 hours of birth by an ophthalmologist with dilated direct ophthalmoscopy.
Results:
150 infants (37.3%) had retinal hemorrhages.
| Mode of delivery | Number of infants with retinal hemorrhages (%) |
| Spontaneous | 118 (38.9) |
| Vacuum extraction | 16 (44.4%) |
| Forceps | 8 (28.6%) |
| Vacuum extraction and Forceps | 4 (57.1) |
| Cesarean section | 4 (12.1) |
Other studies:
| Author | Time from delivery to exam | % of infants with RH |
| Baum, 1970 | 24 hours | 20% |
| Bergen, 1976 | 24 hours | 35 |
| Giles, 1960 | 24 hours | 36 |
| McKeown, 1941 | 18-24 hours | 50.5 |
| Noorden, 1973 | 24 hours | 24.5 |
| Schenker, 1966 | 24 hours | 19.2 |
| Sezen, 1971 | 24 hours | 18.9 |
| Present study | 24 hours | 37.3 |
Conclusion:
37.3% of infants examined within 24 hours of birth had retinal hemorrhages in this study. Mode of delivery influences the incidence of retinal hemorrhages (the incidence is lower in infants delivered by cesarean section).
Schenker JG, Gombos GM. Retinal hemorrhage in the newborn. Obstret Gynecol 1966;27:521-523.
Objective: To study the relationship between type of labor and the fundiscopic changes in newborn infants.
Methods:
317 newborns were evaluated with dilated ophthalmoscopy within 24 hours of birth. The examination results were correlated with the case history of each delivery.
Results:
Sixty-one infants (19.2%) had retinal hemorrhages.
| Mode of delivery | Number | Number with Retinal Hemorrhages (%) |
| "Normal" | 244 | 42 (17.3) |
| Cesarean Section | 20 | 0 |
| Forceps | 16 | 5 (31) |
| Vacuum extraction | 25 | 13 (52) |
| Breech | 12 | 1 (8.3) |
Resolution:
- In 20 neonates the retinal hemorrhages resolved within 3 days
- In 35 neonates, the retinal hemorrhages resolved within 8 days
- In 6 neonates, the retinal hemorrhages persisted beyond 8 days
Conclusion:
Retinal hemorrhages occur in infants following birth and are more common when forceps or vacuum extraction is used. Most retinal hemorrhages in neonates disappear within 8 days.
Beratis NG, Varvarigou A, Katsibris J, Gartaganis SP. Vascular retinal abnormalities in neonates of mothers who smoked during pregnancy. J Pediatr 2000;136:760-766.
Objective:
To investigate whether maternal smoking during pregnancy causes retinal abnormalities in the newborn.
Methods:
162 term neonates whose mothers smoked during pregnancy were examined by one ophthalmologist during the second or third day of life
- 135 births were by spontaneous delivery
- 27 births were by elective cesarean section
- 112 infants were appropriate for gestational age (AGA)
- 30 infants were small for gestational age (SGA)
- 20 infants were large for gestational age (LGA)
162 term neonates whose mothers did not smoke during pregnancy were examined by one ophthalmologist during the second or third day of life = controls.
- 135 births were by spontaneous delivery
- 27 births were by elective cesarean section
- 112 infants were AGA
- 30 infants were SGA
- 20 infants were LGA
Inclusion criteria:
- Clear amniotic fluid
- No signs of fetal distress
- Healthy infants
- Apgar scores >= 7
- Mothers who did not:
- have preeclampsia
- have diabetes
- have hypertension
- use illicit drugs
Results:
| | # of Newborns of Smoking Mothers | # of Newborns of Non-smoking Mothers | p |
| Retinal Hemorrhages (all) | 36 | 18 | .0007 |
| Flame-shaped RH | 14 | 7 | .029 |
| Dot and Blot RH | 33 | 17 | .0005 |
| Both Flame and Dot/Blot | 16 | 9 | |
There was a significant positive correlation between the number of cigarettes smoked per day and the severity of the retinal hemorrhages (determined by extent of retinal area occupied by the hemorrhage)
Resolution of retinal hemorrhages in all infants occurred by the third month of life.
Conclusion:
There was an increased frequency of retinal hemorrhages seen in neonates of mothers who smoked during pregnancy when compared to infants of mothers who did not smoke during pregnancy (smoking information was ascertained by self-report).
Skalina MEL, Annable WL, Kliegman RM, Fanaroff, AA. Hypertensive retinopathy in the newborn infant. J Pediatr 1983;103:781-786.
Objective:
To report the incidence of retinal changes in newborn infants with systemic hypertension.
Methods:- 23 patients observed to have systemic hypertension were examined with dilated indirect ophthalmoscopy.
- Hypertension was defined as mean arterial blood pressure >70mm Hg on at least three separate days.
- The mean onset of hypertension was10.7 days of life (range: birth-52 days).
- Patients were examined only after their medical condition had stabilized or improved (mean or range of days is not given).
Results:
Eleven infants had retinal abnormalities (2 infants died). Of those that had hemorrhages:
- 4 had splinter hemorrhages (and these were still visible at 1 ½ months of life or later)
- 2 had dot/blot hemorrhages
- 2 had exudates
One child with splinter hemorrhages still had evidence of them at 10 weeks following the first examination.
Conclusion:
Retinal hemorrhages are seen in infants with systemic hypertension. The time to resolution of the retinal hemorrhages in one child was longer than what is expected with neonates.
Emerson MV, Pieramici DJ, Stoessel KM, et al. Incidence and rate of disappearance of retinal hemorrhage in newborns. Ophthalmology 2001;108:36-39.
Objective: To determine the incidence of and rate of disappearance of neonatal retinal hemorrhages.
Methods:
Consecutive healthy newborns (as determined by the pediatrics service) were examined within 30 hours of birth.
Dilated indirect ophthalmoscopy was performed. If retinal hemorrhages were detected, indirect ophthalmoscopy was repeated every 2 weeks until hemorrhage was no longer detected.
Examination was by a fellowship trained retinal specialist.
Results:
149 newborns were enrolled
- Retinal hemorrhages were detected in 50/149 (34%) of newborns
- 26 newborns (52%) had bilateral retinal hemorrhages
- 9/12 (75%) of infants born by vacuum-assisted delivery had retinal hemorrhages
- 40/120 (33%) of infants born by spontaneous vaginal delivery had retinal hemorrhages
- 1/15 (7%) of infants born by cesarean section had retinal hemorrhages
- 0/2 (0%) of infants born by forceps-assisted delivery had retinal hemorrhages
17 of 50 patients were lost to follow-up (34%)
Of the remaining 33 patients:
- At two weeks after birth, the retinal hemorrhages had disappeared in 28 patients (85%)
Of the 4 patients (out of 5) that returned for follow-up at 4 weeks after birth:
- One patient had a single subretinal hemorrhage; this hemorrhage was not detected 6 weeks after birth
Conclusions:
- The incidence of retinal hemorrhages in this study (34%) is consistent with reported values from other studies.
- In this study, the incidence of retinal hemorrhages in newborns is highest for infants born by vacuum-assisted delivery and lowest for infants born by cesarean section.
- In this series, most retinal hemorrhages disappeared by 2 weeks of age; one subretinal hemorrhage persisted up to 6 weeks after birth
Does Purtscher Retinopathy Occur in Children?
Tomasi LG, Rosman NP. Purtscher retinopathy in the battered child syndrome. Am J Dis Child 1975;129:1335-1337.
Objective:
To describe two cases of children with chest injury and retinal hemorrhages.
Purtscher Retinopathy: hemorrhagic retinal angiopathy with preretinal, retinal hemorrhages and retinal exudates and decreased visual acuity. It follows compression of the thorax which results in an increase in intravascular pressure to the head and eyes. Most reported cases have been in adults. (author's definition)
Methods:
Two cases reports
Case 1:
- 18 week old presented with bruises on right hemithorax; bruises also on right cheek, buttock, thigh and left foot.
- Bilateral retinal hemorrhages were present and retinal exudates were seen in the left fundus.
- No imaging was performed, but
- Patient had two bilateral subdural taps; the first was negative and the second had 3cc of slightly xanthochromic fluid.
Case 2:
- 23 month old presented with bruises on neck and chest circumferentially; also had bruising on the face, buttocks and legs.
- Preretinal hemorrhages were seen bilaterally; subhyaloid fluid level and exudates were seen in the right fundus.
- No imaging was performed.
Conclusion:
Although these two children had chest wall bruising indicating possible thoracic compression, it is impossible to conclude that an increase in intravascular pressure from thoracic compression was the cause of the retinal hemorrhages because head imaging was not performed.
Does Terson Syndrome Occur in Children?
Kuhn F, Morris R, Witherspoon CD, Mester V. Terson syndrome. Results of vitrectomy and the significance of vitreous hemorrhage in patients with subarachnoid hemorrhage. Ophthalmology 1998;105:472-477.
Objective:
(study A) To determine if vitrectomy is effective for Terson syndrome.
(study B) To determine the incidence of vitreous hemorrhages in patients with subarachnoid hemorrhages.
Terson syndrome: when subarachnoid or subdural hemorrhages are followed by intraoccular hemorrhages (presumably from intracranial pressure impeding the venous outflow from the eye). (author's definition)
Methods:
(study A) Retrospective chart review of 27 patients who had vitectomy performed . All patients had a subarachnoid or subdural hemorrhage. 4 patients were children (3 were <1 year of age). All 4 children had subdural hemorrhage.
(study B) Prospective study to examine the eyes of 100 patients undergoing neurosurgery for subarachnoid hemorrhages. Unsure if any patients were children.
Results:
(study B) Intraocular hemorrhages were found in 17 eyes of 100 patients with ruptured cerebral aneurysms resulting in subarachnoid hemorrhages.
Conclusion:
Because there were no known pediatric patients in Study B, the incidence of Terson syndrome in children cannot be estimated from this study. Four children with subdural hemorrhages also had vitreous hemorrhages that required vitrectomy (this meets the author's definition of Terson syndrome).
