Medical Professional Publications

Specialty Eye Exams May Not Be Necessary in All Suspected Cases of Physical Child Abuse

It is common practice for physicians to request specialty eye exams to help confirm cases of suspected physical abuse in children, but these exams may be overused, according to a study appearing in Pediatrics.

Abusive head trauma (AHT) is the leading cause of inflicted traumatic death in children, especially among infants. Despite a variety of clinical tools and subspecialty consultation available to aid in the detection of AHT, the diagnosis is often missed.

Certain patterns of retinal hemorrhage, especially hemorrhages seen throughout the entire retina, are extremely uncommon in accidental injury and are rarely reported in any condition other than AHT. “Although the isolated finding of retinal hemorrhages is neither necessary nor sufficient to diagnose AHT, the role of ophthalmologic examination undeniably plays a critical role in the assessment of such cases,” said Jonathan D. Thackeray, MD, clinical director of the Center for Child and Family Advocacy at Nationwide Children’s Hospital and one of the study authors. To avoid a missed diagnosis of AHT, some centers have adopted the practice of undertaking specialty retinal examination in any child when there is a suspicion of physical abuse, regardless of the type of abuse.  “Such practice may lead to unnecessary testing, increased costs and inappropriate use of resources,” said Dr. Thackeray.

To help evaluate whether retinal examination is a valuable diagnostic tool in children suspected of having been physically abused, but who do not show evidence of traumatic brain injury, investigators at Nationwide Children’s Hospital and at Brigham and Women’s Hospital in Boston examined patient data from a multi-center database.  They found that the yield of retinal examination of children being evaluated for physical abuse who show no evidence of traumatic brain injury, regardless of other injury, was extremely low.  Less than 1 percent of the studied children had characteristic retinal hemorrhages and the presence did not seem to enhance the diagnostic determination of abuse.

“In the appropriate clinical context, retinal hemorrhages may be highly indicative of AHT; however, dedicated ophthalmology is probably unwarranted if it fails to influence the ultimate opinion of abuse likelihood,” said Dr. Thackeray.  “Our findings indicate that when evaluating children without traumatic brain injury, and without mental status change or head or face injury, clinicians should thoughtfully consider whether ophthalmology consultation is necessary in the assessment and diagnosis of AHT.”

Thackeray JD, Scribano PV, Lindberg DM. Yield of retinal examination in suspected physical abuse with normal neuroimaging. Pediatrics. 2010 May;125(5):e1066-71.

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