84 Ophthalmology exams in suspected child physical abuse: are they overused?

Abstract

Recent studies suggest that fundoscopic examination may not be necessary in children with suspected physical abuse if the physical exam and neuroimaging show no evidence of intracranial injury. The likelihood of encountering retinal hemorrhages in these children is very low. To review the ophthalmologic examinations conducted in our center in children under 2 years of age with suspected physical abuse. A single-center retrospective chart review was completed using the electronic medical record of the ophthalmology department. We included children aged 0 to 24 months who were evaluated by ophthalmology for suspected physical abuse between May 2014 and June 2018. Charts were identified using the key words “suspected child abuse, physical abuse, shaken baby syndrome, shaken, maltreatment, abuse, retinal hemorrhage, non-accidental injury’’. We excluded children with suspected physical abuse who were not evaluated by ophthalmology. We collected data on patient characteristics, reason for referral, presence or absence of cerebral imaging, results of the imaging and of the ophthalmologic examination, as well as on the timing of these different types of investigations. During the study period, 55 children were evaluated by ophthalmology for suspected physical abuse. The mean age was 6 months, 62% of the children were between the age of 0 and 6 months, and most of the patients were males (67%). Of the 55 children included in our study, 45 children had cerebral imaging. Of those who had cerebral imaging, 30 (66%) did not have any intracranial injuries, and none of these patients had abnormal retinal findings. Conversely, among the 15 with intracranial injuries, 10 had abnormal ophthalmologic exams. Of the 10 children without imaging all had normal ophthalmologic examinations. Of the 45 who had cerebral imaging, 29 had their imaging done before ophthalmologic examination. Of the 29, 12 (41%) had normal imaging and none of these cases were found to have abnormal retinal findings. Of the 16 patients who had ophthalmologic examinations conducted before cerebral imaging, 13 (81%) had both investigations ordered at the same time and 3 (19%) had ophthalmology ordered first. Our study suggests that, in our center, there is some overuse of ophthalmologic examinations in patients with suspected physical abuse and such examinations should not be used as a screening tool for intracranial injury. Optimization of patient trajectory in the investigation of children with suspected physical abuse will be the focus of a future quality improvement project.