Nonophthalmologist accuracy in diagnosing retinal hemorrhages in the shaken baby syndrome*1

Abstract

Morad Y, Kim YM, Mian M, et al (University of Toronto, Toronto, Ontario, Canada) Retinal hemorrhage (RH), the most common ocular finding in shaken baby syndrome (SBS), is usually diagnosed in the ED by nonophthalmologists. The charts of children with a diagnosis of SBS were reviewed to compare the accuracy of results of fundus examinations performed by nonophthalmologists with those performed by ophthalmologists. During the period between January 1993 and December 1999, 75 children had diagnoses of SBS and were examined by the ophthalmology service at The Hospital for Sick Children in Toronto. The diagnosis required at least 2 of 5 findings: characteristic neuroradiologic abnormalities, skeletal injury, RHs, a history of child abuse that included shaking, and no adequate history to explain the injuries. Complete records were available for 72 children with an average age of 10.6 months. All were initially seen by a service other than ophthalmology, but 61 (85%) had RHs documented by the ophthalmology consultant. The nonophthalmologist was unable to complete an examination of the retina in 14 cases (19%); in 32 cases (44%), the nonophthalmologist examined the fundi and recorded findings. No documentation of fundus examination was available for 26 children (35%). Nonophthalmologists who did examine the retina correctly recognized the presence or absence of RH in 87% of the cases; their false-negative rate was 13%. The nonophthalmologists did not use pupil-dilating drops and failed to record the type, number, or location of RHs. Because cases of SBS are investigated both medically and legally, it is important that retinal abnormalities be accurately diagnosed and thoroughly described. Nonophthalmologists were found to be fairly accurate in diagnosing RHs, but false-negatives did occur and forensic information was incomplete. Thus, ophthalmologic consultation should be obtained in every case of suspected child abuse. A consistent and accurate diagnosis of retinal hemorrhage in SBS is important for medical and legal reasons. Nonophthalmologists (including emergency physicians) were able to accurately perform a retinal examination in 87% of the cases with 13% false-negative examinations. Direct ophthalmoscopy provides a good method to examine optic discs, macula, and posterior retina. However, we work in circumstances in which the most experienced physician would find a retina examination challenging: poor light, an uncooperative child, or lack of dilating drops. The ophthalmologists in this study were able to visualize the fundi to confirm or deny the presence of retinal hemorrhages in all cases, but in all the examinations pupil-dilating drops had been used. Ideally, we would want to use short-acting dilating drops, such as tropicamide 1% or phenylephrine 2.5%, in 1 eye only, thus preserving the other eye for neurologic evaluation.