Retinal haemorrhages in a child struck by a barbell.

Abstract

The presence of extensive retinal haemorrhages (RH) in infants and toddlers may suggest abusive head trauma (AHT). RH, particularly in AHT do not exist in isolation, and must be interpreted in conjunction with assessment by a multidisciplinary team with careful consideration of any suggested accidental mechanism of injury. Recent evidence suggests significant crush injury to an infant's head is capable of causing RH resembling those observed in AHT.1 A 30-month-old toddler found unconscious on the floor beside weight lifting equipment had bruising to the head, and subsequently developed pulmonary oedema and cardiogenic shock. Subarachnoid and intra-ventricular haemorrhage and cerebral oedema were present on neuroimaging (Fig. 1). An ophthalmologist undertook dilated fundal examination on day 3. This showed bilateral RH, consisting of pre-retinal and intra-retinal haemorrhages, including flame shaped, white-centred and deeper blot RH (Fig. 2a,b,c right eye, 2d, left eye). There were more than 20 haemorrhages in the right eye, and 11 in the left eye, and were confined to the posterior pole (zone 1). No retinoschisis was present in either eye. There was no RetCam (Clarity Medical Systems, Pleasanton, CA, USA), so images were taken under general anaesthetic on colour film with a Zeiss Retinal Camera, with a narrow 25-degree field of view. Computed tomography scan of the child showing subarachnoid and intra-ventricular haemorrhage and cerebral oedema. (a, b, c) Retinal photos of the right eye and (d) left eye, showing widespread retinal and intraocular haemorrhages, of various morphologies including flame, deep blot and pre-retinal – either sub-internal limiting membrane or intravitreal. The haemorrhage in 2a and b (arrow) is pre-retinal. Patchy pale areas in the superficial retina in the posterior pole, as imaged in 2a,c, are most likely artefact and not typical for Purtscher Flecken. Given his serious injuries, following admission he was referred to the child protection team. The police had gone to the scene immediately on the evening of admission. Several adults and an 8-year-old cousin were interviewed. The child was unseen for 5 min when a loud crash was heard. The 8-year old said he saw him swinging on the barbells to the right of the weightlifting frame. He heard the crash but did not see him fall and found him lying face down, head (turned to the left) on a car wheel, with the frame across his body, and barbells lying nearby. He lifted the frame off when he heard the adults coming, let him slump forward, and ran away, fearing blame. Severe retinal haemorrhage associated with head trauma in a young child, in the absence of a clear history of serious accidental trauma, should always raise the possibility of abusive head trauma. Despite our knowledge of the association, there is still much that is unknown about the pathophysiology of retinal haemorrhage in abusive head trauma. Retinoschisis has been described in crush injuries to the head. Valsalva/Purtscher retinopathy associated with crush injury to the chest is reported in adults but not in children. In the reported case, the precise mechanism of the retinal hemorrhages cannot be established with certainty, but is most likely to represent a direct effect of impact to the head, possibly in combination with chest compression. This case report adds another example of the types of accidental trauma that may be capable of causing retinal haemorrhage in children.