Unilateral retinal haemorrhages in non-accidental injury

Abstract

Retinal haemorrhages are often seen in infants with nonaccidental injury, particularly following severe shaking. The classic finding is of widespread multiple haemorrhages in both eyes which may be associated with subdural haemorrhage and rib or limb fractures. An incomplete or atyical pattern of presentation may lead to diagnostic uncertainty. We report three infants with non-accidental injury who presented with unilateral retinal haemorrhages. A 5-week-old boy (case 1) was brought to the casualty department because he had stopped feeding after being generally unwell for 2 days. The infant had several convulsions whilst in the casualty department and was admitted for further management. Computed tomography (CT) of the head showed diffuse cerebral oedema, subdural haemorrhages of differing ages, and contusion clefts in the frontal lobes. Skeletal survey and blood investigations were normal. Ocular examination revealed extensive retinal haemorrhages and a dense premacular haemorrhage in the right eye. The left eye was normal with no evidence of intraocular haemorrhage. 48 h after admission the parents reported having been involved in a road traffic accident 2 weeks earlier, during which their son had been secured in an infant support. No external injuries were reported by the parents at the time and therefore non-accidental injury was still considered to be the most likely unifying diagnosis. As a consequence of the presence of haemorrhage in only one eye the diagnosis was called into question and child protection was not instituted. Two more infants were admitted over the ensuing 4 months. In each case the clinical examination and investigations were diagnostic of non-accidental injury, but once again the retinal haemorrhages were unilateral. As a result of our experience and evidence from published research, the original medicolegal report in case 1 was modified. Brief details of the three infants are shown in the table. Intraocular haemorrhages are present in up to 89% of infants with non-accidental injury. They may follow a direct blow to the eye, severe chest compression, or severe shaking of the head. The mechanism of these haemorrhages is uncertain but is probably related to raised intraocular venous pressure due to a sudden rise in intracranial pressure or raised central venous pressure. One might expect retinal haemorrhages in patients with non-accidental injury to be bilateral due to the nature of the injury. Very few cases of unilateral retinal haemorrhages have been reported and this unilaterality has never been emphasised. Thus the possibility of unilateral retinal haemorrhages occurring in non-accidental injury is not widely recognised. Since retinal haemorrhages can present before other injuries become apparent we feel that in the age group at risk, non-accidental injury should be suspected even in cases of unilateral retinal haemorrhage, and the infant admitted for further evaluation. Although the intraocular haemorrhages have cleared in the three infants, the vision has returned to normal level in case 1 only, and remains greatly reduced in cases 2 and 3 due to associated optic nerve and occipital lobe injury. A good prognosis for visual recovery cannot be assured even if the initial signs of injury are limited to one eye.