Retinal Hemorrhages In Infants Research Articles

Retinal haemorrhage after cardiopulmonary resuscitation of a patient

Aims/Purpose: We present a rare case of a patient who presented with bilateral retinal haemorrhage after cardiopulmonary resuscitation (CPR).Methods: A 37‐year‐old man, with a medical history of allergic bronchial asthma and a BMI >35, was referred to our emergency department from the cardiology clinic. He complained of sudden, painless, monocular visual acuity reduction after cardiac arrest and CPR because of an acute myocardial infarction (right coronary). He underwent a complete ophthalmic examination, as well as multimodal imaging and he was under close monitoring for the following months.Results: In his initial ophthalmic examination, best corrected visual acuity was 0.1 in his right eye and 1.0 in his left eye (Snellen's chart). Intraocular pressure was 14 mmHg and 15 mmHg in his right and left eye, respectively. Dilated fundus examination showed bilaterally scattered sub‐retinal, intraretinal and pre‐retinal haemorrhages in the posterior pole, with involvement of the right fovea. After the resolution of the haemorrhages, a fluoroangiography was performed which revealed delayed central retinal vein filling in the right eye. 2 months later, during follow‐up examination, visual acuity in the right eye was 0.7 and in the left eye 1.0. The haemorrhages have been absorbed bilaterally, leaving in the right eye a sub‐foveal photoreceptor and RPE disruption.Conclusions: Retinal haemorrhages can be observed after CPR. According to the literature, there have been reports of retinal haemorrhages in infants after CPR. Meanwhile, there is only one published case of an adult with associated comorbidities with this clinical presentation. The underlying pathophysiology of this clinical entity is still unclear, although a potential relationship between the increase in central venous pressure during CPR, and sequential retinal venous stasis is suspected.

Morphological Analysis of Retinal Microvasculature to Improve Understanding of Retinal Hemorrhage Mechanics in Infants.

PurposeIn this experimental study, we quantify retinal microvasculature morphological features with depth, region, and age in immature and mature ovine eyes. These data identify morphological vulnerabilities in young eyes to inform the mechanics of retinal hemorrhage in children.MethodsRetinal specimens from the equator and posterior pole of preterm (n = 4) and adult (n = 9) sheep were imaged using confocal microscopy. Vessel segment length, diameter, angular asymmetry, tortuosity, and branch points were quantified using a custom image segmentation code. Significant differences were identified through two-way ANOVAs and correlation analyses.ResultsVessel segment lengths were significantly shorter in immature eyes compared to adults (P < 0.003) and were significantly shorter at increasing depths in the immature retina (P < 0.04). Tortuosity significantly increased with depth, regardless of age (P < 0.05). These data suggest a potential vulnerability of vasculature in the deeper retinal layers, particularly in immature eyes. Preterm retina had significantly more branch points than adult retina in both the posterior pole and equator, and the number increased significantly with depth (P < 0.001).ConclusionsThe increased branch points and decreased segment lengths in immature microvasculature suggest that infants will experience greater stress and strain during traumatic loading compared to adults. The increased morphological vulnerability of the immature microvasculature in the deeper layers of the retina suggest that intraretinal hemorrhages have a greater likelihood of occurring from trauma compared to preretinal hemorrhages. The morphological features captured in this study lay the foundation to explore the mechanics of retinal hemorrhage in infants and identify vulnerabilities that explain patterns of retinal hemorrhage in infants.

Histological dating of subarachnoid hemorrhage and retinal hemorrhage in infants

BackgroundDating the traumatic event is usually done on subdural hematoma (SDH). After infant deaths due to Abusive head trauma (AHT) without SDH available, the magistrates still ask experts to date the traumatic event. To do so, the expert only has tools based on adult series of AHT. We aimed to develop a subarachnoid hemorrhage (SAH) and retinal hemorrhage (RH) dating system applicable to infants aged under 3 years. Methods and resultsWe studied a retrospective multicenter collection of 235 infants who died between the ages of 0 and 36 months, diagnosed with SAH and/or RH by forensic pathological examination and with known posttraumatic interval (PTI). Two pathologists assessed blindly and independently 12histomorphological features in 83 infants (35 girls, 48 boys) whose median age was 3.8 months. For SAH, histopathological changes were significantly correlated with PTI for the appearance of red blood cells, of fibrino-plaquetted organization, the quantity of lymphocytes and macrophages and the presence or absence of siderophages, collagen and fibroblast formation and presence or absence of neovascularization. For RH, histopathological changes were significantly correlated with PTI for the appearance of red blood cells, the presence or absence of siderophages and sclerosis of the retina. ConclusionOur HAS dating system improves the precision and reliability of forensic pathological expert examination of AHT, when SDH are not available, for age estimation in infants. The study of RH histomorphological changes does not allow for reliable dating.

Retinal Hemorrhages: Abusive Head Trauma or Not?

Abusive head trauma is an important cause of morbidity and mortality in infants and young children. Retinal hemorrhages (RHs) are frequently seen, particularly during dilated eye examination of these children. This review focuses on the evaluation of children with RH, with emphasis on the differential diagnosis, pathophysiology, and distinguishing features of RHs due to abusive head trauma. Many causes exist for RHs in infants and children. Most medical and accidental traumatic causes result in a pattern of RH that is nonspecific and not typical of the pattern and distribution of RHs seen in children with abusive head trauma. In children with intracranial hemorrhage and concerns for abuse, the finding of severe, multilayered RHs extending to the periphery of the retina is very specific for abuse as the cause of the findings, especially if retinoschisis is present. There are few other accidental traumatic mechanisms associated with retinoschisis, and the history of such a traumatic event is readily apparent. The indications for ophthalmologic consult, optimal timing of the eye examination, and significance of the findings are specifically discussed.

CLINICAL MANIFESTATIONS AND OUTCOMES OF RETINAL HEMORRHAGES IN INFANTS: A CASE SERIES

Background. Retinal hemorrhages in infants are frequent pathologies, but their causes, clinical forms and functional outcomes are poorly studied. The study of hemorrhage localization in the eye structure, time frames of their resolution, and the long-term effects that may affect the development of vision is of particular interest.Objective. Our aim was to analyze clinical forms, time frames of resolution and long-term clinical and functional outcomes of retinal hemorrhages in infants.Methods. All children with retinal hemorrhages, who applied to a premature baby room in the MRI of ED n. a. Helmholtz at the age from 3 weeks to 3 months for 5 years (2011–2015), were examined using indirect ophthalmoscopy. In case of extensive lesions, the process dynamics was controlled by a pediatric digital retinal imaging system. Long-term clinical and functional outcomes of retinal hemorrhages were studied using ultrasound examination and spectral optical coherence tomography.Results. Fundus hemorrhages were revealed in 108 (5.9%) of 1,825 infants on 142 eyes (34 children had bilateral hemorrhages). Hemorrhages were more frequent in children delivered vaginally (79 children, 73.2%), were unilateral (74 children, 63.5%), pre-retinal (108 eyes, 76.1%), of central localization (119 eyes, 83.8%). The time frames of hemorrhage resolution in 53 children (49.1%) were more than one month. Long-term outcomes of retinal hemorrhages were studied in 22 children (33 eyes) at the age of 2–5 years. Residual changes in the structure of the neuroepithelium and vitreoretinal interface with a decrement in visual acuity were noted in 7 children (9 eyes).Conclusion. Retinal hemorrhages of newborns are characterized by clinical polymorphism, different time frames of resolution and outcomes, which requires a case follow-up.

Photographic assessment of retinal hemorrhages in infant head injury: the Childhood Hemorrhagic Retinopathy Study

Retinal hemorrhages (RH) in babies in the absence of severe trauma or a medical cause have been strongly associated with abusive head trauma (AHT). We examined the pattern of RH in accidental head injury and AHT objectively using widefield retinal imaging. A total of 118 infants and children 1-36months of age admitted with head injuries at two centers were included in this prospective, consecutive, comparative cohort study. Dilated fundus examination was performed with indirect ophthalmoscopy and widefield imaging. Designation of AHT was made using predetermined criteria independent of retinal findings. Retinal images were graded by two independent observers. There were 21 cases of AHT. RH were present in 14 cases (66%); macular retinoschisis or retinal folds, in 8 (38%). There were 86 cases of accidental head injuries, with RH present in 2 (2%); there were none with retinal folds or retinoschisis. In cases of head injury with intracranial hemorrhage, the positive likelihood ratio of AHT with RH was 5.7 (95% CI, 2.6-12.00) and negative likelihood ratio was 0.26 (95% CI, 0.11-0.62). A severe, panretinal pattern with multilayered hemorrhages was the most specific for AHT. Our imaging study confirmed that RH in infants with head injury have a high positive likelihood ratio for AHT. A severe hemorrhagic retinopathy, particularly in association with perimacular folds or macular retinoschisis, has the highest positive predictive value for AHT.

Prevalence of Retinal Hemorrhages in Infants Presenting with Isolated Long Bone Fractures and Evaluation for Abuse

BackgroundFractures are a frequent reason for emergency department visits and evaluation for abusive head trauma is an associated concern in infants. Recent guidelines have suggested that retinal examination may not be necessary in the absence of intracranial injury, but there is a lack of empirical evidence in infants < 1 year of age. ObjectiveOur aim was to evaluate the prevalence of retinal hemorrhages in infants with isolated long bone fractures. MethodsRetrospective chart review of infants < 1 year of age who presented to an urban, tertiary care pediatric hospital between January 2004 and April 2014 with the diagnosis of an acute long bone fracture or retinal hemorrhages. Patients were excluded for head injury, altered mental status, injury mechanism of motor vehicle accident, multiple fractures or injuries outside the fracture area. Patients were identified through trauma registry data and International Classification of Diseases codes. ResultsOne hundred and forty-six patients had isolated long bone fractures, of which 68 patients did not undergo a retinal examination and 78 patients had dilated eye examinations, with no patients identified as having retinal hemorrhages. There were 46 patients identified with retinal hemorrhages concerning for abuse. No patients with retinal hemorrhages had isolated long bone fractures. ConclusionsIn infants < 1 year of age presenting with isolated long bone fractures, a dilated eye examination to evaluate for retinal hemorrhages is not likely to yield additional information. Our results support recent studies that a subset of children and infants may not require dilated eye examinations in the evaluation of possible abuse.

Smartphone Image Acquisition During Postmortem Monocular Indirect Ophthalmoscopy.

The medical usefulness of smartphones continues to evolve as third-party applications exploit and expand on the smartphones' interface and capabilities. This technical report describes smartphone still-image capture techniques and video-sequence recording capabilities during postmortem monocular indirect ophthalmoscopy. Using these devices and techniques, practitioners can create photographic documentation of fundal findings, clinically and at autopsy, without the expense of a retinal camera. Smartphone image acquisition of fundal abnormalities can promote ophthalmological telemedicine--especially in regions or countries with limited resources--and facilitate prompt, accurate, and unbiased documentation of retinal hemorrhages in infants and young children.

Evaluation of optic nerve compression as a potential cause of retinal hemorrhage in infants

Evaluation of optic nerve compression as a potential cause of retinal hemorrhage in infants

Traitement judiciaire des cas de « bébés secoués ». Aspects répressifs et indemnitaires

Shaken baby syndrome (SBS) is defined by the association of intracranial hemorrhage and retinal hemorrhage in infants under 2 years of age, with no obvious external trauma. This syndrome leads to frequent neurological sequelae. Therefore, these infants can claim compensation for damage if sequelae are directly and irrefutably linked to the trauma. Data on the judicial treatment are for the most part inexistent in the medical literature, the reason for which this study was conducted. We conducted a retrospective study over a period of 10 years. We included all cases of SBS reported to the High Courts of the Ille-et-Vilaine department (Rennes and St Malo). The cases were listed from the archives of the Department of Medical Information, the Specialized Unit for Abused Children and Forensic Department at the Rennes University Hospital. We were able to look the judicial cases up after receiving agreement from the prosecutors of the two courts. Of the 34 cases included, 12 could not be used (lost, ongoing, destroyed, transferred to another court), 16 led to an order of dismissal or to no further action because of an unknown perpetrator, insufficiently described offense, or insufficient evidence. Six authors were sentenced. It was the father (n=5) or the childminder (n=1). All perpetrators had confessed to part or all of the charges brought against them. Five children received compensation: three by the civil court and two by the commission of compensation for victims of an offense. Most cases led to no conviction and no compensation. The identification by the physician of the person responsible for the lesions in SBS does not mean that the perpetrator will be convicted because of the strict application of criminal law. The nomination of an administrator representing the infant could resolve the lack of compensation.

Retinal haemorrhages in infants: controversy and cases

Retinal haemorrhages in infants with a head and neck injury raise the possibility of non-accidental injury. Retinal haemorrhages also occur in a variety of other settings such as secondary to falls, raised intracranial pressure (Terson syndrome), coagulopathy and other blood disorders. The microscopic distribution of haemorrhages in the eye may indicate the aetiology of the haemorrhage. In trauma they are usually widespread, extend throughout the retinal layers into the periphery and involve the inner limiting membrane. There may be associated optic nerve and periorbital fat haemorrhage. However, it is becoming increasingly recognised that retinal haemorrhages alone are not diagnostic for non-accidental injury. Post-mortem neuropathology findings of a head and neck injury should also be considered in conjunction with other physical findings. We present four post-mortem cases aged 14 weeks, 4 months, 9 months and 2 years with retinal haemorrhages, head and neck injuries and histories ranging from a fall to the perpetrator pleading guilty to non-accidental injury.

Retinal haemorrhages in infants, abusive head trauma and the ophthalmologist

Clinical & Experimental OphthalmologyVolume 38, Issue 5 p. 435-436 Retinal haemorrhages in infants, abusive head trauma and the ophthalmologist Glen Gole MD FRANZCO, Glen Gole MD FRANZCO Department of Ophthalmology and UQ Discipline of Paediatrics and Child Health, Royal Children's Hospital, Brisbane, Queensland, AustraliaSearch for more papers by this author Glen Gole MD FRANZCO, Glen Gole MD FRANZCO Department of Ophthalmology and UQ Discipline of Paediatrics and Child Health, Royal Children's Hospital, Brisbane, Queensland, AustraliaSearch for more papers by this author First published: 06 July 2010 https://doi.org/10.1111/j.1442-9071.2010.02339.xCitations: 3Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat No abstract is available for this article.Citing Literature Volume38, Issue5July 2010Pages 435-436 RelatedInformation

An infant with subdural hematoma and retinal hemorrhages: does von Willebrand disease explain the findings?

An 11-month-old girl presented to hospital with a massive subdural haematoma and bilateral retinal haemorrhages following an allegedly minor fall. There were no external signs of bruising and no prior bleeding tendency was reported. Although initial analyses were normal, repeated testing of the coagulation-fibrinolysis system led to a diagnosis of mild von Willebrand disease (vWD) Type 1. It was concluded that minor head trauma as described by the parents, in the presence of such a coagulation disorder, could explain the findings. Police charges against the parents, initially accused of child abuse, were withdrawn. Retinal haemorrhages in infants with vWD have not been previously reported. This case highlights the importance of considering vWD as a possible contributory factor in cases of infant head injury.

Evaluation and management of retinal hemorrhages in infants with and without abusive head trauma

Extensive intraocular hemorrhage in young infants in the setting of acute brain injury and in the absence of a history of severe accidental trauma or underlying medical cause must be considered to be nonaccidental injury until otherwise proven. In the absence of any obvious explanation, the presence of any retinal hemorrhage should raise the possibility of abusive head trauma in the differential diagnosis and perhaps lead to such testing as skeletal radiography and neuroimaging, consultation with a child abuse specialist, as well as workup for other relevant systemic conditions. Physicians who treat infants and children are mandated to report suspected child abuse to child welfare agencies for investigation, and ophthalmologists who encounter children with ophthalmic manifestations of abuse need to ensure that the proper steps are taken to protect their patients from the potential for further harm. Ascertainment of abusive head trauma is critical to prevent a potentially fatal recurrence.

Severe retinal hemorrhages in infants with aggressive, fatal Streptococcus pneumoniae meningitis

Retinal hemorrhages in children occasionally accompany bacterial meningitis, usually due to hemophilus or meningococcal organisms. The hemorrhages may be intraretinal, usually in the posterior pole of the eye and few in number, or, more uncommonly, subhyaloid or vitreous. Pathogenesis may include vasculitis, disseminated intravascular coagulation, or intracranial hypertension. We report 2 cases of bilateral severe retinal hemorrhages in fatal Streptococcus pneumoniae meningitis.

Cerebral haemodynamics in patients with glutaryl-coenzyme A dehydrogenase deficiency

In glutaric aciduria type 1, glutaryl-coenzyme A and its derivatives are produced from intracerebral lysine and entrapped at high concentrations within the brain, where they interfere with energy metabolism. Biochemical toxicity is thought to trigger stroke-like striatal degeneration in susceptible children under 2 years of age. Here, we explore vascular derangements that might also contribute to brain damage. We studied injured and non-injured Amish glutaric aciduria type 1 patients using magnetic resonance imaging (n = 26), transcranial Doppler ultrasound (n = 35) and perfusion computed tomography (n = 6). All glutaric aciduria type 1 patients had wide middle cerebral, internal carotid and basilar arteries. In non-injured patients, middle cerebral artery velocities were 18-26% below control values throughout late infancy and early childhood, whereas brain-injured children had an early velocity peak (18 months) and low values thereafter. Perfusion scans from six patients showed that tissue blood flow did not undergo a normal developmental surge. We observed four different perfusion patterns. (i) Three children (two non-injured) had low cerebral blood flow, prolonged mean transit time, elevated cerebral blood volume and high mean transit time/cerebral blood flow and cerebral blood volume/cerebral blood flow ratios. This pattern optimizes substrate extraction at any given flow rate but indicates low perfusion pressure and limited autoregulatory reserve. (ii) Ten hours after the onset of striatal necrosis in an 8-month-old infant, mean transit time and cerebral blood volume were low relative to cerebral blood flow, which varied markedly from region to region. This pattern indicates disturbed autoregulation, regional perfusion pressure gradients, or redistribution of flow from functional capillaries to non-exchanging vessels. (iii) In an infant with atrophic putaminal lesions, striatal flow was normal but mean transit time and cerebral blood volume were low, consistent with perfusion in excess of metabolic demand. (iv) Finally, a brain-injured adult with glutaric aciduria type 1 had regional perfusion values within the normal range, but the putamina, which normally have the highest regional perfusion, had cerebral blood flow values 24% below cortical grey matter. Although metabolic toxicity appears central to the pathophysiology of striatal necrosis, cerebrovascular changes probably also contribute to the process. These changes may be the primary cause of expanded cerebrospinal fluid volume in newborns, intracranial and retinal haemorrhages in infants and interstitial white matter oedema in children and adults. This pilot study suggests important new areas for clinical investigation.

Infantile Convulsions and Retinal Hemorrhages

The prevalence of retinal hemorrhages in infants presenting with convulsions was studied at Hospital Universitari Sant Joan de Deu, Barcelona, Spain.

Do retinal haemorrhages occur in infants with convulsions?

Aim: To determine the prevalence of retinal haemorrhages in infants presenting with convulsions and admitted to hospital, and to consider whether this finding indicates shaken baby syndrome. Methods: Prospective study...

Severe cough and retinal hemorrhage in infants and young children

Severe cough and retinal hemorrhage in infants and young children

Severe cough and retinal hemorrhage in infants and young children

No retinal hemorrhages were detected in any of 100 consecutive children aged 3 months to 2 years with severe, persistent coughing (0 of 100, 95% CI: 0%- 3%). Therefore, if one finds retinal hemorrhage in infants and young children with cough, child abuse must be excluded.