Call in ophthalmologist when abusive head trauma is suspected
Cindy W.Christian, M.D., FAAP
AAP Clinical Report
An infant was brought to the emergency department after his mother said she found
him unresponsive in his crib. She reported that the baby had started vomiting a few
An alert pediatric emergency physician noted what appeared to be a small bruise on
the baby’s leg, and a CT scan showed subdural and subarachnoid hemorrhages. The medical
team ordered an ophthalmology consultation, which revealed too-numerous-to-count sub-,
pre- and intraretinal hemorrhages extending to the retinal edge (ora serrata). Child
protective services was notified, and the first steps to preventing further abuse
had been taken.
This actual case highlights the need to obtain prompt ophthalmology consultation when
abusive head trauma is suspected. Ophthalmic manifestations of child abuse are extremely
variable, and the eye examination often is an important contributor to child abuse
The Academy has released an updated clinical report on this topic, The Eye Examination in the Evaluation of Child Abuse from the Council on Child Abuse and Neglect and the Section on Ophthalmology, along
with the American Association of Certified Orthoptists, the American Association for
Pediatric Ophthalmology and Strabismus, and the American Academy of Ophthalmology.
The report is available at https://doi.org/10.1542/peds.2018-1411 and will be published in the August issue of Pediatrics.
Ocular manifestations of abuse
Retinal hemorrhages are the most common ocular manifestation of child abuse. They
are identified in approximately 75% of infants with abusive head trauma (AHT) when
there is evidence of repetitive deceleration injury with or without blunt head impact.
Ophthalmologists should be asked to examine children if AHT is suspected. Such concern
arises when there are signs of head injury with or without body injury, such as intracranial
hemorrhage. Ocular injury also is a consideration when children present with unexplained
alterations of consciousness or unexplained seizures. When identified, retinal hemorrhages
often, but not always, indicate child abuse. Like everything else, there is always
a differential diagnosis to consider, and findings must be evaluated in their clinical
context. The clinical report reviews the strong association of retinal hemorrhages
and abuse, especially when the hemorrhages are extensive or involve retinoschisis
or retinal folds.
Describing the type, extent and number of retinal hemorrhages is particularly important
in generating and refining a differential diagnosis. The report reviews the differential
diagnoses, mechanisms and pathophysiology of retinal hemorrhages and novel “courtroom
diagnoses” that are inaccurately proffered to explain retinal findings in cases of
Inflicted blunt trauma to the eye can result in a number of eye injuries, including
periorbital ecchymoses, orbital fractures, subconjunctival hemorrhages, hyphema, corneal
abrasion, lacerations and globe rupture. Although these injuries are more commonly
the result of accidental injury or other medical diseases, child abuse should always
Reporting potential abuse
All physicians, including ophthalmologists and other specialists caring for children,
are mandated reporters of suspected child abuse. Reports can be made by calling the
state’s toll-free child abuse reporting hotline.
Whenever possible, the accompanying parent(s)/guardian(s) should be notified about
the concern and the need to report. It can be helpful to raise concern about the finding,
while not apportioning blame. One approach is to inform the family that because of
the nature and circumstance of the examination findings, further investigation is
mandated by law and serves to prevent the child from being injured again should that
prove to be the cause of the observed findings.
Dr. Christian, a lead author of the clinical report, is a former chair of the AAP
Committee on Child Abuse and Neglect.