Improved Documentation of Retinal Hemorrhages Using a Wide-Field Digital Ophthalmic Camera in Patients Who Experienced Abusive Head Trauma Improved Documentation of Retinal Hemorrhages Using a Wide-Field Digital Ophthalmic Camera in Patients Who Experienced Abusive Head Trauma Thomas A. Nakagawa, MD; Ruta Skrinska, MD Objective: To describe the clinical use of a wide-field digital ophthalmic camera (RetCam 120; Massie Re- search Laboratories, Inc, Dublin, Calif) for the docu- mentation of retinal hemorrhages in patients who expe- rienced abusive head trauma. Design: Case series. Setting: Pediatric intensive care unit at a tertiary care center. Participants: Children with suspected abusive head trauma. Results: Eight children were studied during a 9-month period. The median age of the children was 2.25 months (range, 0.8-18.0 months). There were 4 male and 4 female patients. All patients had intracranial bleeding, documented by computed axial tomographic scans of the head. Of the 8 patients, 6 had bilateral retinal hemor- rhages. All patients underwent a formal examination by a pediatric ophthalmologist (R.S. and others) using a wide- field digital ophthalmic camera. Three children died. Conclusions: The wide-field digital ophthalmic camera allowed good visualization and produced high-quality photographic images, resulting in instant bedside docu- mentation of retinal pathological features. The wide- field digital ophthalmic camera provides a new tool for the evaluation and precise documentation of retinal hem- orrhages in suspected and confirmed cases of abusive head trauma. Arch Pediatr Adolesc Med. 2001;155:1149-1152 R ETINAL hemorrhages are a common finding in pa- tients who experience abu- sive head trauma, occur- ring in 50% to 90% of infants who were violently shaken.1-6 Al- though some authorities2-4 believe that reti- nal hemorrhages alone may not be diag- nostic of shaken baby syndrome, their presence clearly reinforces the diagnosis when accompanied by intracranial inju- ries. Therefore, documentation of retinal hemorrhages is imperative to support the diagnosis of shaken baby syndrome. Tra- ditionally, retinal hemorrhages are docu- mented by freehand drawings, which can be time-consuming and may not accu- rately reflect retinal pathological fea- tures. While these drawings may give in- vestigators and medical personnel an idea of the severity and number of the hemor- rhages, they do not compare to actual reti- nal photographs. Retinal photography using special- ized handheld cameras improves bedside documentation of retinal hemorrhages, but requires special training and can be lim- ited by the camera’s field of view. Slit- lamp retinal cameras provide high- quality wide-field images, but require considerable patient cooperation and tech- nical expertise and lack portability. Digi- tal photography provides another alter- native for documenting retinal pathological features. This technology has been incor- porated into a wide-field digital ophthal- mic camera (RetCam 120; Massie Re- search Laboratories, Inc, Dublin, Calif) capable of producing high-quality real- time images of the retina. RESULTS During a 9-month period, we examined 8 children (median age, 2.25 months; age range, 0.8-18.0 months) admitted to the pediatric intensive care unit. There were 4 male and 4 female patients. The pri- mary admitting diagnosis, retinal find- ings, and computed tomographic scan re- sults of the head are shown in the Table. A history of trauma was found in 4 pa- tients: fall from a couch (n = 2), dropping the child 105 cm to the floor (n = 1), and ARTICLE From the Division of Pediatric Critical Care Medicine, Children’s Hospital of The King’s Daughters (Dr Nakagawa), and the Department of Pediatrics, Eastern Virginia Medical School (Dr Nakagawa), Norfolk, Va. Dr Skrinska is in private practice in Norfolk. (REPRINTED) ARCH PEDIATR ADOLESC MED/ VOL 155, OCT 2001 WWW.ARCHPEDIATRICS.COM 1149 ©2001 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ by a Carnegie Mellon University User on 04/05/2021 a child’s head hitting the sink (n = 1). Of the 8 patients, 6 had bilateral preretinal and intraretinal hemorrhages by direct ophthalmic examination and 2 had no retinal hemorrhages. Subdural and/or subarachnoid bleeding was noted on computed tomographic images of the head in all patients. Four patients had skeletal injuries consis- tent with nonaccidental trauma. Two patients required cardiopulmonary resuscitation before admission to the pediatric intensive care unit. Seven patients underwent mechanical ventilation, and 6 had generalized seizures. The median length of stay in the pediatric intensive care unit was 41⁄2 days (range, 2-9 days). The median total hos- pital stay was 8 days (range, 2-17 days). All children underwent a formal ophthalmologic ex- amination using a wide-field digital ophthalmic camera to confirm and document retinal hemorrhages. Exami- nations using the wide-field digital ophthalmic camera were performed by a pediatric ophthalmology attending physician (R.S. and others). The pupils were dilated using 0.2% cyclopentolate hydrochloride and 1% phen- ylephrine hydrochloride (Cyclomydril; Alcon Laborato- ries, Inc, Ft Worth, Tex) or 1% cyclopentolate hydro- chloride (Cyclogyl; Alcon Laboratories, Inc) and anesthetized with 0.5% proparacaine hydrochloride (Alcon Laboratories, Inc) in 5 of the 8 patients studied. Three patients had fixed and dilated pupils. Hydroxy- propyl methylcellulose (Goniosol; Ciba Vision Ophthal- mics, Atlanta, Ga) was used in all patients to provide an interface between the image capture unit and the cor- nea. In 7 of the 8 patients, the retina was easily visual- ized. In 1 child, images appeared cloudy as a result of blood in the vitreous humor; however, the images ob- tained were of acceptable quality. Multiple photographs were obtained, allowing for selection of the best and elimi- nation of inferior-quality and out-of-focus images. At hospital discharge, 2 patients were released to fos- ter care, 1 was institutionalized, and 2 were released to their mother. Three patients died. In 4 cases, the perpe- trator confessed. Perpetrators were the father or male care- taker in 3 cases and the mother in 1. COMMENT Retinal hemorrhages are a common finding in patients who experience abusive head trauma and support the diagnosis of shaken baby syndrome.1-4,7 Retinal hemor- rhages caused by abuse can be unilateral or bilat- eral,1,6,8,9 and result from rapid acceleration and decel- eration and rotational forces as the child’s head moves unsupported during the shaking event.2-4,7 Retinal hemorrhages associated with abusive head trauma are different than those associated with in- creased intracranial pressure, cardiopulmonary resusci- tation, or childbirth. With inflicted head injury, retinal hemorrhages tend to be multiple, tend to involve multiple retinal layers, and are distributed throughout the retina to the ora ser- rata.10 With cardiopulmonary resuscitation, retinal hem- orrhages tend to be small punctate hemorrhages, tend to be confined to the posterior pole of the retina, and tend to occur infrequently.10,11 Retinal hemorrhages are a com- mon finding in childbirth, occurring more frequently dur- ing vacuum-assisted deliveries, followed by spontane- ous vaginal deliveries; they are infrequent with cesarean deliveries.12,13 Direct compression to the globe and he- modynamic and rheologic changes during labor and de- livery contribute to retinal hemorrhages during child- birth.13 Most retinal hemorrhages associated with childbirth are intraretinal and typically resorb by the time the newborn is aged 7 to 10 days,12,14 although they may persist up to 30 days.13 Emerson and colleagues13 found no preretinal hemorrhages or vitreous blood and only rare isolated subretinal hemorrhages in newborns with reti- nal hemorrhages, resulting in their conclusion that in- traretinal hemorrhages in infants older than 1 month are unlikely to be related to birth trauma. Increased intra- cranial pressure can produce retinal hemorrhages, but these hemorrhages tend to be confined to the posterior pole and there are relatively few.10 Last, traumatic reti- noschisis in children has never been described in any en- tity other than shaken baby syndrome.10 Clearly, accu- rate documentation of retinal hemorrhages is important for diagnosing shaken baby syndrome. Traditionally, retinal hemorrhages were observed using a direct ophthalmoscope or a binocular indirect ophthalmoscope and documented by freehand draw- ings. Although these pictures provide a visual image used by investigators and medical personnel to document the number and severity of the retinal hemorrhages, photographs more accurately depict the type and extent of the hemorrhage and are not dependent on an artistic drawing. A wide-field digital ophthalmic camera uses fiber- optic illumination to provide clear, high-resolution, real- time images. It provides a 120° field of view, producing images of the retina that can be stored and recalled in a portable and easy-to-use unit. The image capture unit is placed on the cornea over the dilated pupil, providing real-time images of the retina. These images are viewed on an external monitor, and the retina is photographed, providing instant documentation of retinal injuries (Figure 1 and Figure 2). Digital images are stored, and medical record–ready photographs can be printed at the PARTICIPANTS AND METHODS All children admitted to the pediatric intensive care unit at our institution with suspected abusive head trauma, including intracranial hemorrhages and/or retinal hemorrhages, were included in this study. Age, race, sex, presenting complaint, and survival data were recorded. Intracranial hemorrhages were docu- mented by computed axial tomographic scans of the head. Retinal hemorrhages were documented by the attending intensivist at the time of admission. All chil- dren with suspected abusive head trauma under- went a formal ophthalmologic examination using a wide-field digital ophthalmic camera. This study was conducted with approval for human investigations by the institutional review board at Eastern Virginia Medical School, Norfolk. (REPRINTED) ARCH PEDIATR ADOLESC MED/ VOL 155, OCT 2001 WWW.ARCHPEDIATRICS.COM 1150 ©2001 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ by a Carnegie Mellon University User on 04/05/2021 bedside with the patient’s information imprinted on the photograph, including the time and date of the study. In addition, software allows for the electronic transfer of digital images to other physicians. Photographs of the retina are obtained at the oph- thalmic examination in some centers. This documenta- tion typically depends on an ophthalmologist with spe- cial training in and equipment for photographing the retina. A wide-field digital ophthalmic camera requires minimal training and provides a much wider field of view compared with other more elaborate systems used to pho- tograph the retina. This allows photographic documen- tation to occur at any time by physicians other than oph- thalmologists and improves visualization of hemorrhages that are more peripheral. In addition, digital photo- graphic images provide immediate and precise documen- tation of retinal hemorrhages, eliminating time- consuming freehand illustrations or photographic processing. The visual impact of photographic images al- lows multiple reviewers to independently review pho- tographic documentation of retinal hemorrhages and may play a crucial role in the medicolegal aspects of abusive head trauma as well. Last, a wide-field digital ophthal- mic camera is portable and easily transported to the bed- side, allowing examination of the retina in even the most critically ill child. A wide-field digital ophthalmic camera may prove to play an important role in the early diagnosis and in- tervention of abusive head trauma. Jenny and col- leagues15 noted that an incorrect diagnosis was made in one third of patients who experienced abusive head trauma; the delay resulted in further injury and death to some children. In addition, retinal hemorrhages were missed in almost 30% of abusive head trauma cases when examination of the retina was performed by a nonoph- thalmologist.16 Use of a wide-field digital ophthalmic cam- era by nonophthalmologists is relatively easy and al- lows the fundus of most children to be viewed. Compared Figure 1. Image of the retina produced with a wide-field digital ophthalmic camera (RetCam 120; Massie Research Laboratories, Inc, Dublin, Calif ), showing extensive intraretinal and preretinal hemorrhages throughout the periphery of the retina, with 1 large hemorrhage lateral to the optic nerve. Figure 2. Image of the retina produced with a wide-field digital ophthalmic camera (RetCam 120; Massie Research Laboratories, Inc, Dublin, Calif ), showing extensive retinal and preretinal hemorrhages throughout the periphery. Clinical Characteristics of the 8 Patients Patient No./Sex Admitting Diagnosis Retinal Findings Head CAT Scan Findings* Bony Trauma Outcome 1/F Cardiac arrest Bilateral preretinal, intraretinal, and subretinal hemorrhages Frontal SD hematoma, SA and IP hemorrhages, and cerebral edema Skull, humerus, tibia, and rib fractures Died 2/F Respiratory arrest None Bilateral SD hematoma and cerebral edema Skull and rib fractures Died 3/M Vomiting Bilateral preretinal, intraretinal, and subretinal hemorrhages SA hemorrhage and cerebral edema None Died 4/M Seizures Bilateral preretinal, intraretinal, and subretinal hemorrhages SA and SD hemorrhage None Survived 5/F Respiratory arrest Bilateral preretinal and intraretinal hemorrhages SD hemorrhage Scapula, humerus, femur, ilium, and rib fractures Survived 6/M Vomiting Bilateral preretinal, intraretinal, and subretinal hemorrhages Bilateral frontal SD hematoma and cerebral edema None Survived 7/M Seizures Bilateral preretinal and intraretinal hemorrhages Bilateral SD hematoma None Survived 8/F Seizures None SD hematoma Skull, clavicle, and rib fractures Survived *CAT indicates computed axial tomographic; SD, subdural; SA, subarachnoid; and IP, intraparenchymal. (REPRINTED) ARCH PEDIATR ADOLESC MED/ VOL 155, OCT 2001 WWW.ARCHPEDIATRICS.COM 1151 ©2001 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ by a Carnegie Mellon University User on 04/05/2021 with a direct ophthalmic examination using an ophthal- moscope, the wide field of view allows visualization of the retina to the ora serrata. This technology may prove useful by allowing rapid identification of retinal hemor- rhages in suspected cases of abusive head trauma, allow- ing for earlier intervention. A wide-field digital ophthalmic camera is also an ideal teaching tool, allowing students, residents, other allied health personnel, and investigators to instantly visual- ize retinal pathological features on a 43.2-cm monitor. Digital photographic images can be stored, permitting the creation of teaching files, and images can be reviewed and compared with previous examination results. There are limitations to a wide-field digital ophthal- mic camera. It is not a substitute for a formal ophthal- mic examination. This diagnostic imaging tool should be used in collaboration with an ophthalmologist, ensur- ing that proper diagnosis and follow-up are obtained for children who have retinal pathological features. Image quality may be affected by blood in the vitreous humor and is dependent on patient cooperation. In our limited experience, image quality was somewhat affected by blood in the vitreous humor, but acceptable images were ob- tained. An examination using a wide-field digital oph- thalmic camera may not be well tolerated by the awake or combative child; however, this examination would be no different than attempting to examine the eyes using an ophthalmoscope. In addition, it was not difficult to obtain images of children with an altered mental status even when they were not mechanically ventilated and heavily sedated. Imaging of a nondilated pupil is pos- sible, but shadowing of the retina can limit the field of view and may result in image degradation. Printed im- ages using the color printer have some image deteriora- tion, and although the image quality is acceptable, there is no comparison with the resolution provided by the ex- ternal monitor. Last, although expensive (approxi- mately $64 000 with the color printer), a wide-field digi- tal ophthalmic camera is versatile and can be used to image other retinal lesions besides those associated with abu- sive head trauma. In summary, a wide-field digital ophthalmic cam- era is a unique camera that provides a new level of sophistication for the immediate documentation and evaluation of retinal pathological features in suspected cases of abusive head trauma. Accepted for publication April 16, 2001. Corresponding author and reprints: Thomas A. Nakagawa, MD, Division of Pediatric Critical Care Medi- cine, Children’s Hospital of The King’s Daughters, 601 Children’s Ln, Norfolk, VA 23507 (e-mail: NakagaTA @CHKD.com). REFERENCES 1. American Academy of Pediatrics’ Committee on Child Abuse and Neglect. Shaken baby syndrome: inflicted cerebral trauma. Pediatrics. 1993;92:872-875. 2. Conway EE Jr. Nonaccidental head injury in infants: “the shaken baby syndrome revisited.” Pediatr Ann. 1998;27:677-690. 3. Duhaime AC, Christian CW, Rorke LB, Zimmerman RA. Nonaccidental head injury in infants: the “shaken-baby syndrome.” N Engl J Med. 1998;338:1822-1829. 4. Green MA, Lieberman G, Milroy CM, Parsons MA. Ocular and cerebral trauma in non-accidental injury in infancy: underlying mechanisms and implications for pae- diatric practice. Br J Ophthalmol. 1996;80:282-287. 5. Munger CE, Peiffer RL, Bouldin TW, Kylastra JA, Thompson RL. Ocular and asso- ciated neuropathic observations in suspected whiplash shaken infant syndrome: a retrospective study of 12 cases. Am J Forensic Med Pathol. 1993;14:193-200. 6. Ludwig S, Warman M. Shaken baby syndrome: a review of 20 cases. Ann Emerg Med. 1984;13:104-107. 7. Elner SG, Elner VM, Arnall M, Albert DM. Ocular and associated systemic findings in suspected child abuse: a necropsy study. Arch Ophthalmol. 1990;108:1094-1101. 8. Lancon JA, Haines DE, Parent AD. Anatomy of the shaken baby syndrome. Anat Rec. 1998;253:13-18. 9. Budenz D, Farber M, Mirchandani H, Park H, Rorke LB. Ocular and optic nerve hemorrhages in abused infants with intracranial injuries. Ophthalmology. 1995; 101:559-565. 10. Levin A. Retinal hemorrhages in child abuse. In: David TJ, ed. Recent Advances in Paediatrics. Edinburgh, Scotland: Churchill Livingstone Inc; 2000:151-219. 11. Odom A, Christ E, Kerr N, et al. Prevalence of retinal hemorrhages in pediatric patients after in-hospital cardiopulmonary resuscitation: a prospective study. Pediatrics. 1997;99:e3. Available at: http://www.pediatrics.org/cgi/content/full /99/6/e3. Accessed June 1997. 12. Giles CL. Retinal hemorrhage in the newborn. Am J Ophthalmol. 1960;49:1005-1011. 13. Emerson MV, Pieramici DJ, Stoessel KM, Berreen JP, Gariano RF. Incidence and rate of disappearance of retinal hemorrhages in newborns. Ophthalmology. 2001; 108:36-39. 14. Jain I, Singh Y, Grupta S, Gupta A. Ocular hazards during birth. J Pediatr Oph- thalmol Strabismus. 1980;17:14-16. 15. Jenny C, Hymel KP, Ritzen A, Reinert SE, Hay TC. Analysis of missed cases of abusive head trauma. JAMA. 1999;281:621-626. 16. Kivlin JD, Simons KB, Lazoritz ST, Ruttum MS. Shaken baby syndrome. Oph- thalmology. 2000;107:1246-1254. What This Study Adds Freehand drawings may not always reflect the extent of retinal hemorrhages in patients who have experienced abu- sive head trauma. Retinal photography using specialized handheld cameras improves bedside documentation of retinal hemorrhages, but requires special training and can be limited by the camera’s field of view. Wide-field digi- tal photography using a wide-field digital ophthalmic camera can improve bedside documentation of retinal pathological features in this select group of patients. To our knowledge, this study is the first to describe the use of wide-field digital photography for document- ing retinal hemorrhages in patients who have experi- enced abusive head trauma. The wide-field digital oph- thalmic camera allowed good visualization and produced high-quality photographic images, resulting in instant bed- side documentation of retinal pathological features. This technology improves efficiency and provides a new tool for the evaluation and precise documentation of retinal hemorrhages in suspected and confirmed cases of abu- sive head trauma. (REPRINTED) ARCH PEDIATR ADOLESC MED/ VOL 155, OCT 2001 WWW.ARCHPEDIATRICS.COM 1152 ©2001 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ by a Carnegie Mellon University User on 04/05/2021