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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
Arch Pediatr Adolesc Med. 2001;155:1149-1152.
ABSTRACT
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Objective To describe the clinical use of a wide-field digital ophthalmic camera
(RetCam 120; Massie Research Laboratories, Inc, Dublin, Calif) for the documentation
of retinal hemorrhages in patients who experienced 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 hemorrhages. 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
documentation of retinal pathological features. The wide-field digital ophthalmic
camera provides a new tool for the evaluation and precise documentation of
retinal hemorrhages in suspected and confirmed cases of abusive head trauma.
INTRODUCTION
RETINAL hemorrhages are a common finding in patients who experience
abusive head trauma, occurring in 50% to 90% of infants who were violently
shaken.1, 2, 3, 4, 5, 6
Although some authorities2, 3, 4
believe that retinal hemorrhages alone may not be diagnostic of shaken baby
syndrome, their presence clearly reinforces the diagnosis when accompanied
by intracranial injuries. Therefore, documentation of retinal hemorrhages
is imperative to support the diagnosis of shaken baby syndrome. Traditionally,
retinal hemorrhages are documented by freehand drawings, which can be time-consuming
and may not accurately reflect retinal pathological features. While these
drawings may give investigators and medical personnel an idea of the severity
and number of the hemorrhages, they do not compare to actual retinal photographs.
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. Slitlamp retinal cameras provide
high-quality wide-field images, but require considerable patient cooperation
and technical expertise and lack portability. Digital photography provides
another alternative for documenting retinal pathological features. This technology
has been incorporated into a wide-field digital ophthalmic camera (RetCam
120; Massie Research Laboratories, Inc, Dublin, Calif) capable of producing
high-quality real-time images of the retina.
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
documented by computed axial tomographic scans of the head. Retinal hemorrhages
were documented by the attending intensivist at the time of admission. All
children with suspected abusive head trauma underwent 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.
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 primary admitting diagnosis,
retinal findings, and computed tomographic scan results of the head are shown
in Table 1. A history of trauma
was found in 4 patients: fall from a couch (n = 2), dropping the child 105
cm to the floor (n = 1), and 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 consistent 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 4 days (range, 2-9 days). The median total
hospital stay was 8 days (range, 2-17 days).
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Clinical Characteristics of the 8 Patients
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All children underwent a formal ophthalmologic examination using a wide-field
digital ophthalmic camera to confirm and document retinal hemorrhages. Examinations
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% phenylephrine hydrochloride
(Cyclomydril; Alcon Laboratories, Inc, Ft Worth, Tex) or 1% cyclopentolate
hydrochloride (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. Hydroxypropyl methylcellulose
(Goniosol; Ciba Vision Ophthalmics, Atlanta, Ga) was used in all patients
to provide an interface between the image capture unit and the cornea. In
7 of the 8 patients, the retina was easily visualized. In 1 child, images
appeared cloudy as a result of blood in the vitreous humor; however, the images
obtained were of acceptable quality. Multiple photographs were obtained, allowing
for selection of the best and elimination of inferior-quality and out-of-focus
images.
At hospital discharge, 2 patients were released to foster care, 1 was
institutionalized, and 2 were released to their mother. Three patients died.
In 4 cases, the perpetrator confessed. Perpetrators were the father or male
caretaker 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, 2, 3, 4, 7
Retinal hemorrhages caused by abuse can be unilateral or bilateral,1, 6, 8, 9 and result
from rapid acceleration and deceleration and rotational forces as the child's
head moves unsupported during the shaking event.2, 3, 4, 7
Retinal hemorrhages associated with abusive head trauma are different
than those associated with increased intracranial pressure, cardiopulmonary
resuscitation, 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 serrata.10 With cardiopulmonary
resuscitation, retinal hemorrhages 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 common finding in childbirth, occurring more frequently during vacuum-assisted
deliveries, followed by spontaneous vaginal deliveries; they are infrequent
with cesarean deliveries.12, 13
Direct compression to the globe and hemodynamic and rheologic changes during
labor and delivery contribute to retinal hemorrhages during childbirth.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 retinal hemorrhages,
resulting in their conclusion that intraretinal hemorrhages in infants older
than 1 month are unlikely to be related to birth trauma. Increased intracranial
pressure can produce retinal hemorrhages, but these hemorrhages tend to be
confined to the posterior pole and there are relatively few.10
Last, traumatic retinoschisis in children has never been described in any
entity other than shaken baby syndrome.10 Clearly,
accurate 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 drawings.
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 fiberoptic 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 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.
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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.
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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.
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Photographs of the retina are obtained at the ophthalmic examination
in some centers. This documentation typically depends on an ophthalmologist
with special 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 photograph
the retina. This allows photographic documentation to occur at any time by
physicians other than ophthalmologists and improves visualization of hemorrhages
that are more peripheral. In addition, digital photographic images provide
immediate and precise documentation of retinal hemorrhages, eliminating time-consuming
freehand illustrations or photographic processing. The visual impact of photographic
images allows multiple reviewers to independently review photographic 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 ophthalmic camera
is portable and easily transported to the bedside, 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 intervention of abusive head trauma. Jenny
and colleagues15 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 nonophthalmologist.16 Use of a wide-field digital ophthalmic camera by
nonophthalmologists is relatively easy and allows the fundus of most children
to be viewed. Compared with a direct ophthalmic examination using an ophthalmoscope,
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
hemorrhages in suspected cases of abusive head trauma, allowing 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 visualize 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 ophthalmic camera. It
is not a substitute for a formal ophthalmic examination. This diagnostic imaging
tool should be used in collaboration with an ophthalmologist, ensuring 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 obtained. An examination using a wide-field digital ophthalmic
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 possible,
but shadowing of the retina can limit the field of view and may result in
image degradation. Printed images using the color printer have some image
deterioration, and although the image quality is acceptable, there is no comparison
with the resolution provided by the external monitor. Last, although expensive
(approximately $64 000 with the color printer), a wide-field digital
ophthalmic camera is versatile and can be used to image other retinal lesions
besides those associated with abusive head trauma.
In summary, a wide-field digital ophthalmic camera 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.
AUTHOR INFORMATION
Accepted for publication April 16, 2001.
What This Study Adds
Freehand drawings may not always reflect the extent of retinal hemorrhages
in patients who have experienced abusive 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 digital 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 documenting retinal hemorrhages in patients who have
experienced abusive head trauma. The wide-field digital ophthalmic camera
allowed good visualization and produced high-quality photographic images,
resulting in instant bedside 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 abusive head trauma.
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.
Corresponding author and reprints: Thomas A. Nakagawa, MD, Division
of Pediatric Critical Care Medicine, Children's Hospital of The King's Daughters,
601 Children's Ln, Norfolk, VA 23507 (e-mail: NakagaTA{at}CHKD.com).
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