Unilateral retinal hemorrhages and ipsilateral intracranial bleeds in nonaccidental trauma.

The classic ophthalmologic finding in nonaccidental traumatic injury is bilateral widespread retinal hemorrhage with or without intracranial hemorrhage. We present 3 cases of unilateral retinal hemorrhage associated with ipsilateral intracranial bleeds to extend the many different presentations of nonaccidental trauma. Nonaccidental traumatic injury can be a difficult, though lifesaving, diagnosis to make during the initial presentation to the emergency department or the private physician’s office. Histories regarding the nature of the injury are usually vague; they conflict and change, and eyewitness reports are usually lacking. Most of the children with nonaccidental traumatic injury are preverbal, and presenting signs can often be subtle, ranging from seemingly unrelated complaints of decreased appetite, vomiting, and behavioral changes, to those that are more ominous. Unfortunately, this diagnosis is often missed or delayed. A recent review of abusive head trauma in children younger than 3 years at a major academic hospital demonstrated that 54 (31.2%) of 173 cases of inflicted nonaccidental trauma were missed at the first presentation to a physician. Of those cases in which diagnoses were missed, more than 25% of the patients were reinjured at a later date, and 4 of 5 associated deaths could possibly have been prevented by earlier diagnosis. Patients more likely to have had a delay in diagnosis were white and younger than 6 months; they had milder symptoms than infants who were correctly diagnosed at initial presentation and came from “intact” homes where both parents lived with the child.1 Similar findings have been reported previously.2,3 Ophthalmologists are frequently consulted to add to the diagnostic evaluation of suspected nonaccidental injury in infants. The classic ophthalmologic findings are bilateral widespread retinal hemorrhages, the extent of which can vary greatly depending on the retinal layers involved. The presence of unilateral retinal hemorrhages has been reported, but it is not a well-known or emphasized phenomenon and has not been described in association with ipsilateral intracranial bleeds.4,5 We report 3 cases of infants with injuries strongly suspicious of nonaccidental trauma who had unilateral retinal hemorrhage associated with ipsilateral intracranial bleeds. Case 1: A 5-month-old previously healthy white male infant was taken to the emergency department (ED) with the chief complaint of a seizure. Intermittent seizures were observed in the ED. Head computed tomography (CT) revealed acute and subacute subdural hemorrhage near the right convexity, with mass effect and midline shift. The result of a skeletal radiologic series was negative. The findings from the pupillary examination and anterior segment examination were normal. Dilated fundus examination revealed numerous preretinal and intraretinal flame-shaped hemorrhages near the optic nerve of the right eye, extending past the arcades. The left fundus had no hemorrhages. Case 2: A 4-week-old term white female neonate was brought to the ED with the chief complaint of multiple apneic episodes, several of which were observed in the ED. Head CT revealed subarachnoid hemorrhage over the right frontal convexity and the right sylvian fissure. Magnetic resonance imaging showed these to be consistent with acute or early subacute hemorrhage of 4 days or less. A small hemorrhage was also present within the occipital horn of the left lateral ventricle, without evidence of mass effect or midline shift. The results of a skeletal survey were negative, and the results of anterior segment examination were normal. Dilated fundus examination revealed multiple preretinal and subretinal hemorrhages of the right eye, extending past the arcades. The left fundus was uninvolved.