Retinal hemorrhages (areas of bleeding within the retina of the eye) can occur in both accidental and inflicted brain traumas. Past research has noted general differences in amount of hemorrhaging between accidental and inflicted injury, but had not to date been able to define specific characteristics.
The ability to predict whether a brain injury was inflicted or accidental is of critical importance because of the social and legal ramifications involved. Misdiagnosis can lead to a child being returned to an abusive situation, a caregiver being wrongfully accused, or a child being mistakenly referred to Child Protective Services.
In a recent study of children who had been admitted to a hospital for traumatic brain injury, researchers defined the specific characteristics of retinal hemorrhaging that could objectively predict whether the injury had been inflicted or accidental. Children in the inflicted brain injury group were confirmed by the Child Protective Services having made provisions for the immediate safety of the child and subsequent legal proceedings. The research findings are as follows:
1. There were 10 times as many retinal hemorrhages due to inflicted brain injury than accidental brain injury.
2. Severe cases of accidental brain injury were associated with a higher likelihood of retinal hemorrhage, and severe cases of inflicted brain injury were associated with greater severity of retinal hemorrhage.
3. Inflicted brain injury cases were more likely to have retinal hemorrhages in the peripheral area and in deeper layers of the retina. Accidental brain injury cases were more likely to have hemorrhages in the central area, near the optic disc, and in more superficial layers of the retina.
4. Retinal hemorrhages from inflicted brain injury were more likely to be bilateral. If the hemorrhages were unilateral, they were more likely to be in the left eye than in the right.
5. Younger age (under 3 years) and high dot-blot hemorrhages (over 25) were highly predictive of inflicted brain injury.
The study had some limitations. Children were deemed "probable" or "definite" cases of inflicted brain injury, but there was no other way to know for certain except for the presence of any retinal hemorrhage. The study took into account all possible causes of pediatric traumatic brain injury (i.e., car accident, fall, sports accident, blow to the head, bicycle accident) as well as cases of non-traumatic brain injury to determine the specific characteristics of retinal hemorrhaging due to inflicted traumatic brain injury.
Minns RA, Jones PA, Tandon A, et al. Prediction of inflicted brain injury in infants and children using retinal imaging. Pediatrics. (October 2012).