Champ Program Child Abuse Medical Provider Program Education for Child Abuse Medical Providers, CHAMP Program, www.champprogram.comHome CHAMPMember AreaCourseworkSkip navigation, go to content directlybackground
CHAMP Home Page
Whats New
About us
CHAMP Mentors and Faculty
CHAMP Network Members
Caring with Compassion
Child Victims of Human Trafficking
Test Your Knowledge
Practice Recommendations
Resources for Professionals
DOH Initiatives
Educational Resources for Medical Residents
Position Statement
Contact Us

Back to list of cases

Child Abuse Case 17

A 4-month-old infant without a history of trauma presents with rib fractures, acute bilateral subdural hemorrhages and the unilateral retinal hemorrhage shown below.

Which of the following is a true statement about this retinal hemorrhage?

  1. This finding of a unilateral retinal hemorrhage indicates that inflicted head trauma is unlikely.
  2. This unilateral retinal hemorrhage is likely due to birth trauma.
  3. This unilateral retinal hemorrhage supports a diagnosis of inflicted head trauma.
  4. This hemorrhage is most likely due to increased intracranial pressure.

retinal hemorrhage


The answer is C.

The association of retinal hemorrhages with inflicted head trauma and child abuse is well recognized. Repeated acceleration-deceleration forces of the eye/head, with or without impact, is the most likely etiology in inflicted injury. When inflicted head trauma is suspected, a complete retinal examination performed by an ophthalmologist skilled in pediatric examinations is recommended. It is important to obtain a three dimensional view of the entire retina, preferably through a dilated pupil using an indirect ophthalmoscope, and have accurate descriptions of the hemorrhages.

The hemorrhages photographed in this case show intraretinal bleeding as well as pre-retinal bleeding. This is often described as "multi-layered." The larger hemorrhage near the 5 o’clock position is a pre-retinal hemorrhage. Intraretinal blood that is more superficial and streams along nerve fibers is often described as "flame" or "splinter" retinal hemorrhages. These can be seen in this photograph as well. Deeper intraretinal hemorrhages are often described as "dot" hemorrhages and are not clearly visible in this photo. Further descriptive terms can be reviewed in the suggested references below.

Retinal hemorrhages can be seen in approximately 85% of abusive of head trauma victims. Retinal hemorrhages can occur, less commonly, when there is not evidence of intracranial bleeding.

Unilateral retinal hemorrhages can occur with accidental or non-accidental (inflicted) head trauma. Retinal hemorrhages isolated to the posterior pole of the retina and located on the same side as an intracranial hemorrhage have been associated with accidental head trauma. However, the presence of unilateral retinal hemorrhages does not rule out inflicted trauma.

Birth related trauma may result in retinal hemorrhages. These intraretinal hemorrhages usually resolve within a few weeks. Infants born with vacuum assisted extraction have been reported to have prolonged presence of retinal hemorrhages (up to 58 days in one report). It is rare to see birth related hemorrhages after a few months of age and those that do remain for prolonged periods are residual, discrete hemorrhages. Extensive confluent hemorrhages resolve quickly (days to a few weeks). Although retinal hemorrhages have been rarely reported after Caesarean section delivery, other types of delivery with instrumentation have a higher risk of retinal hemorrhages. The presence of birth- related retinal hemorrhages in a 4 month old, as in this case, has not been reported.

Papilledema from increased intracranial pressure occurs in a very small percentage of cases of inflicted head trauma. This photograph does not demonstrate papilledema. Increased intracranial pressure may play some role in the development of retinal hemorrhages, but there is no evidence demonstrating a clear association between retinal hemorrhages that are "too numerous to count" and increased intracranial pressure in children.

Special thanks to Leon-Paul Noel, MD (Pediatric Ophthalmologist, Syracuse, NY) for review of this "Test Your Knowledge" question.

Arlotti SA, Forbes BJ, Dias MS, Bonsall DJ. Unilateral retinal hemorrhages in shaken baby syndrome. J AAPOS. 2007 Apr;11(2):175-8.

Hughes LA, May K, Talbot JF, Parsons MA. Incidence, distribution, and duration of birth-related retinal hemorrhages: A prospective study. J AAPOS. 2006 Apr;10(2):102-6.

Levin AV, Christian CW; Committee on Child Abuse and Neglect, Section on Ophthalmology. The eye examination in the evaluation of child abuse. Pediatrics. 2010 Aug;126(2):376-80.

Levin AV. Retinal hemorrhage in abusive head trauma. Pediatrics. 2010 Nov;126(5):961-70.

Back to list of cases


Copyright 2006-2021 The CHAMP Program, Syracuse, New York. All Rights Reserved.
SUNY Upstate Medical University
Syracuse, New York