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Leoni Joubert (M.Phil Optom (RAU); B.Optom; MBCO(UK); CAS (NECO - USA)); FOA(SA)

In this second part pertaining to child abuse I will discuss the ocular signs of child abuse. As optometrists it is of utmost importance to be vigilant of these signs as we are often the fi rst professional visited by child who may have been abused.

Ocular signs of abuse:

1. Cataracts:

Cataracts found due to abuse are usually traumatic cataracts. They can be due to a number of causes including direct blunt trauma like, from a fi st hitting the eye. They can also be due to a direct penetrating injury from an object being stuck into the eye. If the child suffers a concussion, which might occur when their head is hit against a hard object, a Vossius' ring might result. This is an "imprinting" of the iris pigment onto the anterior lens capsule. The cataracts that result from a concussion are often flower shaped. If a child has been abused by having electric shocks, a cataract can also develop. This is however relatively rare.

2. Hyphema:
Hyphema is blood in the anterior chamber. It is a common complication of blunt trauma, such as being hit in the eye. The source of the bleeding is the iris or ciliary body. Because the blood blocks the outfl ow of aqueous, prolonged elevation of intra-ocular pressure may result. The size of the hyphema provides a good indication as to the risk of complications as well as the visual prognosis. If it involves less than half of the anterior chamber there is an incidence of 4% of raised IOP, 22% incidence of complications and a fi nal VA of better than 6/18 can be expected in 78% of cases. If the hyphema involves more than half the anterior chamber there is an incidence of 85% raised IOP, 78% complications and VA better than 6/18 only occurs in 28% of eyes.

The blood can also permanently stain the cornea. Treatment is medical (beta blockers, carbonic anhydrase inhibitors or hyperosmotic agents) or surgical, depending on IOP and extent of hyphema.

3. Corneal lacerations and scars:
These are due to direct contact with the eye. An extremely painful form of abuse is cigarette burns to the cornea. Immediate medical intervention is required to prevent loss of vision as well as secondary infection.

4. Lid lacerations:
These result from direct trauma to eye and can take many forms.

5. Echymosis or Haematoma:
This is your classic "Black eye" which results from trauma to the orbit, eyelid or forehead. Blood leaks into the area surrounding the eyelids and forms a bruise. It is a classic sign of a fist to the eye area. It is generally innocuous, however it is very important to exclude more serious conditions. For example, bilateral bruising around eyes. This sign could indicate a basal skull fracture. The term used to describe this condition is "Panda eyes". Radiological evaluation is indicated. Also, if the black eye is associated with a subconjunctival haemorrhage without a visible posterior limit it could indicate an orbital roof fracture.

6. Subconjunctival haemorrhage:
The blood vessels in the conjunctiva are extremely delicate and so can bleed easily. When they do, a subconjunctival haemorrhage results. It will disappear slowly over approximately 10-14 days during which time colour changes will take place. See Figure 5

7. Retinal detachment:
Retinal dialysis, equatorial tears and macular holes could all lead to retinal detachment. They can follow blunt trauma to the eye and therefore it is imperative to do a dilated fundus exam following ocular trauma. One also has to be aware of choroidal rupture which could occur.

8. Phthiriasis Palpebrarum (crab louse):
When crab lice are seen on the eyelashes of children, it is a good indicator of sexual abuse. These crab lice have a predilection for pubic hair but will also live in eyelash hair due to the similar spacing of the hairs. As children do not have pubic hair, they rarely get crab lice unless it is due to sexual contact with an infected adult or by sharing a bed with an infected adult and also due to extremely poor hygiene. One will also see the nits (egg casings) attached to the eyelashes. Treatment is by removal of lice and nits with forceps, topical ointment to smother the lice as well as delousing the patient, bedding and clothing. Other family members need to be deloused as well.

9. Retinoschisis:
Rupture of the retina can also occur due to blunt trauma.

10. Papiloedema:
Swelling of the optic nerve head can occur as a sign of increased intra-cranial pressure. If this is seen, the child must be referred to a neurologist as there might be intra-cranial bleeding following trauma to the head.

11. Optic atrophy:
Optic atrophy can result from blunt trauma to the eye.

12. Macula oedema:
Trauma to the eye can also cause swelling in the macula. This will severely affect vision. It is imperative to do a dilated fundus exam following any suspected trauma to the head or eye.

13. Proptosis:
Any bleeding into the orbit or surrounds could produce proptosis. It is usually but not always painful and of sudden onset. If any proptosis is seen in a suspected ocular trauma case the child must be referred for radiological assessment.

14. Strabismus:
If there has been intracranial damage, one or more of the cranial nerves can be affected. This is especially true for the fourth (trochlear) nerve as it is very long and slender and susceptible to damage following trauma. When a strabismus is seen following suspected abuse, neuroophthalmological investigation must be done. The complete break-down of all the traumatic strabismus types is beyond the scope of this article and the reader is referred to neuro-ophthalmological text for this.

15. Nystagmus:
Once again this warrants a neurological evaluation if nystagmus was not present before.

16. Diplopia:
Diplopia usually follows sudden onset of strabismus and should be investigated together with that.

17. Pre-ret, vitreous or retinal haemorrhages:
Bleeding following trauma occurs into different levels of the retina. It is seen as dot, blot or flame-shaped haemorrhages. They are usually multiple and bilateral. They can also occur due to vitreous movement. Damage to the Central Retinal vein can occur.

18. Cortical blindness:
Cortical blindness can result from severe trauma to the back of the head, in the occipital region. This usually follows from the child being bashed against a wall or the floor. Neurological consultation is mandatory in this case.

19. Ruptured globe:
If the trauma to the eye is severe enough, the globe can rupture. Immediate emergency ophthalmological referral is required to try and save the eye. Success in saving the vision following such severe trauma is limited and often the eye has to be enucleated.

20. Dislocated/subluxated lens:
Any blunt trauma can dislocate the lens. One must be very careful dilating a patient with a dislocated or subluxated lens as the lens can often become entrapped in the pupil when the pupil returns to its normal size.

21. Ptosis:
Damage to the third (oculomotor) nerve as well as anywhere along the sympathetic pathway could lead to ptosis. Neurological investigation is warranted.

22. Disconjugate eye movements:
This often is closely associated with neurological damage and investigation is similar to that mentioned under strabismus and diplopia.

Shaken Baby Syndrome (SBS):
SBS occurs when an abuser violently shakes an infant, creating whiplash-type motion. It is usually seen in infants under 1 year old. Usually the perpetrators are male.

Anatomical factors like a large head relative to body size, weak neck muscles, more CSF, softer and immature unmyelinated brain and larger sub-arachnoid space makes them susceptible to brain damage. It occurs due to an acceleration/deceleration injury. 80% of SBS infants have retinal bleeding and as such we as optometrists might be in a position to be one of the fi rst professionals consulted. Any infant with bilateral intraocular/ retinal haemorrhages and intracranial bleeding should be suspect of abuse.

These children can have no external signs of trauma but can also have fractures of ribs or vertebrae or a cervical spine injury from being shaken. Infants appear irritable and lethargic. They are vomiting, have seizures, their fontanels are bulging, they have dilated pupils and their eating patterns are altered.

The pathogenesis of the sub-dural hematoma is due to tearing of bridging cerebral vessels from falx cerebri. Blood in ONH (Optic Nerve Head) sheath which is continuous with sub-arachnoid haemorrhage penetrates lamina cribrosa. However, it is more likely to be due to an increase in ICP (Intracranial Pressure) with rupture of retinal veins.

When doing a fundus exam then ONH looks swollen and CWS (Cotton Wool Spots) are present. Sometimes, even something innocent like tossing a baby into air or swinging in circles can cause SBS. SBS kills 1/3 of victims. Those who survive are plagued by learning disabilities, seizure disorders, speech disability, hydrocephalus, cerebral palsy and visual disorders.

It is important to remember that 20-50% of vaginally delivered neonates have retinal bleeding. Look for the other signs as well! Less prominent retinal bleeding will resolve in 3 weeks.

Purtscher Retinopathy:

This retinopathy is also usually a sign of abuse and it shows pre-retinal and retinal haemorrhages in absence of any head injury. It is due to sudden compression of thoracic and abdominal cavity. This could occur when someone lies on top of child. It causes an increase in vascular pressure of head and eyes leading to retinal haemorrhages.

Optometrist's responsibility:
We are legally obliged to report any suspected abuse. This can be done with the SAPS - Child protection Unit. This unit has however been decentralized and so there is supposed to be someone at each major police station to help. Unfortunately this is not always the case.

If the child is <12y old you can also report any suspected abuse to the local child welfare. If the child is >13y old you would need to report suspected abuse to the Department of Social Services. It is important to note that you can choose to remain anonymous unless your legal testimony is required.

Another good source of advice is Childline (080 005 5555) or Child Welfare (011 492-2888).

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Figure 1 & 12 Courtesy of Online Journal of Optomology, www.onjoph.com


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