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CHILD ABUSE - PART 2: OCULAR SIGNS OF CHILD ABUSE
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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).
References:
Smith S.K. Child abuse and neglect: a diagnostic guide for the optometrist. Journal
of the American Optometric Association. 1988 Vol 59 No 10.
Barber M.A, Sibert J.R. Diagnosing physical child abuse: the way forward. Postgraduate
Medical Journal. 2000 Vol 76 p743-749.
Blumenthal I. Shaken baby syndrome. Postgraduate Medical Journal. 2002 Vol 78
p732-735
Sugar N.F.S, Taylor J.A, Feldman K.W. Bruises in infants and toddlers: those who don't
cruise rarely bruise. Archives of Pediatric and Adolescent Medicine. 1999 Vol 153
p 399-403
Carpenter R.F. The prevalence and distribution of bruising in babies. Arch Dis Child.
1999 Vol 80 p363-366
Thomas S.A, Rosenfi eld N.S, Leventhal J.M. et al. Long-bone fractures in young
children: distinguishing accidental injuries from child abuse. Pediatrics. 1991 Vol 88
p471-476
Feldman K.W, Schaller R.T, Feldman J.A, et al. Tap water scald burns in children.
Pediatrics. 1978 Vol 62 p1-7
Davis P, McClure R.J, Rolfe K, et al. Procedures placement and risks of further abuse
after Munchausen by proxy, non-accidental poisoning and non-accidental suffocation.
Arch Dis Child. 1998 Vol 78 p217-221
Jacklin L. Personal communication at TMI during 2007.
Kanski JJ. Clinical Ophthalmology, Sixth edition. 2007. Butterworth, Heineman, Elsevier.
Edinburgh.
Figure 1 & 12 Courtesy of Online Journal of Optomology, www.onjoph.com
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