All ophthalmologic examinations were performed as part of routine clinical care and did not require separate informed consent. Informed consent was obtained from all subjects for inclusion in the prospective study and was waived for the retrospective review. The study was approved by the institutional review boards of both institutions and was conducted in compliance with the principles of the Declaration of Helsinki and the Health Insurance Portability and Accountability Act.
15 These data included medical history and opening pressure (OP) on LP. Portions of data unrelated to RH from a previously published study of children with optic nerve head swelling were included in the current analysis because these children were enrolled in the prospective study. Subjects in Columbus were identified from a clinical database of all patients seen in an outpatient ophthalmology clinic, using a diagnosis search of headache, intracranial hypertension, papilledema, or RHs, between January 2009 and December 2011 nearly all of these patients were seen as an emergency department consultation or urgent outpatient visit. In both centers, subjects were enrolled consecutively. Data were collected as part of a prospective study of children undergoing LP during their routine clinical care in Philadelphia between January 2007 and February 2009 14 the data were collected retrospectively in Columbus. This 2-center cohort study was conducted at The Children’s Hospital of Philadelphia in Philadelphia, Pennsylvania, and Nationwide Children’s Hospital in Columbus, Ohio. The goal of the current study was to determine the incidence and patterns of RH associated with increased ICP in children, as measured by using lumbar puncture (LP). 13 However, there are limited published data describing RH findings associated with raised ICP in children. The extensive clinical experience of pediatric ophthalmologists suggests that isolated raised ICP rarely causes RH, and that RH due to raised ICP is limited to the peripapillary RHs sometimes seen with papilledema. 1, 13 Because ICP may be elevated in children being evaluated for AHT, understanding the association between increased ICP and RHs, and more specifically the RH patterns observed with raised ICP, is important because the diagnostic specificity of RHs for trauma may be altered. Increased ICP has been proposed as an isolated cause of RH in children with suspected traumatic head injury. 1, 12 Additional proposed mechanisms have included venous occlusion from raised intrathoracic or intracranial pressure (ICP) and tracking of intracranial blood along the optic nerves.
Vitreoretinal traction injury to the retinal vessels caused by repetitive deceleration injury is the leading and most-supported hypothesized mechanism underlying these findings, based on clinical, autopsy, laboratory, and finite element modeling evidence. 1, 10, 11 This range includes no RH a few intraretinal hemorrhages confined to the posterior pole of the eye multilayered, too-numerous-to-count RHs extending into the retinal periphery and hemorrhagic macular retinoschisis (splitting of the retinal layers) with or without retinal folds. 1 – 9 A range of RH findings may be present, with increasing severity of RHs being associated with an increasing specificity for AHT. Retinal hemorrhages (RHs) are an important sign of pediatric abusive head trauma (AHT), present in an estimated 85% of cases. This pattern does not match the widespread pattern seen in abusive head trauma. When it does, RH are superficial intraretinal and located adjacent to a swollen optic nerve head. Nontraumatic, markedly elevated ICP rarely causes RH in children.
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