Aims: To investigate what patterns of bruising are diagnostic or suggestive of child abuse by means of a systematic review 

Methods: All language literature search 1951–2004 Included: studies that defined patterns of bruising in non-abused or abused children <18 years Excluded: personal practice, review articles, single case reports, inadequate confirmation of abuse Two independent full text reviews using standardised data extraction and critical appraisal forms Studies ranked by study design and definition of abuse used 

Results: Twenty three studies included: seven non-abusive bruising, 14 abusive bruising, and two both Non-abusive: The prevalence, number, and location of bruises is related to increased motor development Bruising in non-independently mobile babies is very uncommon (<1%) Seventeen per cent of infants who are starting to mobilise, 53% of walkers, and the majority of schoolchildren have bruises These are small, sustained over bony prominences, and found on the front of the body Abuse: Bruising is common in children who are abused Any part of the body is vulnerable Bruises are away from bony prominences; the commonest site is head and neck (particularly face) followed by the buttocks, trunk, and arms Bruises are large, commonly multiple, and occur in clusters They are often associated with other injury types that may be older Some bruises carry the imprint of the implement used 

Conclusion: When abuse is suspected, bruising must be assessed in the context of medical, social, and developmental history, the explanation given, and the patterns of non-abusive bruising Bruises in non-mobile infants, over soft tissue areas, that carry the imprint of an implement and multiple bruises of uniform shape are suggestive of abuse Quality research across the whole spectrum of children is urgently needed

Are There Patterns of Bruising in Childhood Which Are Diagnostic or Suggestive of Abuse? A Systematic Review.

This article will discuss the subject of inflicted or abusive head injury in infants and young children. Inflicted neurotrauma is a very common injury and a frequent problem in attempting to distinguish between inflicted and accidental injury. Inflicted head injury occurs usually in the home in the presence of the individual who has inflicted the injury outside the view of unbiased witnesses. Distinguishing between inflicted and accidental injury may be dependent upon the pathological findings and consideration of the circumstances surrounding the injury. The most common finding in an inflicted head injury is the presence of subdural hemorrhage. Subdural hemorrhage may occur in a variety of distributions and appearances. The natural history of subdural bleeding and the anatomy of the "subdural" will be considered. The anatomy of the dura and its attachment to the skull and to the arachnoid determines how subdural bleeding evolves into the cleaved dural border cell layer and as well as how bridging veins are torn and anatomically where bleeding will occur. Different biomechanical mechanisms result in different distributions of subdural blood and these differences will be discussed.

Inflicted traumatic brain injury in infants and young children

BACKGROUND: Ophthalmologists are commonly asked to interpret appearance of retinal hemorrhages (RH) in children with suspected traumatic head injury. We sought to determine the natural history of RH in young children with head trauma and to identify patterns suggestive of chronicity in order to help establish timing of suspected traumatic injury. METHODS: The medical records of children 20, too numerous to count [TNTC]). RESULTS: A total of 91 eyes of 52 children were studied. All eyes had IRH (62 eyes with TNTC). In all but one eye, IRH resolved to none or mild within 1-2 weeks. TNTC IRH did not persist beyond a few days. The longest an isolated IRH persisted was 32 days. Preretinal hemorrhage (PRH) was present in 68 eyes, persisting 5-111 days. On initial examination, 25% of eyes had only IRH, 75% both PRH and IRH; no eyes had only PRH. At 2 weeks, 3% had only IRH, 18% both, and 45% only PRH. In no eyes did RH worsen. CONCLUSIONS: IRH clears rapidly, whereas PRH may persist for many weeks. The presence of TNTC IRHs indicates that trauma occurred within a few days prior to examination, whereas the presence of PRH with no or few IRHs suggests days to weeks since trauma. To accurately identify these patterns, eye examinations should be completed as soon as possible after admission, preferably within 24-48 hours.Copyright © 2016 American Association for Pediatric Ophthalmology and Strabismus. Published by Elsevier Inc. All rights reserved. Language: en

The natural history of retinal hemorrhage in pediatric head trauma

The discussion surrounding shaken baby syndrome (SBS) arose from the lack of evidence implicating diffuse axonal injury (DAI) as a cause of death It was assumed instead that injury to the cervical cord, medulla, and nerve roots played a causal role The present pathomorphological study examines 18 selected infants (<1-year-old) whose deaths were highly suspicious for SBS, exhibiting the classical SBS triad of acute subdural hemorrhage (SDH), retinal bleeding, and encephalopathy Gross autopsy and microscopic findings of these infants were compared with those of 19 victims of sudden infant death syndrome (SIDS; control group 1) and of 14 infants who died of disease or injuries/violence not involving the head, neck or eyes (control group 2) Symptoms of mechanical impact to the head were evident in seven of the SBS infants, but in none of the control infants DAI was not detected in either the SBS or control cases Localized axonal injury (AI) was regularly present in the brains of the SBS infants surviving longer than 15–30 h, but only occasionally in the craniocervical junction and within the nerve roots of the upper cervical cord; it was never present in the medulla Epidural hemorrhage of the cervical cord was seen in four of the ten examined SBS cases, but in none of the control cases Based on the absence of DAI in the brain and of signs of generalized cervical cord or nerve root injuries, we conclude that the cause of death in the SBS victims was a global cerebral ischemia secondary to SDH, focal vasospasm, trauma-induced transitory respiratory and/or circulatory failure

Shaken baby syndrome: re-examination of diffuse axonal injury as cause of death.

Purpose
To study the anatomical and visual outcomes and prognostic factors that may predict the outcomes of rhegmatogenous retinal detachment (RRD) in children.

Rhegmatogenous retinal detachment in children 16 years of age or younger

Purpose: The purpose of this retrospective chart review is to delineate what convergence insufficiency looks like to a strabismologist. By classifying the entity, determining the most prevalent symptoms and findings of the disease, a standard will be set for further research into the disease patterns and treatment parameters. Conclusion: Our study suggests that CI can present in ways that are not expected. Symptoms: A large number of our patients were asymptomatic at presentation. The presence or absence of strabismus may not play a role in the diagnosis of CI Up to 8% of patients who have been diagnosed with CI were described by some strabismologists as esotropic or esophoric. 20% of patients had a NPC of 1 cm Fusional amplitudes may play a role in diagnosis of CI, data has been collected, results pending.

What does convergence insufficiency look like to the strabismologist

Background Convergence insufficiency (CI) is a common entity but seems to be an ill-defined diagnosis that incorporates many near-vision symptoms. The current literature often varies in its criteria for diagnosis. Without a clear definition and standardization of the clinical examination, there is the potential for misdiagnosis and/or the inclusion of other diagnoses as CI. The purpose of this study was to assess the uniformity of diagnostic criteria in a well-defined practice environment. Methods The medical records of individuals diagnosed with CI between June 2007 and November 2014 who were patients of 6 fellowship-trained strabismologists in private practices and at Wills Eye Hospital clinics were reviewed retrospectively. Exclusion criteria included any previous treatments for CI, prior strabismus surgery, or other causes for strabismus, including cranial nerve palsies. The following data were collected: age, sex, race, age at diagnosis, past medical and family history, relevant symptoms, visual acuity, near point of convergence (NPC), strabismus measurements, and fusional amplitudes at distance with base-out and base-in prisms. Results A total of 387 patients fit our inclusion criteria and were analyzed in our study. There was no uniformity across clinicians in the clinical evaluation and diagnosis of patients with CI. The amplitude of the NPC was highly variable, and most clinicians did not assess the quality of the convergence movement or perform convergence fusional amplitude testing in making the diagnosis of CI. Conclusions Our review has demonstrated the range of criteria within one group of practitioners to diagnose CI. This may reflect our current understanding and the need for an evidence-based definition of the disease and its diagnosis.

Inconsistent diagnostic criteria for convergence insufficiency.

Ophthalmic manifestations of child abuse can be seen in the form of physical abuse, neglect and noncompliance, sexual abuse, and emotional abuse. This chapter reviews these forms of abuse and their ocular manifestations. Ophthalmologists are a key component of the multidisciplinary team and may be the first to recognize abuse and neglect or act as consultants describing the ocular findings and their forensic significance.

Ocular Manifestations of Child Abuse

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What does convergence insufficiency look like to the strabismologist

Inconsistent diagnostic criteria for convergence insufficiency.

Ocular Manifestations of Child Abuse