Retinal Findings in Children with Increased Intracranial Pressure
Angell Shi, BS; Abhaya Kulkarni, MD; Kenneth W. Feldman, MD; Avery Weiss, MD; Emily A. McCourt, MD; Susan Schloff, MD; Michael Partington, MD; Gil Binenbaum, MD, MSCE; Brian Forbes, MD, PhD; Brooke E. Geddie, DO; Karin Bierbrauer, MD; Paul H. Phillips, MD; David L. Rogers, MD; Alex V. Levin, MD, MHSc, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA
Division of Neurosurgery, The Hospital for Sick Children, Toronto, ON
Department of Pediatrics, University of Washington, Seattle Children’s Hospital, Seattle, WA
Department of Ophthalmology, University of Washington, Seattle Children’s Hospital, Seattle, WA
Department of Ophthalmology, University of Colorado, Children’s Hospital Colorado, Aurora, CO
Associated Eye Care, St. Paul, MN
Department of Ophthalmology, Children’s Minnesota-St. Paul Hospital, St. Paul, MN
Department of Neurosurgery, Gillette Children’s Specialty Healthcare, St. Paul, MN
Division of Ophthalmology, Children’s Hospital of Philadelphia, Philadelphia, PA
Division of Pediatric Ophthalmology, Helen DeVos Children’s Hospital, Grand Rapids, MI
Division of Neurosurgery, Cincinnati Children’s Hospital, Cincinnati, OH
Jones Eye Institute, University of Arkansas for Medical Sciences, Little Rock, AR
Department of Ophthalmology, Arkansas Children’s Hospital, Little Rock, AR
Department of Ophthalmology, Nationwide Children’s Hospital, Columbus, OH
Wills Eye Hospital, Philadelphia, PA
Introduction: Increased intracranial pressure (ICP) has been suggested in courtrooms as an alternative cause of retinal hemorrhages (RH) in suspected victims of abusive head trauma (AHT). We assessed the role of increased ICP in the formation of RH in children.
Methods: We conducted a prospective, multicenter study of children < 4 years old with increased ICP, as determined by direct measurement or clinical criteria. Premature infants, neonates, and AHT victims were excluded. Fundus examinations were performed; extent, number, and type of RH in each of four distinct retinal zones were recorded.
Results: 56 patients (27 males) were enrolled (mean age 14.8 months, range 1-43 months). All patients had elevated ICP which required intervention. One child had papilledema. No child (0%, 95% CI: 0-6.3%) or eye (0%, 95% CI: 0-3.32%) was found to have RH. Imaging findings revealed hydrocephalus, intraventricular hemorrhage, congenital malformations, malfunctioning shunts, and presence of a mass, lesion, or cyst.
Discussion: Many studies have sought to elucidate the role of ICP in the formation of RH in children. In our cohort, we found no cases of ICP causing RH and only one child with papilledema.
Conclusion: Our study supports the published evidence that increased ICP uncommonly results in the formation of RH in the absence of papilledema and is therefore not a satisfactory explanation of RH seen in cases of AHT.
References: Shiau T, Levin AV. Retinal hemorrhages in children: the role of intracranial pressure. Arch Pediatr Adolesc Med. 2012;166(7):623-628.
Binenbaum G, Rogers DL, Forbes BJ, et al. Patterns of retinal hemorrhage associated with increased intracranial pressure in children. Pediatrics. 2013;132(2):e430-e434.