Retinal Hemorrhage

Hemorrhages in the retina represent a broad range of ocular manifestations of systemic disease and/or trauma. The most important diagnosis to discover is nonaccidental trauma. Recognition of the pattern of hemorrhaging, coupled with patient characteristics, history, and physical examination leads to the proper workup and diagnosis. An eye consultation will serve well in streamlining the evaluation and maximizing intervention.

Differential Diagnosis

• It is critical to realize that hemorrhages do not progress but represent altered structure, and as such may affect acuity
• Nonaccidental trauma must be the first etiology considered
• Pigmented lesions of the retina including choroidal nevi, congenital hypertrophy of the retinal pigment epithelium, retinal pigment epithelial hyperplasia
• Diabetic retinopathy is characterized by dot/blot, flame, preretinal, vitreous hemorrhages
• Hypertensive retinopathy is typically accompanied by signs of hypoxia, e.g., cotton wool spots and optic disc swelling
• May be associated with any systemic vascular disease or collagen vascular disease (e.g., systemic lupus erythematosus)
• Vein occlusion
  –Occlusion of a central vein may involve the entire retina, occlusion of one branch vein involves a section of the retina
• Peripheral retinal hemorrhaging may be associated with vascular insufficiency due to carotid stenosis
• May be associated with optic disc swelling
• Traumatic truncal injury may create intraretinal hemorrhages called Purtscher lesions
• Intracranial hemorrhage may dissect forward to surround optic nerve (Terson phenomenon)
• Blood dyscrasias, anemias, leukemias, sickle cell, ocular sarcoidosis, Behçet disease, Eales disease may cause retinopathy
• If sudden loss of vision is associated, wet macular degeneration, macular hemorrhage of histoplasmosis, preretinal hemorrhage, or vitreous hemorrhage may be the etiology
• Retinal vascular tumors, which may have an associated neurologic aneurysm
• HIV retinopathy presents with hemorrhage as first sign but may progress to involve and destroy vision

Workup and Diagnosis

• History
  –Evaluate status of known systemic diseases; e.g., hypertension, diabetes
  –Investigate for undiagnosed systemic disease: Hypertension, diabetes, carotid occlusion, cardiac anomalies, blood disorders, HIV

• Physical exam
  –Visual acuity: Acuity is compromised if the hemorrhage lies within the foveal area
  –Pupillary evaluation: Look for Marcus Gunn pupil
  –Extraocular muscle evaluation for diplopia (may be associated with diabetes)
  –Confrontation visual fields are indicated in all cases
  –Perform a dilated fundus evaluation
• Labs
  –CBC, differential, lipid profile, ANA, sickle cell, ACE, serum calcium

• Studies
  –Ultrasonography, fluorescein angiography, ocular CT may be performed in conjunction with an ophthalmology consultation
  –If secondary to a retinal vascular tumor, orbital and brain imaging with and without contrast is indicated with a neurologic consultation

Treatment

• Condition-dependent
  –Treatment of underlying systemic disease is often the only treatment
• Laser and surgical intervention may be of benefit in diabetic retinopathy, vein occlusions, hypertensive retinopathy, Eales disease, retinal vascular tumors
• Prognosis depends on degree of retinal damage and neurologic involvement
• Report suspect child abuse to state agency

Book Source Details

• Book Title: In A Page: Pediatric Signs and Symptoms
• Author(s): Jonathan E. Teitelbaum, Kathleen O. Deantonis, Scott Kahan
• Year of Publication: 2007
• Copyright Details: In A Page: Pediatric Signs and Symptoms, Copyright © 2007 Lippincott Williams & Wilkins.

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Copyright Details: In A Page: Pediatric Signs and Symptoms, Copyright © 2008 Williams & Wilkins.

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More About This Book: Title: In A Page: Pediatric Signs and Symptoms Authors: Jonathan E. Teitelbaum, Kathleen O. Deantonis, Scott Kahan Publisher: Lippincott Williams & Wilkins Copyright: 2007 ISBN: 1-4051-0427-9

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