Researchers say criterion for diagnosing child abuse not always accurate

WINSTON-SALEM, N.C. When it comes to looking for damage to the eyes to prove child abuse, new research shows that things aren't always as they seem, according to Patrick Lantz, M.D., a forensic pathologist from Wake Forest University Baptist Medical Center.

"Contrary to what many doctors have been taught, we found that number and location of hemorrhages of the eye's retina aren't always proof of child abuse," said Lantz, who reported the results today at the 58th annual meeting of the American Academy of Forensic Sciences in Seattle. "Retinal hemorrhages occur more often than most doctors think are associated with a wide variety of conditions."

Lantz found that about 16 percent of the 700 individuals he examined during autopsy had hemorrhages of the retina, which is light-sensitive nerve tissue at the back of the eye. The bleeding occurs when tiny blood vessels on the retina's surface rupture. Lantz found the hemorrhages in individuals who had died from ruptured aneurysms, falls, car wrecks, gunshot wounds, meningitis and even drug overdose.

"Our research shows that you see the hemorrhages in a lot of different situations," Lantz said. "Retinal hemorrhages occur in child abuse, but they don't always mean a child was abused. Unfortunately, many pathologists, pediatricians and ophthalmologists have been taught that retinal hemorrhages are diagnostic of child abuse unless the child was involved in a high-speed car crash or fell more than two stories."

Currently, when child abuse is suspected, doctors conduct an eye exam to look for retinal hemorrhages and other eye changes that are considered proof of child abuse. Lantz got the idea to question this common assumption after he found that another eye condition, a buckling of the retina, is not always diagnostic for shaken baby syndrome. He reported those results in the British Medical Journal.

To test his theory that retinal hemorrhages also may not always be indicative of child abuse, Lantz decided to look for the condition during autopsies to learn more about when they occur.

Previously, the only way to look for the hemorrhages during an autopsy was to remove the eyes. Lantz came up with an alternative performing eye exams during autopsies using a surgical headlight and a handheld lens. This simple technique is sometimes used by ophthalmologists when more sophisticated equipment is not available, but no one had ever reported using it during autopsies.

The 700 deaths were in people ranging in age from birth to 96. Causes of death or conditions associated with retinal hemorrhages included suffocation, sudden infant death syndrome, meningitis, blunt trauma to the head, ruptured cerebral aneurysms, hemorrhagic strokes, cancer that had spread to the brain, high blood pressure, bleeding disorders, diabetes and gunshot wounds to the head.

"Many doctors have been taught to look for the hemorrhages when they suspect child abuse and often will diagnose child abuse without considering other possibilities," Lantz said. "Our research shows that you see the hemorrhages in a variety of different situations in infants, children and adults."

According to medical literature, retinal hemorrhages in infants are rare except in cases of abuse. "We're finding just the opposite," said Lantz. "We've found more retinal hemorrhages in non-abuse cases than in abuse cases, but most doctors don't look in the eyes of children unless they suspect child abuse."

Retinal hemorrhages were found in 30 children under age 14, yet only 6 cases were associated with child abuse.

As one of the first pathologists to routinely look at the back of the eye during autopsies, Lantz has learned that the technique can help diagnose hypertension, glaucoma, Marfan syndrome and even diabetes. He has taught residents and medical students to conduct the examinations and published an article in the Journal of Forensic Science (Nov. 2005) on the technique.

Lantz's co-researcher was Constance A. Stanton, M.D., neuropathologist, from Wake Forest University Baptist Medical Center.

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Contacts: Karen Richardson, krchrdsn@wfubmc.edu; Shannon Koontz, shkoontz@wfubmc.edu; at 336-716-4587.

Wake Forest University Baptist Medical Center is an academic health system comprised of North Carolina Baptist Hospital and Wake Forest University Health Sciences, which operates the university's School of Medicine. The system comprises 1,187 acute care, psychiatric, rehabilitation and long-term care beds and is consistently ranked as one of "America's Best Hospitals" by U.S. News & World Report.


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