Association of subconjunctival haemorrhage with non-accidental injury
Reviewed by Fiona Rowe

This study assessed the frequency and nature of diagnostic work-ups in infants with subconjunctival haemorrhage (SCH), the incidence of occult injuries among these patients and the factors that may have influenced the work-up. This was a retrospective secondary analysis of data from the Timely recognition of Abuse Injuries (TRAIN) collaboration in the State of Ohio, USA. This is a collaboration of six children’s hospitals and about 20 regional community hospitals. Eighty-four infants were identified. Additional injuries were found in 23 (27%) and all were mucocutaneous. Of these, all had bruising: face (87%), chest / abdomen (26%), extremities (13%) and back (4%). One patient had an intra-oral frenulum injury. Sixty-one patients (73%) only had SCH. Occult injuries in 14% (n=12) included fractures and subdural haemorrhages. The overall rate of positive skeletal surveys was 38% and positive neuroimaging of 15%. Children with SCH plus injuries were more likely to undergo skeletal surveys and neuroimaging. The authors suggest that SCH is not consistently recognised as an injury that should prompt additional investigation for occult injury. As a result, abuse is likely under reported. Further, presence of SCH is often not explained in the medical notes. The authors discuss the association of SCH with Valsalva manoeuvres and that this is questionable in occurrence in infants. They did not find an influence of race or health insurance as factors in detection of abuse. They caution of the potential to miss cutaneous findings in patients with darker skin colour. They conclude that SCH in infants should raise concern for non-accidental injury and prompt further investigation including skeletal survey and neuroimaging.

Occult injury screening among infants with subconjunctival haemorrhage.
Koti AS, Criochton KG, Liker K, et al.
JOURNAL OF PEDIATRIC OPHTHALMOLOGY AND STRABISMUS
2021;58:213-7.