Spitzer Stephen G, Luorno Joseph, Noël Léon-Paul
Department of Ophthalmology, Upstate Medical University, Syracuse, New York, USA.
J AAPOS. 2005 Feb;9(1):53-6. doi: 10.1016/j.jaapos.2004.10.003.
To establish child abuse as part of the differential diagnosis of isolated bilateral subconjunctival hemorrhages in infants.
To review three cases of nonaccident trauma initially presenting with isolated bilateral subconjunctival hemorrhages as the only significant clinical finding.
Ophthalmic examination in cases 1 and 2 were entirely normal except for the large bilateral subconjunctival hemorrhages. Hematological parameters were normal in all three infants. Initial radiological findings were normal in case 1 but multiple healing rib fractures were identified when the chest X-ray was repeated 3 weeks later. Case 2 had skin and skeletal X-ray findings compatible with abuse at time of presentation to the ophthalmologist. Case 3 was admitted to hospital for multiple unexplained limb fractures but had been seen 2 weeks prior for poorly explained bilateral isolated subconjunctival hemorrhages and facial petechiae.
Nonaccidental trauma should be considered in the differential diagnosis of bilateral isolated subconjunctival hemorrhages in infants especially if associated with facial petechiae. These isolated subconjunctival hemorrhages may be part of the traumatic asphyxia syndrome caused by severe, prolonged compression of the child's chest and upper abdomen. Appropriate assessment includes a complete ophthalmic and pediatric examination as well as hematological testing and imaging studies. If the coagulation profile and initial imaging studies are normal yet there remains a high suspicion of abuse, an immediate nuclear scan or a repeat skeletal survey or chest film 2 weeks later is indicated.
将虐待儿童纳入婴儿孤立性双侧结膜下出血鉴别诊断的范畴。
回顾3例非意外创伤病例，这些病例最初仅以孤立性双侧结膜下出血作为唯一显著的临床发现。
病例1和病例2除双侧结膜下大量出血外，眼科检查完全正常。所有3例婴儿的血液学参数均正常。病例1最初的放射学检查结果正常，但3周后复查胸部X线片时发现多处愈合的肋骨骨折。病例2在眼科医生初诊时，皮肤和骨骼X线检查结果符合虐待表现。病例3因多处不明原因的肢体骨折入院，但2周前曾因双侧孤立性结膜下出血和面部瘀点原因不明前来就诊。
婴儿双侧孤立性结膜下出血的鉴别诊断应考虑非意外创伤，尤其是伴有面部瘀点时。这些孤立性结膜下出血可能是儿童胸部和上腹部受到严重、长时间压迫所致创伤性窒息综合征的一部分。适当的评估包括完整的眼科和儿科检查以及血液学检测和影像学检查。如果凝血指标和初始影像学检查正常，但仍高度怀疑存在虐待，应立即进行核素扫描或2周后复查骨骼检查或胸部X线片。
