Retinal hemorrhage is bleeding within the retina, the light-sensitive tissue lining the back of the eye. While common in adults, its presence in a child often signals a serious, underlying medical issue requiring immediate attention. Bleeding into the retina’s delicate layers can severely impact vision. Understanding the types of hemorrhage and their causes is the first step in ensuring a child receives proper care.
Anatomy and Classification of Retinal Hemorrhage
The retina is a multi-layered structure, and the location of the bleeding determines its classification. Superficial bleeding occurs in the nerve fiber layer, the topmost layer, and often appears as flame-shaped streaks because the blood follows the nerve fibers.
Deeper bleeding pools in the inner nuclear and outer plexiform layers, presenting as rounder, more distinct spots known as dot-and-blot hemorrhages. When blood collects beneath the innermost retinal surface, it forms a preretinal hemorrhage, which can appear large and boat-shaped due to gravity. The most severe form is a vitreous hemorrhage, where blood breaks into the vitreous gel that fills the main cavity of the eye.
Hemorrhages are also classified by their extent. Mild cases may involve only a few scattered hemorrhages confined to the posterior pole, the central area of the retina. In contrast, a pattern involving numerous, multilayered hemorrhages extending to the periphery is considered an alarming finding.
Traumatic and Non-Traumatic Etiologies
The causes of retinal hemorrhage are separated into non-traumatic and traumatic categories. In newborns, birth itself is a common non-traumatic cause of mild hemorrhages, especially following vaginal or assisted deliveries. These hemorrhages are typically small, few in number, and resolve entirely within the first few weeks of life without lasting visual problems.
Beyond the neonatal period, non-traumatic causes are often systemic conditions affecting blood vessels or clotting ability. These include hematologic disorders, such as leukemia, severe anemia, or coagulation disorders, which can lead to spontaneous bleeding. Severe, uncontrolled hypertension can also cause vessel rupture, resulting in flame-shaped hemorrhages. Terson syndrome, characterized by vitreous or preretinal hemorrhage, results from a sudden, massive increase in intracranial pressure, often due to a subarachnoid hemorrhage. Infections like sepsis or meningitis have also been documented as causes.
Traumatic causes are categorized as either accidental or non-accidental. Accidental trauma, such as severe falls or motor vehicle collisions, rarely results in extensive retinal hemorrhage. When accidental hemorrhages occur, they are often mild and confined to the posterior pole. In contrast, non-accidental trauma, particularly Abusive Head Trauma (AHT), is strongly associated with severe retinal hemorrhage. The repetitive acceleration-deceleration forces involved in AHT cause a unique pattern of severe, multilayered hemorrhages extending far into the peripheral retina. The presence of retinoschisis, a splitting of the retinal layers, strongly suggests AHT, especially when combined with intracranial bleeding or skeletal fractures.
Clinical Assessment and Diagnostic Workup
The diagnostic workup begins with a thorough physical examination and detailed medical history, documenting any recent trauma and assessing for systemic illness. Vital signs, including blood pressure, are measured to identify underlying conditions like severe hypertension.
The presence and characteristics of the hemorrhage are confirmed through a dilated fundus examination, typically performed by a pediatric ophthalmologist using indirect ophthalmoscopy. This specialized examination documents the location, number, and layers involved in the bleeding, providing clues to differentiate between various causes.
A systemic workup is required to investigate underlying causes. Neuroimaging, such as a computed tomography (CT) scan or magnetic resonance imaging (MRI), checks for associated intracranial hemorrhage or brain injury. For young children, a skeletal survey (a series of specialized X-rays) is often performed to identify occult fractures that might indicate non-accidental trauma. Blood tests, including a complete blood count and coagulation studies, are ordered to rule out non-traumatic causes like bleeding disorders.
Management Strategies and Visual Prognosis
Management depends entirely on the underlying cause and the severity of the bleeding. For mild hemorrhages, such as those caused by birth or minor medical events, observation is the primary approach. These small, intraretinal hemorrhages typically clear on their own within a few weeks, making direct intervention unnecessary.
The immediate focus is treating the underlying systemic or traumatic cause, such as controlling severe hypertension or managing a hematologic disorder. Direct intervention for the hemorrhage itself is necessary when the bleeding is severe, particularly when it is preretinal or has broken into the vitreous cavity.
A massive vitreous hemorrhage can block light from reaching the retina, risking permanent vision loss (amblyopia) in developing eyes. In these cases, a surgical procedure called a vitrectomy may be performed to clear the blood from the eye’s cavity. Vitrectomy is often indicated if dense hemorrhage persists and does not show signs of clearing within an appropriate time frame.
The long-term visual prognosis is highly variable. The most significant factor determining the final outcome is associated damage to the optic nerve or brain, rather than the hemorrhage itself. Children with hemorrhages secondary to severe brain injury, such as from Abusive Head Trauma, often have a guarded prognosis. Conversely, children whose hemorrhages are caused by birth trauma or mild, resolving medical conditions typically experience a complete visual recovery.