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Bilateral Retinal Hemorrhages in a Preterm Infant With Retinopathy of Prematurity Immediately Following Cardiopulmonary Resuscitation
Arch Ophthalmol. 2001;119:913-914.
INTRODUCTION
The relationship, if any, between intraretinal hemorrhages (IRH) and cardiopulmonary resuscitation (CPR) in pediatric patients is unclear. We describe an infant who developed bilateral IRH immediately following CPR. This case is unique in that the infant was examined by 2 retinal specialists (K.-G.A.E. and D.J.P.) immediately before and following CPR, with the interval between the 2 examinations being approximately 2 hours.
Report of a Case
A black male infant born at 24 weeks' gestation with a birth weight of 670 g was examined by 2 retinal specialists prior to planned laser photocoagulation at 35 weeks' postmenstrual age. Ophthalmoscopy disclosed bilateral stage 3 retinopathy of prematurity (ROP) in zone II. The left eye had 7 hours of stage 3 with plus ROP (threshold) and rare IRH, while the right eye was prethreshold with no hemorrhage.
During intravenous sedation in preparation for laser ablation, the infant developed severe apnea, bradycardia, and oxygen desaturation. He was immediately intubated, and chest compression with bag ventilation was begun and continued for approximately 15 minutes. Epinephrine was administered, and his condition stabilized on positive pressure ventilation.
Ophthalmoscopy 1 hours following resuscitation disclosed multiple flame-shaped IRH, some of which were white-centered, distributed diffusely throughout the entire vascularized retina, including the posterior pole bilaterally (Figure 1). A strip of blood lined the ridge of ROP for 360° in both eyes. He had no infective, hematological, or systemic condition that could account for the IRH. The patient received laser photocoagulation to the avascular retina in the left eye. The IRH disappeared within 2 weeks in both eyes. The threshold ROP regressed following the laser treatment, while the right eye did not progress to threshold disease. Both eyes have attained a favorable anatomic outcome as described by the Cryo-ROP Cooperative Group.
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Fundus photograph of the left eye demonstrates flame-shaped intraretinal hemorrhages in the posterior pole.
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Comment
Whether CPR can cause retinal hemorrhage is still an unresolved issue with many medical, social, and legal implications. Current literature supports the very strong association of IRH with child abuse.1 However, a few case reports have suggested a causal relationship between CPR and IRH.2-4 These authors speculate that elevated intrathoracic pressure owing to chest compression can increase retinal venous pressure by elevating the jugular venous and intracranial pressure, resulting in a hemorrhagic retinoangiopathy.2 Others contend that incompetence of the jugular venous valves—a condition present only in right heart failure or other cardiac disorders—is necessary for the increased venous pressure from chest compression to be transmitted to the cephalic veins, and they also have stated that increased intracranial pressure can be related to other conditions such as asphyxia.5 However, a postmortem study of 169 children5 and a prospective clinical study of 43 pediatric patients6 showed no case of IRH as a direct result of CPR. The authors of these reports concluded that once obvious causes of IRH such as blood dyscrasias and infections have been ruled out, physicians should always suspect child abuse.
Our case suggests that an association between CPR and IRH exists, although the immature retinal vasculature and ROP in our infant may have been predisposing factors. We suggest that the possible association of CPR with IRH in former preterm infants with ROP should be considered before categorically concluding that there must be child abuse. We cannot determine from this case if the vascular predisposition to bleed is temporary or may last throughout childhood in these infants.
AUTHOR INFORMATION
Dr Polito was supported by a stipend from the University of Verona School of Medicine, Verona, Italy; Dr Au Eong was supported by a National Medical Research Council–Singapore Totalisator Board Medical Research Fellowship, Singapore.
Corresponding author: Dante J. Pieramici, MD, Wilmer Ophthalmological Institute, The Johns Hopkins Hospital, Maumenee 215, 600 N Wolfe St, Baltimore, MD 21287 (e-mail: dpieramici{at}jhmi.edu).
Antonio Polito, MD;
Kah-Guan Au Eong, MMed(Ophth), FRCS;
Michael X. Repka, MD;
Dante J. Pieramici, MD
Baltimore, Md
REFERENCES
1. Gayle MO, Kissoon N, Hered RW, Harwood-Nuss A. Retinal hemorrhage in the young child: a review of etiology, predisposed conditions, and clinical implications. J Emerg Med. 1995;13:233-239.
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2. Goetting MG, Sowa B. Retinal hemorrhage after cardiopulmonary resuscitation in children: an etiologic reevaluation. Pediatrics. 1990;85:585-588.
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3. Kramer K, Goldstein B. Retinal hemorrhages following cardiopulmonary resuscitation. Clin Pediatr (Phila). 1993;32:366-368.
4. Weedn VW, Monsour AM, Nichols MM. Retinal hemorrhage in an infant after cardiopulmonary resuscitation. Am J Forensic Med Pathol. 1990;11:79-82.
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5. Gilliland MGF, Luckenbach MW. Are retinal hemorrhages found after resuscitation attempts? a study of the eyes of 169 children. Am J Forensic Med Pathol. 1993;14:187-192.
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6. Odom A, Christ E, Kerr N, et al. Prevalence of retinal hemorrhages in pediatric patients after in-hospital cardiopulmonary resuscitation: a prospective study. Pediatrics. [serial online]. June 1997;e3.
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