OSLI Retina

December 2020

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December 2020 · Vol. 51, No. 12 715 ■ B R I E F R E P O R T ■ Visual and Anatomic Outcomes of Premacular Hemorrhage in Non-Accidental Trauma Infants Managed With Observation or Vitrectomy Ogul E. Uner, BA; Christopher R. Stelton, MD; G. Baker Hubbard III, MD; Prethy Rao, MD, MPH BACKGROUND AND OBJECTIVE: The management of premacular hemorrhage secondary to non-acciden- tal trauma (NAT) is unclear. The authors describe the outcomes of NAT infants referred for surgical evaluation of premacular hemorrhage. PATIENTS AND METHODS: Retrospective institution- al review board-approved case series between 2000 and 2019 of vision-threatening premacular hemor- rhage (sub-hyaloid or sub-internal limiting mem- brane hemorrhage without vitreous hemorrhage) in NAT infants. Time to hemorrhage resolution, vi- sion, and comorbidities were collected. RESULTS: Thirty-six patients (62 eyes) with mean age of 5.4 months (range: 2-10 months) were in- cluded. Nine eyes (14.5%) underwent vitrectomy. Median time to hemorrhage resolution by observa- tion was 75 days (interquartile range [IQR]: 60-120 days), and time to vitrectomy was 54.5 days (IQR: 47.8-58.5 days). Eight eyes (12.9%) had amblyo- pia, which was not significantly different between groups. Despite hemorrhage clearance, a higher proportion of eyes in the vitrectomy group had pig- mentary changes (P = .04) and strabismus (P = .002) at follow-up. CONCLUSIONS: Most cases of NAT-related premac- ular hemorrhage resolve within 3 months without surgical intervention. Comorbidities may limit vi- sual prognosis. [Ophthalmic Surg Lasers Imaging Retina. 2020;51:715-722.] INTRODUCTION Retinal hemorrhage is a cardinal manifestation of pediatric non-accidental trauma (NAT), in which violent repeated acceleration-deceleration forces that damage the retina via vitreomacular traction. 1 In 1971, Guthkelch first described the concept of "whiplash-shaking" and "jerking" of infants re- sulting in severe deleterious effects to an infant's brain and eyes. 2 Since then, much work has gone into understanding the mechanisms and spectrum of clinical findings associated with pediatric NAT. 3 However, the specific management of premacular hemorrhage (sub-hyaloid or sub-internal limiting membrane [ILM]) has not been as well studied. Minimal consensus exists on the optimal timing for surgical intervention or whether surgery is benefi- cial. The purpose of this single-center, retrospec- tive study was to evaluate the clinical character- istics, course, and management of infants referred for surgical evaluation of premacular hemorrhage due to NAT. To our knowledge, this is the largest retrospective series that has evaluated NAT eyes specifically with premacular hemorrhage as the predominant feature for surgical evaluation and in- tervention. PATIENTS AND METHODS We performed a single-center, retrospective re- view of children younger than 2 years of age who were referred to the Emory Eye Center (Atlanta, GA) between January 1, 2000, and February 1, 2019, for surgical evaluation of premacular hemorrhage due to NAT. Patients were identified by a computerized search of billing records at the Emory Eye Center for children younger than 2 years with the Interna- tional Classification of Disease (ICD 9 and ICD 10) codes for "vitreous hemorrhage," "retinal hemor- From School of Medicine, Emory University, Atlanta, Georgia (OEU); the Department of Ophthalmology, Emory University School of Medicine, At- lanta, Georgia (OEU, CRS, GBH, PR); and SK Retina, Sarasota, Florida (CRS). Originally submitted July 29, 2020. Revision received September 20, 2020. Accepted for publication October 7, 2020. A preliminary version of this manuscript was presented June 7, 2014, at Resident Research Day, Emory Eye Center in Atlanta, Georgia, and again in poster format on May 7, 2015, at The Association for Research in Vision and Ophthalmology (ARVO) Annual Meeting in Denver, Colorado. Supported by National Eye Institute Core Grant P30 EY006360. Dr. Rao is a consultant for and receives royalties from Vortex Surgical outside the submitted work. The remaining authors report no relevant financial disclosures. Address correspondence to Prethy Rao, MD, MPH, Department of Ophthal- mology, Emory University, 1365B Clifton Road, Atlanta, GA 30322; email: prethy.rao@emory.edu. doi: 10.3928/23258160-20201202-06

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