Non-accidental ocular injury

Non-accidental ocular injury includes direct injury to the eyelids, globe or orbit and eye manifestations of inflicted head trauma. The presenting clinician may see a small subconjunctival haemorrhage, a painful damaged eye, unexplained poor visual behaviour, or an infant with neurological collapse. The visible lesion and the child's overall circumstances must both be assessed. An apparently minor surface mark can matter greatly when its explanation is incompatible with developmental ability; extensive internal damage may occur without an impressive external bruise.

NICE advises suspecting maltreatment when a child has retinal haemorrhages or another eye injury without major confirmed accidental trauma or an established medical explanation, including birth-related causes. This is a threshold for safeguarding action and further evaluation. It does not mean that every retinal haemorrhage proves abuse. Distinguish what is known, what has been reported and what remains uncertain. Avoid both premature accusation and the assumption that an unconfirmed benign explanation has excluded risk.

Abusive head trauma is associated particularly with numerous retinal haemorrhages affecting several layers, both eyes and the peripheral retina. Retinal folds or retinoschisis may add weight to concern. Nevertheless, no fundus pattern is independently diagnostic of child abuse. A specialist interpretation brings together the number, distribution and morphology of lesions, neurological findings, other injuries and the history. Unilateral haemorrhage can occur in inflicted and accidental injury. Conversely, absence of haemorrhage does not establish that head trauma was accidental.

Developmental history changes the meaning of a mechanism. A mobile toddler may sustain an independently witnessed collision; a pre-mobile infant cannot generate the same event unaided. Ask for a clear account of events, who was present, the child's behaviour afterwards and the reason for any delay. Clarify relevant birth, medical and bleeding histories. Differences in accounts require accurate exploration rather than an immediate assumption about motivation. Use an interpreter where needed and avoid making a child repeatedly recount distressing events to successive clinicians.

Stabilisation and urgent treatment run alongside safeguarding assessment. An infant with seizures or impaired consciousness needs emergency paediatric care. A chemical exposure still needs immediate irrigation, and a suspected open globe needs pressure-free protection and emergency ophthalmology. Once immediate threats are addressed, a suitably experienced ophthalmologist should examine both eyes and document the findings early. The joint RCOphth/RCPCH recommendation for assessment within 48 hours of initial paediatric referral is a good-practice timeframe, not permission to postpone an active emergency.

Potential alternatives include birth-related haemorrhage in a neonate, severe accidental trauma, haematological disorders and selected systemic or ocular diseases. Their relevance depends on positive clinical evidence rather than a checklist of rare possibilities. Birth history and the child's age are essential, but retinal appearances cannot usually date an injury precisely. Systemic investigation is coordinated by the paediatric safeguarding team so that ophthalmic evidence is evaluated with the whole clinical picture. A normal initial screening test need not exclude every bleeding disorder.

Care continues beyond establishing the cause of bleeding. A child may develop reduced acuity, strabismus or amblyopia, while cerebral visual impairment can persist despite resolution of visible retinal lesions. Follow-up should connect ophthalmology, paediatrics and developmental services with an agreed protection plan. Families need understandable information about immediate care and future appointments. Uncertainty can be explained honestly while maintaining the child's safety and preserving a respectful relationship with those involved.