Retinal hemorrhages in children are important clinical findings. They may be associated with trauma or systemic diseases(1). In the absence of bleeding disorders, retinal hemorrhage most often result from non - accidental injuries such as direct streaking of the head, severe shaking causing acceleration - deceleration and thoracic compressions. Sever contraction of chest muscles in convulsion, crying or vomiting may cause retinal hemorr-hages(2,3).

The prevalence of retinal hemorrhage after convulsions is unclear, and there are few and small studies in this relation(2-4). So, we conducted this study to evaluate the incidence, nature and distribution of retinal hemorrhage in children after a convulsion which required hospitalization and to help clinicians how to deal with this problem.

Thirty one children aged 2 months to 5 years who hospitalized in pediatric ward (of Shahid Beheshti hospital) due to acute seizure attack, in 2002 were included in the study. All children underwent dilated fundus examination with indirect ophthalmoscope within 48 hours after attacks. Informed consent was obtained from their parents. A detailed history of nature, duration of seizure and any associated history of trauma or vomiting was taken, then complete neurological examination was done by pediatric neurologist. Classification of seizure was done on the basis of nature and type of epilepsy. The study was designed on type, pattern, distribution, and rate of resorption with appropriate follow up in the out-patient department of those children who were noted to have retinal hemorrhage.

Thirty one children with convulsion were examined including 19 boys (61.3%) and 12 girls (38.7%). Their ages ranged from 2 months to 5 years and a median of 18 months. Ten (32.2%) children were less than 2 years old. 29 (93.5%) had generalized seizures, 15 (48.4%) had febrile seizure, and 2 (6.5%) had complex seizure. In two cases with generalized seizure, we noticed streak retinal hemorrhage that disappeared 2 weeks later in both of them.

Retinal hemorrhages occur when blood extravasates from blood vessells due to variety of causes from benign to life - threatening conditions. It is usually seen in children with trauma (including child abuse), vomiting, coughing or cardiopulmonary resucitation. Theoretical mechanism is sudden rise of retinal venous pressure secondary to forceful thoracoabdominal muscle contraction. Such a mechanism is also possible after convulsion. There are a number of reports in literature about retinal hemorrhages after convulsion(3,4).

The prevalence of retinal hemorrhage after convulsion has not been established in review of literature. Sandramouli, et al. in a study of 33 children with convulsion find no retinal hemorrhage(2), but Mei-Zahav in 153 children with convulsion attacks noticed one case with retinal hemorrhage(4).

Our study in 31 children with convulsion revealed 2 patients (7%) with streak unilateral retinal hemorrhage in first 48 hours after convulsion attacks. Although theoretically convulsion can cause retinal hemorrhage in children, but its occurrence is very low and a direct connection between the convulsion attacks and retinal hemorrhages could not be proved.

Due to low occurrence of retinal hemorrhages with convulsion, we can not rule out its occurance. Statistically, it has been shown that proving prevalence less than 1% requires examining 300 children and finding normal fundi in all of them(5). So, the finding of a retinal hemorrhage in a child after a convulsive episode should therefore trigger an extensive search for other causes, such as non accidental injuries including child abuse.

D. Aghadoost,
A. Talebian,
Department of Ophthalmology,
Mattinii Hospital,
Amirkabir Avenue,
Kashan, Iran.
E-mail: Dawood_ [email protected]

1. Gayle MO, Kisson N, Hered RW, Harwood Nuss A. Retinal hemorrhages in the young child: a review of etiology, predisposed conditions, and clinical implications. J Emerg Med. 1995; 13: 233-239.

2. Sandramouli S, Robinson R, Tsuloumas M, Willshaw HE. Retinal hemorrhages and convulsions. Arch Dis child 1997; 76: 449-451.

3. Tyagi AK, Scotcher S, Kozeis N, Willshaw HE. Can Convulsions alone cause retinal hemorrhages in infants? Br J Ophthalmol 1998; 82: 659-660.

4. Mei - Zahav. M, Uziel Y, Raz J, Ginot W, Wolach B, Fainmesser P. Convulsion and retinal hemorrhage, should we look further? Arch Dis Child 2002; 86: 334-335.

5. O’ Donohoe JM. Retinal hemorrhages and convulsion. Arch Dis Child 1997; 77: 466.