Retinal hemorrhage in abusive head trauma: finding a common language

Abstract

Purpose: To assess the performance of a refined Web-based tool for documenting retinal hemorrhage characteristics in suspected abusive head trauma.

Methods: Using a comprehensive tabular secure platform, with access to digital images in color, black and white, and 4-zone system schematic overlay, four pediatric ophthalmologists performed pilot testing with 80 images for tool refinement. In a second phase, retinal hemorrhages were documented by number, zone, and type. Interobserver agreement was calculated using the Fleiss kappa coefficient. Intraobserver agreement was calculated using Cohen's kappa statistic. We used surface area mapping software for further analysis.

Results: Interobserver agreement was good (kappa 0.4-0.6) and very good (kappa 0.6-0.8) for all questions in Zone A (peripapillary). For zones C (midperiphery) and D (peripheral retina), agreement was very good for all questions except number of hemorrhages, for which agreement was good. Zone B (macula) showed good and fair agreement except for superficial hemorrhage, for which agreement was poor. There was very good intraobserver agreement for number (kappa 0.68, 0.65, 0.67) and type of hemorrhages in zones A, B, and C. Surface area mapping results revealed no significant differences between zones A and B. Zones C and D had significantly less hemorrhage than A and B.

Conclusions: Our tool performed with good or very good interobserver and intraobserver agreement in almost all domains. We attribute zone B underperformance to the significant increased area covered by hemorrhages compared to zones C and D and the lack of contrast with normal anatomical structures in zone A.

FIGURE 1

Schematic of retinal hemorrhage assessment tool. Retina is divided into four zones: A (yellow circle), B (green circle), C (black circle), and D (peripheral retina beyond zone C). The nasal edge of zone B is tangential to the nasal edge of zone A. The edges of the midperipheral zone C run approximately through the vortex veins (yellow dots). The x represents the fovea.

FIGURE 2

Phase 1 questionnaire. Four pediatric ophthalmologists used this tabular format for the 80 images, and based on their feedback, the questionnaire was then refined (see Figure 3).

FIGURE 3

Phase 2 questionnaire. Screenshot showing the standard final Web page, including zone schematic and an image under review using the overlay option. The tabular format questionnaire reflects alterations based on the feedback of the examiners in phase 1 (see Figure 2). This new format, with forced-choice, mutually exclusive selections and automatic inactivation of choices, prevents inconsistent entries..