Unilateral retinal hemorrhages in shaken baby syndrome

doi:10.1016/j.jaapos.2006.09.023

Journal of American Association for Pediatric Ophthalmology and Strabismus

Volume 11, Issue 2, April 2007, Pages 175-178

https://doi.org/10.1016/j.jaapos.2006.09.023 Get rights and content

Purpose

To present a detailed series of patients with unilateral retinal hemorrhages in shaken baby syndrome.

Methods

Patients with a diagnosis of Shaken Baby Syndrome evaluated by the Ophthalmology Department at Penn State University between January 1999 and January 2004 were reviewed. Patients were identified and their medical records, photographs, and computed tomographic scans were reviewed. Additional records were obtained from the Children’s Hospital of Philadelphia.

Results

Of the 12 patients evaluated at Penn State University, the age at presentation ranged from 6 weeks to 15 months, with an average age of 4.3 months. Six (50%) had bilateral intracranial hemorrhage, while 6 (50%) had unilateral intracranial hemorrhage. The six patients with unilateral intracranial hemorrhage all had ipsilateral retinal hemorrhages. The perpetrators were male (100%) and 11 (92%) were the babies’ fathers. For the five patients evaluated at Children’s Hospital of Philadelphia, the age at presentation ranged from 4 weeks to 1 year, with an average of 4.35 months. Three (60%) had bilateral intracranial hemorrhage and two (40%) had unilateral intracranial hemorrhage. The perpetrators were male in four (80%) cases and three (60%) were the babies’ fathers.

Conclusions

These patients demonstrate the varied presentations of shaken baby syndrome. Unilateral retinal hemorrhages do not rule out the diagnosis of shaken baby syndrome.

Section snippets

Subjects and Methods

After obtaining approval from the institutional review board (IRB) at Penn State University Milton S. Hershey Medical Center, all patients with a diagnosis of shaken baby syndrome evaluated by the Ophthalmology Department between January1999 and January 2004 were reviewed. Of 92 consecutive consults reviewed, 12 had unilateral retinal hemorrhages. After obtaining approval from the IRB at Children’s Hospital of Philadelphia, five additional patients were obtained of 84 consecutive consults from

Results

Of the 12 patients evaluated at Penn State University, 9 patients (75%) were boys and 3 (25%) were girls. Ten (83%) were White, and 2 (17%) were African American. The age at presentation ranged from 6 weeks to 15 months, with an average age of 4.3 months. One patient (8%) was born prematurely. Where birth history was available, there was no difference between the incidence of cesarean sections versus vaginal deliveries. Six (50%) had bilateral intracranial hemorrhages, while 6 (50%) had

Discussion

Retinal hemorrhages are bilateral in the majority of patients with shaken baby syndrome; however, the presence of unilateral hemorrhages does not refute the diagnosis. There have been three main mechanisms proposed for the development of retinal hemorrhages in shaken baby syndrome.¹¹ The first theory involves vitreous traction from repeated acceleration and deceleration during shaking. The vitreous traction transmits force to the retina and retinal blood vessels, which can cause retinal

References (15)

Y. Morad et al.
Correlation between retinal abnormalities and intracranial abnormalities in the shaken baby syndrome
Am J Ophthalmol
(2002)
A.K. Tyagi et al.
Unilateral retinal hemorrhages in non-accidental injury
Lancet
(1997)
J.C. Paviglianiti et al.
Unilateral retinal hemorrhages and ipsilateral intracranial bleeds in nonaccidental trauma
J AAPOS
(1999)
A.V. Drack et al.
Unilateral retinal hemorrhages in documented cases of child abuse
Am J Ophthalmol
(1999)
Y.M. Buys et al.
Retinal findings after head trauma in infants and young children
Ophthalmology
(1992)
B. Kaur et al.
Fundus hemorrhages in infancy
Surv Ophthalmol
(1992)
R.K. Kanter
Retinal hemorrhage after cardiopulmonary resuscitation or child abuse
J Pediatr
(1986)

There are more references available in the full text version of this article.

Cited by (31)

Ophthalmological lesions in shaken baby syndrome: A retrospective analysis of 133 consecutive cases (1992–2018)
2022, Neurochirurgie
Citation Excerpt :
RH are typically described as flame-shaped, diffuse, and multilayered [1,7,8]. They are usually present in both eyes but can be unilateral without questioning the diagnosis [1,4,9]. Thus, our results are consistent with that, showing a unilateral nature of RH in 16 infants.
Shaken Baby Syndrome (SBS) is a non-accidental head trauma in which shaking causes cranio-cerebral lesions. Shaking can lead to ophthalmologic lesions such as retinal hemorrhage (RH). The aim of the present study was to compare our long-term results in to the literature data.
This study was a single-center retrospective descriptive analysis of 133 consecutive SBS cases (1992–2018). Only seniors in ophthalmology were authorized to perform these examinations. We studied type of lesion (retinal, intra-vitreal, papilledema), location (uni- or bi-lateral), and correlation with gender and age. Infants with a traumatic context without suspicion of child abuse were excluded.
Mean age at diagnosis was 131 days (range, 14 days–10 months). Boys accounted for 72.2% of the population. The prevalence of ophthalmologic lesions was 70.3%. 94.4% were RH; intra-vitreous hemorrhage (6.7%) and papilledema (11.1%) were less frequent. Lesions were bilateral in 81.1% of cases. Retinal lesions were classified in terms of location. Macular involvement was diagnosed in 8.2% of cases. 18.8% of retinal lesions could not be classified because of lack of precision in the ophthalmology report. The prevalence of ophthalmic lesions was higher for children aged over 6 months: 80%.
This series highlighted a high rate of ophthalmic lesions in SBS, with a high rate of bilateral involvement. RH was the most frequent lesion. RH in a context of subdural hematoma is a strong argument in favor of SBS. The forensic implications are that rigorous ophthalmologic examination by a senior practitioner is mandatory.
Nonaccidental trauma in pediatric patients: evidence-based screening criteria for ophthalmologic examination
2020, Journal of AAPOS
Ophthalmologic examination is included in the work-up for pediatric nonaccidental trauma (NAT) when there is concern for retinal hemorrhage. However, dilated fundus examination entails patient discomfort and prohibition of assessment of pupillary response. Previous studies have suggested that patients without neuroimaging abnormalities are unlikely to have retinal hemorrhage. The purpose of the current study was to analyze the findings in patients who received NAT evaluation with eye examination at our institution, and to propose screening criteria for inclusion of ophthalmologic examination in NAT evaluation.
The medical records of patients who received NAT evaluation with ophthalmologic examination at The Johns Hopkins Children's Center Pediatric Emergency Department from August 2014 to July 2018 were reviewed retrospectively. Data collected included demographics, presenting symptoms, imaging findings, and ophthalmologic examination findings. The main outcome measure was presence of retinal hemorrhage.
A total of 192 evaluations with ophthalmologic examination were included, representing 190 unique individuals of mean age 8.4 ± 9.5 months at presentation. In approximately half (54%) of the evaluations, there were abnormal findings on neuroimaging. Fifteen children (8%) had retinal hemorrhage, all of whom also had abnormal neuroimaging. Abnormal neuroimaging was associated with presence of retinal hemorrhage, with an odds ratio of 21.0 (95% CI, 3.47-∞; P < 0.001). Of the 15 children with retinal hemorrhage, 14 had subdural hemorrhage.
When neuroimaging abnormalities are present, ophthalmologic examination should be performed as part of the pediatric NAT evaluation. When there is no evidence of head injury on neuroimaging, ophthalmologic examination should not be routine.
Clinicopathological findings in abusive head trauma: Analysis of 110 infant autopsy eyes
2014, American Journal of Ophthalmology
Citation Excerpt :
However, at least 1 unilateral presentation for each finding, except subdural hemorrhage, was found in all cases. These findings corroborate previous studies26 that should alert the clinician to the significant, non-zero incidence of abusive head trauma cases with unilateral findings, including retinal hemorrhages. These dramatic clinicopathologic findings show that vitreomacular attachments most likely are needed for transmitting intense acceleration–deceleration forces throughout the eye.
To investigate the histopathology in a large series of autopsy eyes from children with abusive head trauma.
Retrospective case-control series.
One hundred and ten eyes from 55 autopsies examined at an academic tertiary referral center over 21 years were tabulated for histopathology: subdural hemorrhage in the optic nerve sheath, intrascleral hemorrhage, any retinal hemorrhage, ora-extended hemorrhage, cherry hemorrhage, perimacular ridge, and internal limiting membrane tear. Select tissues with cherry hemorrhage were further examined by transmission electron microscopy.
Sixty eyes were identified as “abusive head trauma” (cases), 46 as “alternative cause” (controls), and 4 as “abusive head trauma survivor”. Cases were legally verified or confirmed by confession in all except 1 case. All ocular histopathologic observations from cases were similar or more frequent in infants younger than 16 months of age. When present, a cherry hemorrhage and perimacular ridge were most often found together, and only with a torn internal limiting membrane. Both abusive head trauma survivor cases demonstrated severe optic nerve atrophy and macular ganglion cell loss.
Younger infants may be even more susceptible to damage from vitreomacular traction by rotational and/or acceleration–deceleration forces. Identifying cherry hemorrhages may aid abusive head trauma diagnosis. Survivor abusive head trauma pathology demonstrates unique, irreversible macular and optic nerve damage.
The eye in child abuse
2022, Child's Nervous System
Characteristics of Ocular and Non-Ocular Manifestations of Shaken Baby Syndrome
2022, SSRN
INVESTIGATION OF THE LEVEL OF KNOWLEDGE OF MOTHER'S ABOUT THE SHAKEN BABY SYNDROME
2021, Journal of Midwifery and Health Sciences

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Major articleUnilateral retinal hemorrhages in shaken baby syndrome

Purpose

Methods

Results

Conclusions

Section snippets

Subjects and Methods

Results

Discussion

Am J Ophthalmol

Lancet

J AAPOS

Am J Ophthalmol

Ophthalmology

Surv Ophthalmol

J Pediatr

Major article
Unilateral retinal hemorrhages in shaken baby syndrome