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Rohrbach JM. [Still room for dispute: on shaken baby syndrome and abusive head trauma (AHT)]. DIE OPHTHALMOLOGIE 2024; 121:328-330. [PMID: 38443493 DOI: 10.1007/s00347-024-01999-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 01/23/2024] [Indexed: 03/07/2024]
Affiliation(s)
- Jens Martin Rohrbach
- Ophthalmopathologisches Labor/Forschungsbereich "Geschichte der Augenheilkunde", Universitäts-Augenklinik Tübingen, Elfriede-Aulhorn-Str. 7, 72076, Tübingen, Deutschland.
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Ang JL, Collis S, Dhillon B, Cackett P. The Eye in Forensic Medicine: A Narrative Review. Asia Pac J Ophthalmol (Phila) 2021; 10:486-494. [PMID: 34524140 DOI: 10.1097/apo.0000000000000426] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
ABSTRACT The eye, with its distinctive anatomy, not only reflects a wide variety of diseases in life but also undergoes a myriad of post-mortem changes. Consequently, the eye has long been an area of interest in forensic science, primarily for the estimation of post-mortem interval and therefore the time of death and also for assistance in ascertaining the cause of death. There has been significant progress in the knowledge of ophthalmic forensic science using new technologies which have allowed further possibilities to arise where understanding of this field can assist the forensic pathologist. This review aims to highlight the current knowledge which exists in this field and also to identify important avenues for further investigation. Post-mortem changes of the eye along with its current applications and challenges will be discussed. These include the important areas of post-mortem iris biometrics, pupil size correlation with post-mortem interval, use of point-of-care technology on vitreous humor, and the use of ophthalmic imaging in pediatric abusive head trauma.
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Affiliation(s)
- Juan Lyn Ang
- Princess Alexandra Eye Pavilion, Edinburgh, United Kingdom
| | - SallyAnne Collis
- Department of Forensic Pathology, The University of Edinburgh, Edinburgh, United Kingdom
| | - Baljean Dhillon
- Princess Alexandra Eye Pavilion, Edinburgh, United Kingdom
- The University of Edinburgh, Edinburgh, United Kingdom
| | - Peter Cackett
- Princess Alexandra Eye Pavilion, Edinburgh, United Kingdom
- The University of Edinburgh, Edinburgh, United Kingdom
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Ksiaa I, Ghachem M, Besbes H, Khochtali S, Chouchane S, Khairallah M. Swept-source OCT findings in shaken baby syndrome: case report. BMC Ophthalmol 2020; 20:396. [PMID: 33028244 PMCID: PMC7541327 DOI: 10.1186/s12886-020-01666-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Accepted: 09/29/2020] [Indexed: 11/29/2022] Open
Abstract
Background Our purpose was to document the swept source optical coherence tomography (SSOCT) findings in a patient with Shaken baby syndrome (SBS). Case presentation SSOCT was obtained without sedation in a six-month-old girl with bilateral multilayered retinal hemorrhages due to SBS. It documented vitreoretinal interface abnormalities, including internal limiting membrane (ILM) detachment with retinal traction, in association with other specific changes in the inner and outer retinal layers. Six weeks later, retinal hemorrhages had substantially resolved, and there was optic disc pallor. OCT showed ILM reattachment with release of retinal traction and the development of severe diffuse retinal atrophy involving the fovea. Conclusions SS OCT can provide useful information in SBS, revealing a wide variety of vitreoretinal interface, inner, and outer retinal changes not detected by clinical examination. It also may have a prognostic value over follow-up.
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Affiliation(s)
- Imen Ksiaa
- Department of Ophthalmology, Faculty of Medicine, Fattouma Bourguiba University Hospital, University of Monastir, Monastir, Tunisia
| | - Mohamed Ghachem
- Department of Ophthalmology, Faculty of Medicine, Fattouma Bourguiba University Hospital, University of Monastir, Monastir, Tunisia
| | - Habib Besbes
- Department of Pediatrics, Faculty of Medicine, Fattouma Bourguiba University Hospital, University of Monastir, Monastir, Tunisia
| | - Sana Khochtali
- Department of Ophthalmology, Faculty of Medicine, Fattouma Bourguiba University Hospital, University of Monastir, Monastir, Tunisia
| | - Slaheddine Chouchane
- Department of Pediatrics, Faculty of Medicine, Fattouma Bourguiba University Hospital, University of Monastir, Monastir, Tunisia
| | - Moncef Khairallah
- Department of Ophthalmology, Faculty of Medicine, Fattouma Bourguiba University Hospital, University of Monastir, Monastir, Tunisia.
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Shouldice M, Al-Khattabi F, Thau A, McIntyre S, Ng WKY, Levin AV. Traumatic macular retinoschisis in infants and children. J AAPOS 2018; 22:433-437.e2. [PMID: 30394342 DOI: 10.1016/j.jaapos.2018.08.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2018] [Revised: 08/16/2018] [Accepted: 08/16/2018] [Indexed: 11/25/2022]
Abstract
PURPOSE To provide detailed description of pediatric traumatic retinoschisis. METHODS The medical records of children with either abusive head trauma and traumatic macular retinoschisis seen at a single center from 1993 to 2006 were reviewed retrospectively. Clinical details were extracted from the record and photographic documentation. Evaluation regarding abuse excluded ophthalmology findings to avoid circular reasoning. RESULTS Of 134 patients with suspected abusive head trauma, 31 had retinoschisis. Mean age was 9 months. Of the 31, 22 (71%) offered a history of injury, and 9 (29%) were found unresponsive without history of injury; 6 were reportedly shaken. All patients had seizures, vomiting, and/or altered responsiveness. All had subdural hemorrhage, with cerebral edema in 17 (55%). In 10 (32%), there were findings of blunt force head injuries; in 4 of these there was no impact history. Retinal hemorrhages were present in all cases. Agreement between sidedness of retinoschisis and subdural hemorrhage was poor. Eleven patients had retinal folds, 3 of which had a hemorrhagic edge to the schisis. Nine patients had extracranial manifestations of abuse. Multidisciplinary team adjudications were as follows: of the 31 cases, 18 were suspicious for abuse, 11 were indeterminate, and 2 were possibly accounted for by accidental severe crush injury. Three children died, and 11 suffered neurological sequelae. CONCLUSIONS Traumatic retinoschisis in children is highly associated with subdural hemorrhage, neurologic symptoms, and poor outcomes. Even with a conservative approach to opinion formulation, traumatic retinoschisis was associated with likely abuse.
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Affiliation(s)
| | - Fadiah Al-Khattabi
- College of Medicine at Alfaisal University, King Faisal Specialist Hospital & Research Centre, Riyadh, Kingdom of Saudi Arabia
| | - Avrey Thau
- Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Susan McIntyre
- Schulich School of Medicine and Dentistry, The University of Western Ontario, London, Ontario
| | - Wendy K Y Ng
- Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania; Schulich School of Medicine and Dentistry, The University of Western Ontario, London, Ontario
| | - Alex V Levin
- Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania; Pediatric Ophthalmology and Ocular Genetics, Wills Eye Hospital, Philadelphia, Pennsylvania.
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Abstract
PURPOSE To demonstrate vitreoretinal traction as a mechanism for perimacular folds in abusive head trauma. METHODS We performed gross and histopathologic examination of eyes of children with suspected abusive head trauma and identified those with typical perimacular folds. Information was collected regarding the incident that led to the child's death and systemic manifestations noted at autopsy. Eyes were prepared in a fashion that allowed for demonstration of the vitreoretinal interface. RESULTS Ten eyes of five patients (2-13 months) were examined. All patients had systemic manifestations of abusive trauma including intracranial injury. All cases provided evidence of vitreoretinal traction producing perimacular folds. Condensed vitreous was seen attached to the apices of the retinal folds, and the detached internal limiting membrane comprising the inner surfaces of the schisis cavity. Four cases showed severe bilateral multilayered symmetric retinal hemorrhages extending to the ora serrata. All cases showed optic nerve sheath subdural hemorrhage and subarachnoid hemorrhage. Orbital hemorrhage was unilateral in two cases and bilateral in three cases. Four cases showed orbital fat hemorrhage. One case showed extraocular muscle sheath and cranial nerve sheath hemorrhage. Two cases showed juxtapapillary intrascleral hemorrhage. CONCLUSION Vitreoretinal traction is the likely mechanism of perimacular folds in abusive head trauma.
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Salvatori MC, Lantz PE. Retinal haemorrhages associated with fatal paediatric infections. MEDICINE, SCIENCE, AND THE LAW 2015; 55:121-128. [PMID: 24644226 DOI: 10.1177/0025802414527077] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
For many physicians, retinal haemorrhages (RHs) in infants and young children remain highly diagnostic of non-accidental (abusive) head trauma. Because clinicians have applied indirect ophthalmoscopy selectively to cases of suspected child abuse, the association between RH and other conditions such as infection, coagulopathy and accidental trauma has encountered habitual bias, creating the potential for iatrogenic misdiagnosis of child abuse. We present an autopsy case series of four children, aged three years old or younger, in whom RHs were detected by post-mortem monocular indirect ophthalmoscopy after the patients had died from infections. We discuss the laterality, number, type and location of RHs in these cases, and summarize proposed mechanisms of RH formation in fatalities from paediatric infection. We demonstrate that many of the ophthalmological findings that have been considered diagnostic of abusive head trauma can also occur in association with infective processes.
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Affiliation(s)
| | - Patrick E Lantz
- Department of Pathology, Wake Forest University School of Medicine, USA
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Oshima T, Yoshikawa H, Ohtani M, Mimasaka S. Examination of postmortem retinal folds: A non-invasive study. J Forensic Leg Med 2015; 30:16-20. [DOI: 10.1016/j.jflm.2014.12.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2014] [Revised: 12/06/2014] [Accepted: 12/13/2014] [Indexed: 10/24/2022]
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Breazzano MP, Unkrich KH, Barker-Griffith AE. Clinicopathological findings in abusive head trauma: analysis of 110 infant autopsy eyes. Am J Ophthalmol 2014; 158:1146-1154.e2. [PMID: 25127695 DOI: 10.1016/j.ajo.2014.08.011] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2014] [Revised: 08/05/2014] [Accepted: 08/06/2014] [Indexed: 01/31/2023]
Abstract
PURPOSE To investigate the histopathology in a large series of autopsy eyes from children with abusive head trauma. DESIGN Retrospective case-control series. METHODS 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. RESULTS 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. CONCLUSIONS 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.
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Abbott J, Shah P. The epidemiology and etiology of pediatric ocular trauma. Surv Ophthalmol 2014; 58:476-85. [PMID: 23969021 DOI: 10.1016/j.survophthal.2012.10.007] [Citation(s) in RCA: 81] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2012] [Revised: 10/11/2012] [Accepted: 10/16/2012] [Indexed: 11/25/2022]
Abstract
Eighteen million people worldwide have uniocular blindness from traumatic injury. Injuries occur disproportionally commonly in childhood. Every year a quarter of a million children present with serious ocular trauma. For the vast majority the injury is preventable. We review the international literature that identifies high-risk circumstances.
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Affiliation(s)
- Joseph Abbott
- Moorfields Eye Hospital, University College London Partners, London, UK.
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Meier P, Wiedemann P. Surgery for Pediatric Vitreoretinal Disorders. Retina 2013. [DOI: 10.1016/b978-1-4557-0737-9.00115-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Retinal haemorrhages and related findings in abusive and non-abusive head trauma: a systematic review. Eye (Lond) 2012; 27:28-36. [PMID: 23079748 DOI: 10.1038/eye.2012.213] [Citation(s) in RCA: 115] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
AIM To report the retinal signs that distinguish abusive head trauma (AHT) from non-abusive head trauma (nAHT). METHODS A systematic review of literature, 1950-2009, was conducted with standardised critical appraisal. Inclusion criteria were a strict confirmation of the aetiology, children aged <11 years and details of an examination conducted by an ophthalmologist. Post mortem data, organic disease of eye, and inadequate examinations were excluded. A multivariate logistic regression analysis was conducted to determine odds ratios (OR) and probabilities for AHT. RESULTS Of the 62 included studies, 13 provided prevalence data (998 children, 504 AHT). Overall, retinal haemorrhages (RH) were found in 78% of AHT vs 5% of nAHT. In a child with head trauma and RH, the OR that this is AHT is 14.7 (95% confidence intervals 6.39, 33.62) and the probability of abuse is 91%. Where recorded, RH were bilateral in 83% of AHT compared with 8.3% in nAHT. RH were numerous in AHT, and few in nAHT located in the posterior pole, with only 10% extending to periphery. True prevalence of additional features, for example, retinal folds, could not be determined. CONCLUSIONS Our systematic review confirms that although certain patterns of RH were far commoner in AHT, namely large numbers of RH in both the eyes, present in all layers of the retina, and extension into the periphery, there was no retinal sign that was unique to abusive injury. RH are rare in accidental trauma and, when present, are predominantly unilateral, few in number and in the posterior pole.
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Abstract
PURPOSE The purpose of this study was to document the hand-held spectral domain optical coherence tomography (HHSD-OCT, Bioptigen, Durham, NC) findings in shaken-baby syndrome (SBS). The nonaccidental trauma in SBS has been associated with retinal findings, including hemorrhages in all layers of the retina and retinoschisis. METHODS Three consecutive patients with presumed SBS underwent complete ocular examination, fundus photography with the RetCam (Clarity Medical Systems, Pleasanton, CA), and imaging with the HHSD-OCT. Acquisition of the HHSD-OCT images required an assistant to stabilize the head of the infant. RESULTS All three patients had clinical findings consistent with SBS, including preretinal and intraretinal hemorrhages. Hand-held spectral domain optical coherence tomography documented focal posterior vitreous separation in four of the five eyes with multilayered retinoschisis in one eye, disruption of the foveal architecture and foveolar detachment in one eye, and disinsertion of the internal limiting membrane or inner retinoschisis in one eye. Hand-held spectral domain optical coherence tomography documented preretinal hemorrhages in all five eyes. CONCLUSION Hand-held spectral domain optical coherence tomography is helpful in the evaluation of patients with SBS. All patients in our series had vitreoretinal abnormalities not detected on clinical examination, including, for example, multilayered retinoschisis. Hand-held spectral domain optical coherence tomography allows high-resolution imaging of the vitreoretinal interface and retina in infants with SBS and has provided insight into the mechanism of various retinal findings.
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Bhardwaj G, Chowdhury V, Jacobs MB, Moran KT, Martin FJ, Coroneo MT. A systematic review of the diagnostic accuracy of ocular signs in pediatric abusive head trauma. Ophthalmology 2010; 117:983-992.e17. [PMID: 20347153 DOI: 10.1016/j.ophtha.2009.09.040] [Citation(s) in RCA: 95] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2009] [Revised: 09/24/2009] [Accepted: 09/24/2009] [Indexed: 11/20/2022] Open
Abstract
TOPIC To review systematically the diagnostic accuracy of various ocular signs for pediatric abusive head trauma (AHT). CLINICAL RELEVANCE Intraocular hemorrhages (IOH), perimacular retinal folds, traumatic retinoschisis and optic nerve sheath hemorrhages have been reported as cardinal signs of AHT. The evidence base supporting the accuracy of this interpretation, however, has not been systematically reviewed. METHODS A systematic keyword search of MEDLINE, EMBASE, and Evidence-Based Medicine Reviews was conducted for original studies reporting ocular findings in AHT. Articles were graded using a checklist for systematic reviews of diagnostic accuracy. RESULTS The initial search yielded 971 articles, of which 55 relevant studies were graded, and 20 studies met inclusion criteria and were included in the review. The overall sensitivity of IOH for AHT was 75% and their specificity was 94%. Intraretinal hemorrhage at the posterior pole was the most common finding, although extensive, bilateral, and multilayered IOH were the most specific for AHT. Optic nerve sheath hemorrhages had a sensitivity and specificity for AHT of 72% and 71%, respectively. Traumatic retinoschisis and perimacular retinal folds were reported in 8% and 14% of AHT, respectively, but were not reported in other conditions. CONCLUSIONS Prospective, consecutive studies confirm that IOH in infants-particularly bilateral, extensive, and multilayered-are highly specific for AHT. Optic nerve sheath hemorrhages are significantly more common in AHT than in other conditions, in autopsy studies. Traumatic retinoschisis and perimacular folds are present in a minority of AHT, but rarely seen in other conditions.
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Affiliation(s)
- Gaurav Bhardwaj
- Faculty of Medicine, University of New South Wales, Randwick, NSW, Australia.
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Clarke MP. Vitreoretinal traction is a major factor in causing the haemorrhagic retinopathy of abusive head injury?--no. Eye (Lond) 2009; 23:1761-3. [PMID: 19662082 DOI: 10.1038/eye.2009.200] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Affiliation(s)
- M P Clarke
- Department of Ophthalmology, Newcastle University/Royal Victoria Infirmary, Newcastle upon Tyne, Tyne and Wear, UK.
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Retinal Hemorrhages and Shaken Baby Syndrome: An Evidence-Based Review. J Emerg Med 2009; 37:98-106. [DOI: 10.1016/j.jemermed.2008.06.022] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2007] [Revised: 04/08/2008] [Accepted: 06/11/2008] [Indexed: 11/21/2022]
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Comment on ocular manifestations of crush head injury in children. Eye (Lond) 2009; 23:235-6; author reply 236-7. [DOI: 10.1038/eye.2008.67] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
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Frasier LD. Abusive head trauma in infants and young children: a unique contributor to developmental disabilities. Pediatr Clin North Am 2008; 55:1269-85, vii. [PMID: 19041457 DOI: 10.1016/j.pcl.2008.08.003] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Abusive head trauma in infants and young children is the leading cause of death and disability from child abuse. This article discusses the history, epidemiology, clinical aspects, developmental outcomes, and associated injuries of this unique contributor to developmental disabilities. Prevention of abusive injuries and prevention of child abuse and neglect are also discussed.
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Affiliation(s)
- Lori D Frasier
- University of Utah School of Medicine, Center for Safe and Healthy Families, Primary Children's Medical Center, 100 North Medical Drive, Suite 3400, Salt Lake City, UT 84113, USA.
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Ocular pathology in shaken baby syndrome and other forms of infantile non-accidental head injury. Int J Legal Med 2008; 123:189-97. [DOI: 10.1007/s00414-008-0293-8] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2008] [Accepted: 10/01/2008] [Indexed: 10/21/2022]
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Forbes BJ. Clues as to the pathophysiology of retinal hemorrhages in Shaken Baby syndrome determined with optical coherence tomography. Am J Ophthalmol 2008; 146:344-5. [PMID: 18724978 DOI: 10.1016/j.ajo.2008.06.015] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2008] [Revised: 06/09/2008] [Accepted: 06/11/2008] [Indexed: 11/26/2022]
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Watts P, Obi E. Retinal folds and retinoschisis in accidental and non-accidental head injury. Eye (Lond) 2008; 22:1514-6. [PMID: 18636080 DOI: 10.1038/eye.2008.224] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
AIMS To report the similarity of retinal findings in an infant who sustained an accidental head injury and an infant with non-accidental head trauma. METHODS Two male infants sustained head injuries with skull fractures. Case 1 was an accidental head injury and case 2 was a non-accidental head injury. RESULTS On examination, in case 1, there were four superficial retinal haemorrhages in the right fundus. The left eye had a haemorrhagic optic disc oedema with extensive retinal haemorrhages, retinal folds, and schitic cavities within the retina at the posterior pole. In case 2, the right fundus had a single blot haemorrhage at the posterior pole. The left fundus revealed optic disc haemorrhage and oedema with extensive retinal haemorrhages. There was a haemorrhagic retinoschisis with a retinal fold. CONCLUSIONS The two cases, one with accidental and the other with non-accidental injury, demonstrate very similar ophthalmic findings. This supports the argument that there may be no retinal signs seen exclusively in non-accidental head injury.
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Affiliation(s)
- P Watts
- Department of Ophthalmology, University Hospital of Wales, Cardiff, Wales, UK.
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Tang J, Buzney SM, Lashkari K, Weiter JJ. Shaken baby syndrome: a review and update on ophthalmologic manifestations. Int Ophthalmol Clin 2008; 48:237-246. [PMID: 18427274 DOI: 10.1097/iio.0b013e3181693236] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Affiliation(s)
- Johnny Tang
- The Schepens Eye Research Institute, 20 Staniford Street, Boston, MA 02114, USA
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Guidelines for Postmortem Protocol for Ocular Investigation of Sudden Unexplained Infant Death and Suspected Physical Child Abuse. Am J Forensic Med Pathol 2007; 28:323-9. [DOI: 10.1097/paf.0b013e31815b4c00] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Emerson MV, Jakobs E, Green WR. Ocular autopsy and histopathologic features of child abuse. Ophthalmology 2007; 114:1384-94. [PMID: 17613329 DOI: 10.1016/j.ophtha.2007.04.015] [Citation(s) in RCA: 67] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2005] [Revised: 04/14/2007] [Accepted: 04/16/2007] [Indexed: 11/19/2022] Open
Abstract
PURPOSE To study the ocular histopathologic features in eyes of children with fatal suspected child abuse. DESIGN Retrospective case series. PARTICIPANTS One hundred eighteen autopsy cases of known or suspected child abuse. METHODS The ocular autopsy and histopathologic features of a cohort of consecutive cases of known or presumed child abuse submitted by Maryland's Office of the Chief Medical Examiner or Johns Hopkins Hospital to the Wilmer Eye Pathology Laboratory were tabulated. MAIN OUTCOME MEASURE Ocular hemorrhage or structural abnormality. RESULTS Retinal hemorrhage was present in 44% of cases. Circumferential folds with macular schisis cavities were present in 23% of cases and were bilateral in half of those cases. Peripapillary scleral hemorrhage was present in 38% of cases, and subdural hemorrhage was present in the distal optic nerve in 46% of cases. Hemosiderin was present in 27% of cases. CONCLUSIONS Intraretinal hemorrhages, circumferential macular folds with schisis cavities, peripapillary scleral hemorrhages, and subdural hemorrhages are common pathologic findings in cases of fatal known or suspected child abuse. Their presence on autopsy should raise the suspicion of shaking or blunt nonaccidental trauma.
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Affiliation(s)
- M Vaughn Emerson
- Wilmer Eye Institute, Johns Hopkins Hospital, Baltimore, Maryland, USA
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Meier P, Wiedemann P. Surgical Aspects of Vitreoretinal Disease in Children. Retina 2006. [DOI: 10.1016/b978-0-323-02598-0.50151-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Abstract
The English-language medical case literature was searched for cases of apparent or alleged child abuse between the years 1969 and 2001. Three-hundred and twenty-four cases that contained detailed individual case information were analyzed yielding 54 cases in which someone was recorded as having admitted, in some fashion, to have shaken the injured baby. Individual case findings were tabulated and analyzed with respect to shaking as being the cause for the injuries reported. For all 54 admittedly-shaken-infant cases, the provided details regarding the shaking incidents and other events are reported. Data in the case reports varied widely with respect to important details. Only 11 cases of admittedly shaken babies showed no sign of cranial impact (apparently free-shaken). This small number of cases does not permit valid statistical analysis or support for many of the commonly stated aspects of the so-called shaken baby syndrome.
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Affiliation(s)
- Jan E Leestma
- Department of Pathology, Children's Memorial Hospital, Chicago, Illinois 60622, USA.
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Meier P, Schmitz F, Wiedemann P. Vitrectomy for premacular hemorrhagic cyst in children and young adults. Graefes Arch Clin Exp Ophthalmol 2005; 243:824-8. [PMID: 15906060 DOI: 10.1007/s00417-005-1213-y] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2003] [Revised: 03/04/2004] [Accepted: 04/05/2004] [Indexed: 10/25/2022] Open
Abstract
BACKGROUND A pre-macular accumulation of blood is termed a hemorrhagic macular cyst and may be found both in eyes with Terson's syndrome and in shaken baby syndrome. In this study, we report on our experience and results of vitreoretinal surgery for treatment of pre-macular hemorrhagic cyst in eyes of patients suffering from Terson's syndrome and shaken baby syndrome. PATIENTS AND METHODS Between November 1995 and May 2003 seven eyes of six children underwent vitrectomy for pre-macular hemorrhagic cyst. Patients' age ranged from 5 months to 17 years. Indication for vitreoretinal surgery was pre-macular hemorrhagic cyst in eyes with Terson's syndrome (n=5) and shaken baby syndrome (n=2). During vitrectomy, rhexis of internal limiting membrane was performed. Four children received intensive orthoptic treatment postoperatively. RESULTS All eyes in our series showed a submembranous localization of pre-macular hemorrhagic cyst. The results of electron microscopic examination showed that the excised anterior walls contain internal limiting membrane. In all eyes improvement of the anatomic situation and of visual acuity was achieved. Duration of follow-up ranged from 6 months to 5 years. CONCLUSIONS Vitrectomy for hemorrhagic macular cyst in children is a safe and effective alternative to observation, offering visual rehabilitation, especially if amblyopia has developed or if both eyes are affected. If a hemorrhagic macular cyst is encountered, its complete removal is recommended to prevent development of proliferative vitreoretinopathy.
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Affiliation(s)
- Petra Meier
- University Eye Hospital, University of Leipzig, Liebigstrasse 10-14, 04103 Leipzig, Germany.
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Abstract
PURPOSE We report four patients with gaze-evoked amaurosis attributable to incomplete posterior vitreous detachment and ensuing vitreopapillary traction. We present these cases to illustrate and extend the spectrum of vitreopapillary syndromes and to draw attention to vitreopapillary traction and its expected manifestations in both optic disk appearance and optic nerve and retinal function. DESIGN This is a retrospective observational case series culled from tertiary neuro-ophthalmology practice. METHODS Patients were evaluated with direct and indirect ophthalmoscopy, Hruby (precorneal) lens, three-mirror Goldmann contact lens, macular contact lens, formal perimetry, fundus photography, fluorescein angiography, and orbital ultrasound. RESULTS Four patients with gaze-evoked amaurosis had disk edema associated with a partial posterior vitreous separation. These patients were young and had atypical posterior vitreous detachments characterized by persisting vitreopapillary attachments. CONCLUSIONS Gaze-evoked amaurosis is a rare visual obscuration precipitated by changes in volitional gaze, usually associated with an underlying orbital mass. We extend its etiologies to implicate the vitreous through traction expressed at the optic disk. In our cases, vitreopapillary traction elevated the nerve head and eye movements precipitated transient visual phosphenes followed by gaze-evoked amaurosis caused by traction transmitted from the vitreous to superficial nerve fibers of the retina and disk.
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Affiliation(s)
- Barrett Katz
- Departments of Ophthalmology, Neurology, and Neurosurgery, New York-Presbyterian Hospital, Weill Medical College of Cornell University, New York, New York, USA.
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Affiliation(s)
- P E Lantz
- Department of Pathology, Wake Forest University School of Medicine, Winston-Salem, NC 27157, USA.
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Forbes BJ, Christian CW, Judkins AR, Kryston K. Inflicted childhood neurotrauma (shaken baby syndrome): ophthalmic findings. J Pediatr Ophthalmol Strabismus 2004; 41:80-8; quiz 105-6. [PMID: 15089062 DOI: 10.3928/0191-3913-20040301-07] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Inflicted childhood neurotrauma (shaken baby syndrome) is the term used for violent, nonaccidental, repetitive, unrestrained acceleration-deceleration head and neck movements, with or without blunt head trauma, combined with a unique, age-related biomechanical sensitivity in children typically younger than 3 years. This syndrome is typically characterized by a combination of fractures, intracranial hemorrhages, and intraocular hemorrhages. Retinal hemorrhage is the most common ophthalmic finding, and usually occurs at all levels of the retina. In recent years, increasing pressure has been placed on ophthalmologists to render diagnostic interpretations of the retinal findings in children suspected to be victims, which may have great forensic implications in criminal proceedings. New research has increased our understanding of the pathophysiology of retinal hemorrhages, the importance of specifically characterizing the types, patterns, and extent of these retinal hemorrhages, and the differential diagnosis.
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Affiliation(s)
- Brian J Forbes
- Department of Ophthalmology, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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31
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Arnold RW. Macular hole without hemorrhages and shaken baby syndrome: practical medicolegal documentation of children's eye trauma. J Pediatr Ophthalmol Strabismus 2003; 40:355-7. [PMID: 14655984 DOI: 10.3928/0191-3913-20031101-09] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Affiliation(s)
- Robert W Arnold
- Pediatric Ophthalmology and Strabismus, Ophthalmic Associates, Anchorage, Alaska 99501-2242, USA
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32
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Donohoe M. Evidence-based medicine and shaken baby syndrome: part I: literature review, 1966-1998. Am J Forensic Med Pathol 2003; 24:239-42. [PMID: 12960659 DOI: 10.1097/01.paf.0000083635.85457.97] [Citation(s) in RCA: 71] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Gardner H. Correlation between retinal abnormalities and intracranial abnormalities in the shaken baby syndrome. Am J Ophthalmol 2003; 135:745; author reply 746. [PMID: 12719103 DOI: 10.1016/s0002-9394(02)02284-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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34
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Affiliation(s)
- Kailenn Tsao
- Department of Ophthalmology, Massachusetts Eye and Ear Infirmary, Boston, 02114, USA
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Sharma T, Gopal L, Biswas J, Shanmugam MP, Bhende PS, Agrawal R, Shetty NS, Sanduja N. Results of Vitrectomy in Terson Syndrome. Ophthalmic Surg Lasers Imaging Retina 2002. [DOI: 10.3928/1542-8877-20020501-05] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Marshall DH, Brownstein S, Dorey MW, Addison DJ, Carpenter B. The spectrum of postmortem ocular findings in victims of shaken baby syndrome. CANADIAN JOURNAL OF OPHTHALMOLOGY 2001; 36:377-83; discussion 383-4. [PMID: 11794386 DOI: 10.1016/s0008-4182(01)80081-8] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND Ophthalmologists and ocular pathologists are called on to help identify children who have undergone violent shaking. The objective of this study was to describe the spectrum of postmortem ocular findings in victims of shaken baby syndrome and to correlate the ocular findings with the nonocular features found at autopsy. METHODS The ocular pathology registry at the University of Ottawa Eye Institute was reviewed to identify all victims of fatal shaken baby syndrome whose eyes had been submitted for examination between Apr. 1, 1971, and Dec. 31, 1995. Autopsy reports were accessed from the hospital charts of the identified patients. RESULTS Six patients, aged 1 to 34 months, were identified. Intraocular findings ranged from a focal globular hemorrhage at the posterior pole to extensive intraocular hemorrhage involving the entire retina with perimacular folds. All the children had evidence of optic nerve sheath hemorrhage. Nonocular findings included intracranial hemorrhage (in all cases), skull fracture (in two), rib fractures (in three) and high spinal cord hemorrhage (in four). The extent of the intraocular hemorrhage was not consistent with the nonocular findings. INTERPRETATION Abused children may display a range of postmortem ocular findings, with intraocular hemorrhage varying from minimal to severe. These findings may not correlate with the severity of the child's other injuries. The presence of any retinal or optic nerve sheath hemorrhage in an infant, in the absence of an appropriate explanation for these findings, should raise suspicion of child abuse.
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Affiliation(s)
- D H Marshall
- Department of Ophthalmology, University of Ottawa Eye Institute, Ottawa Hospital, Ont
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37
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Abstract
Retinal hemorrhages are the most common fundus finding in the shaken baby syndrome. They vary in type and location; no particular type is pathognomonic for the condition. Retinal hemorrhages are not needed to make a diagnosis of shaken baby syndrome. However, in a child under age 3 years, the presence of extensive bilateral retinal hemorrhages raises a very strong possibility of abuse, which must be investigated. The other possible causes for hemorrhages in this age child can be investigated and eliminated. The diagnosis of abuse should be made by someone particularly trained in this area, who can put together the entire picture of inadequate or changing history, fractures of various ages, particularly rib fractures, subdural hematoma of the brain, and retinal hemorrhages. Photographs of retinal hemorrhages are very helpful to child advocacy experts who take these cases to court.
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Affiliation(s)
- J D Kivlin
- Department of Ophthalmology, Medical College of Wisconsin, Milwaukee, Wisconsin 53226-4812, USA.
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Russell-Eggitt IM, Thompson DA, Khair K, Liesner R, Hann IM. Hermansky-Pudlak syndrome presenting with subdural haematoma and retinal haemorrhages in infancy. J R Soc Med 2000; 93:591-2. [PMID: 11198692 PMCID: PMC1298152 DOI: 10.1177/014107680009301110] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- I M Russell-Eggitt
- Department of Ophthalmology, Great Ormond Street Hospital for Children, Great Ormond Street, London WC1N 3JH, UK.
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39
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Affiliation(s)
- D Taylor
- Eye Department, Great Ormond Street Hospital, London, UK
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40
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Affiliation(s)
- R W Block
- Department of Pediatrics, University of Oklahoma Health Sciences Center-Tulsa Campus, Tulsa, USA
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41
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Abstract
PURPOSE To describe the occurrence of unilateral retinal hemorrhages in four cases of documented child abuse, including a case in which retinal hemorrhages were an incidental finding on routine examination. METHODS Case reports. RESULTS Three children, 5 to 17 months of age, with suspected child abuse had fundus examinations with a dilated pupil as part of their evaluation. An additional child, 6 months of age, received fundus examination with a dilated pupil as part of follow-up for regressed retinopathy of prematurity. Each of the four children had extensive retinal or preretinal hemorrhages in one eye only. Three of the four had ecchymoses on the ipsilateral face or neck. Two had evidence of bone fractures on skeletal surveys. All four had neuroimaging that documented cerebral hemorrhage or infarct. In all four cases an adult caretaker was found responsible for shaking, choking, or squeezing the child. One child died. Two had resolution of retinal hemorrhage, whereas one required vitrectomy. All three had at least partial recovery of vision in the affected eye after amblyopia treatment. CONCLUSION In cases of documented child abuse, unilateral retinal or preretinal hemorrhages may be present. Ophthalmologists should recognize that unilateral retinal or preretinal hemorrhages may be associated with child abuse.
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Affiliation(s)
- A V Drack
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia, USA
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43
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Abstract
Traumatic retinal hemorrhages in young children are considered pathognomonic of child abuse. We identified 3 children with unilateral retinal hemorrhages caused by accidental household trauma. The hemorrhages were ipsilateral to intracranial hemorrhage and isolated to the posterior retinal pole.
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Affiliation(s)
- C W Christian
- University of Pennsylvania School of Medicine, Philadelphia; and the Division of General Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania 19104, USA
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Tufail A, Pearson RV. An ophthalmological view of retinal haemorrhages in shaken babies. JOURNAL OF CLINICAL FORENSIC MEDICINE 1999; 6:69-71. [PMID: 15335493 DOI: 10.1016/s1353-1131(99)90202-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/30/2023]
Affiliation(s)
- A Tufail
- Department of Ophthalmology, Southend Hospital, Southend-on-Sea, UK
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Abstract
PURPOSE The shaken baby syndrome (SBS) has been defined as a syndrome of intraocular and intracranial hemorrhage in young children, thought to be caused by violent shaking inflicted by an adult. In many cases SBS is fatal as a result of intracranial injury. Intraocular findings include hemorrhage, which may be accompanied by characteristic retinal folds or retinoschisis lesions. This study was performed to determine whether acute ophthalmologic findings might predict a fatal outcome. METHODS A consecutive series of 10 patients meeting a strict definition of SBS was reviewed for ophthalmic findings at presentation and outcome. RESULTS Seven patients survived, and three died. Of the six funduscopic characteristics identified in these patients, two were significantly associated with a fatal outcome: circular perimacular retinal folds found in four patients (p = 0.048) and peripheral retinoschisis lesions seen in three patients (p = 0.012). Lack of visual response at initial examination was also significantly associated with a fatal outcome (p = 0.033). CONCLUSIONS Ophthalmic examination of children with suspected SBS is important for prognostic as well as diagnostic purposes. Circular perimacular retinal folds, peripheral retinoschisis lesions, and lack of visual response correlated with fatal neurologic trauma and may be useful in predicting severity of central nervous system injury in shaken baby syndrome.
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Affiliation(s)
- M Mills
- Department of Ophthalmology and Visual Sciences, University of Wisconsin Medical School, Madison 53705, USA
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46
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Fishman CD, Dasher WB, Lambert SR. Electroretinographic findings in infants with the shaken baby syndrome. J Pediatr Ophthalmol Strabismus 1998; 35:22-6. [PMID: 9503311 DOI: 10.3928/0191-3913-19980101-09] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
PURPOSE To determine if electroretinography is helpful in the work-up of children with the shaken baby syndrome. METHODS Six children with retinal hemorrhages and the shaken baby syndrome underwent electroretinography (ERG). The ERGs of these six children were compared with six age-matched controls using the sign-rank test. RESULTS Neither the implicit time nor the amplitude of the white scotopic ERG response was significantly different between these patients and age-matched controls. Although the amplitude of the blue scotopic and 30 Hz flicker responses were attenuated (p < 0.05), the implicit times were not significantly different from controls. Three of the patients had serial ERGs recorded. The b-wave implicit time and amplitude improved in two of these patients. The ERG was helpful in distinguishing between a CNS and a retinal cause of visual loss in one child. CONCLUSIONS The ERG can be helpful in assessing retinal function in children with the shaken baby syndrome who have persistent visual impairment. In most cases, the ERG is not helpful in the initial assessment of children with the shaken baby syndrome.
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Affiliation(s)
- C D Fishman
- Emory Eye Center, Emory University, Atlanta, GA 30322, USA
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47
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Abstract
It is a sad indictment of human society that the abuse of children is such a prevalent and widespread problem. The acknowledgement that physical, emotional and sexual injury as well as intentional neglect can be inflicted upon the young by any person but especially by caregivers has been increasingly realised by the community. As a result, many professionals, especially in the medical sciences, are involved in the study and management of such cases with the ultimate goals of recognising children at risk, diagnosing those cases that have occurred, preventing initial or subsequent injury and bringing perpetrators to justice. The aim of this paper is to review recent published work on the pathology of abuse leading to death of the child. Particular reference is made to the patterns of observed physical damage as well as to the interpretation of those observations. Clearly many more children are abused than die directly as a result of that abuse, but pathologists are infrequently involved in the management of clinical abuse cases. Exceptions to this rule, of course, include assessment of biochemical changes in cases of Munchausen syndrome by proxy, diagnosis of infective lesions resulting from sexual assault as well as the interpretation of unexplained cutaneous lesions subsequently shown to be caused by physical assault (such as burns and bite marks). Cases of physical abuse are usually managed by pediatric specialists with assistance from radiologists, neurosurgeons and ophthalmologists, and it is important that effective communication be maintained by pathologists with these practitioners when investigating a case that has unfortunately culminated in death.
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Affiliation(s)
- P S Ellis
- Department of Forensic Medicine, Westmead Hospital, NSW, Australia
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48
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Affiliation(s)
- T W Olsen
- Department of Ophthalmology, Emory University School of Medicine, Atlanta, GA, USA
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49
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Gayle MO, Kissoon N, Hered RW, Harwood-Nuss A. Retinal hemorrhage in the young child: a review of etiology, predisposed conditions, and clinical implications. J Emerg Med 1995; 13:233-9. [PMID: 7775796 DOI: 10.1016/0736-4679(94)00145-6] [Citation(s) in RCA: 26] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Retinal hemorrhage is a frequent finding in child abuse, but may also be associated with cardiopulmonary resuscitation, accidental trauma, and a variety of illnesses such as blood dyscrasias and infections. Although it is imperative that child abuse be considered in all children who present with retinal hemorrhages, whether retinal hemorrhages can be attributed to cardiopulmonary resuscitation in suspected cases of abuse poses a dilemma. The etiologies of retinal hemorrhage as well as the literature presently available to support or refute the various diagnoses are discussed. Guidelines for funduscopic examination in the Emergency Department as well as a clinical classification of retinal hemorrhage are provided. In addition, guidelines are suggested for the appropriate clinical investigations in children with retinal hemorrhages.
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Affiliation(s)
- M O Gayle
- Department of Pediatrics, University of Florida Health Science Center/Jacksonville 32209, USA
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Katz B, Hoyt WF. Intrapapillary and peripapillary hemorrhage in young patients with incomplete posterior vitreous detachment. Signs of vitreopapillary traction. Ophthalmology 1995; 102:349-54. [PMID: 7862424 DOI: 10.1016/s0161-6420(95)31018-4] [Citation(s) in RCA: 75] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
PURPOSE The authors describe a benign condition characterized by intrapapillary and subretinal peripapillary hemorrhage, incomplete posterior vitreous detachment with persisting attachments to the disc, and preservation of optic nerve function in young patients. METHODS Eight patients 11 to 42 years of age with no or mild symptoms (blur, spot, or smudge) were referred for disc hemorrhage; seven of these patients were Asian. All underwent complete ophthalmologic examination, including detailed slit-lamp microscopy; particular attention was paid to vitreous attachments. RESULTS Superficial hemorrhage occurred predominantly in the superior hemidisc and was often striking in appearance. Subretinal hemorrhage occurred at the superonasal disc margin in six patients and was centered inferonasally in two. Discs were generally small, mildly dysplastic, and tilted; all were mildly elevated. The posterior vitreous body was separated from the retina but remained attached to the disc. Six patients had subtle visual field abnormalities in the involved eye. The hemorrhages resolved without sequelae or impairment of vision. During a 6-month follow-up, no patient progressed to complete vitreous detachment, retinal tear, or retinal detachment or required surgery to release traction. CONCLUSION The authors postulate that vitreopapillary traction traumatized disc vessels, causing hemorrhage in and around the disc. The superior hemidisc received the shearing force of detachment, which tore superficial vessels; transmission of the force through the retina caused subretinal bleeding. Posterior vitreous detachment remained incomplete because of tenacious vitreopapillary attachments. Mildly dysplastic discs, as in the young patients with myopia reported here, may have unusual vitreous attachments, predisposing them to the occurrence of and trauma from premature vitreous separation. The condition described is benign and requires no further evaluation or intervention.
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Affiliation(s)
- B Katz
- Neuro-ophthalmology Unit, California Pacific Medical Center, San Francisco 94115
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