Eye Findings in Shaken Baby Syndrome
by Alex V. Levin 5.23.2007
Alex V. Levin, MD, MHSc, FAAP, FAAO, FRCSC
Departments of Paediatrics and Ophthalmology and Vision Sciences
The Hospital for Sick Children, University of Toronto
Chair, International Advisory Board, NCSBS
Retinal haemorrhages are a cardinal manifestation of abusive head injury, in particular Shaken Baby Syndrome (SBS). Examination by ophthal- mologists familiar with ocular findings in SBS, is an essential part of evaluating suspected child victims and in situations of unexplained life threatening events or sudden death. Examination should be carried out with pupil dilation, either using eye drops, or through the naturally dilated pupils of the severely ill child. Ophthalmologists use an instrument called the indirect ophthalmoscope to view the entire retina. Examination by non-ophthalmologists using only a direct ophthalmoscope is insufficient. After death, eyeball removal along with all orbital contents, is important to help to establish the cause of the child's death and detect signs of abuse. Post mortem protocols have been published*
In considering causation of retinal haemorrhage, it is important to detail types of retinal haemorrhage (preretinal, intraretinal, subretinal), number of haemorrhages, distribution of haemorrhages (confined to back [posterior pole] of the retina or spreading to edges [ora] of retina) and pattern of haemorrhages. Two-thirds of SBS victims have too numerous to count, multi-layered retinal haemorrhages extending to the ora. Fifteen percent have no retinal haemorrhages. Absence of retinal haemorrhage does not rule out child abuse. Traumatic retinoschisis is a particularly diagnostic lesion caused by traction applied to the retina by the vitreous jelly (which fills the eye and is attached firmly to the retina) as the child is submitted to repetitive acceleration-deceleration forces. The retina splits, creating a blood filled cystic cavity, not reported in otherwise well children except SBS victims and perhaps severe head crush injury or severe fatal motor vehicle accidents both of which would otherwise be obvious by history.
Multiple other causes of retinal haemorrhage are usually easy to diagnose by history, other medical findings, and laboratory/radiologic evaluations. Most other causes, including accidental short falls and cardiopulmonary resuscitation, perhaps with the exception of haemorrhages due to birth or leukemia, present only rarely and with few retinal haemorrhages confined to the posterior pole. Although blood clotting disorders should be ruled out, these entities rarely result in severe haemorrhagic retinopathy. Routine childhood vaccinations and seizures do not cause retinal haemorrhage.
Although increased intracranial pressure, hypoxia, increased intrathoracic pressure (from the perpetrator?s hands squeezing the rib cage), and anemia may play small roles in the development of retinal haemorrhages, the key factor is the unique repeated acceleration-deceleration forces that characterize SBS with or without head impact. This results in vitreo-retinal traction and perhaps damage to blood vessels and nerves behind the eye (orbit).
SBS survivors may have long term visual compromise. The main cause is brain injury to the vision centers (occipital lobes) and direct optic nerve injury.
* Gilliland MG, Levin AV, Enzenauer RW, Smith C, Parsons MA, Rorke-Adams LB, Lauridson JR, LaRoche GR, Christmann LM, Mian M, Jentzen J, Simons K, Morad Y, Alexander R, Jenny C, Wygnanski-Jaffe T: Guidelines for postmortem protocol for ocular investigation of sudden unexplained infant death and suspected physical child abuse. Am J Forensic Med Pathol [in press]
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