Although most eye injuries in childhood are accidental or innocently caused by other children, a significant number of them result from physical abuse by adults. The terms used for intentional physical abuse of a child include nonaccidental trauma and child abuse. Child abuse includes emotional abuse, sexual abuse, and neglect as well as physical abuse. It is a pervasive problem, with an estimated 750,000 cases per year in the United States.
A reliable history is often difficult to obtain when nonaccidental trauma has occurred. Suspicion of nonaccidental trauma should be aroused when repeated accounts of the circumstances of injury or histories obtained from different individuals are inconsistent or when the events described do not correlate with the injuries (eg, bruises on multiple aspects of the head after “a fall”) or with the child’s developmental level (eg, a 1-month-old “rolling off a bed” or a 4-month-old “climbing out of a high chair”).
Any physician who suspects child abuse is required by law in every US state and Canadian province to report the incident to a designated governmental agency. Once this obligation has been discharged, full investigation of the situation by appropriate specialists and authorities is usually performed. Physicians should be familiar with the regulations in their own country. If possible, ocular abnormalities should be documented photographically or with a detailed drawing to use as evidence in court.
Abusive Head Trauma
A unique complex of ocular, intracranial, and sometimes other injuries occurs in infants who have been abused by violent shaking. This is recognized as one of the most important manifestations of child abuse. Although the term shaken baby syndrome is still occasionally used, it has largely been replaced with the terms abusive head trauma (AHT) and inflicted childhood neurotrauma because these infants may sustain impact injury as well as shaking injury involving the head.
Patients with AHT are usually younger than 5 years and most often younger than 12 months. When a reliable history is available, it typically involves a parent or other caregiver who shook an inconsolable crying baby in anger or frustration. Often, however, the only information provided is that the child’s mental status deteriorated or that a seizure or respiratory difficulty developed. The involved caregiver may relate that an episode of relatively minor trauma occurred, such as a fall from a bed. Even without a supporting history, the diagnosis of AHT can still be made with confidence on the basis of characteristic clinical findings. It must be kept in mind, however, that answers to important questions concerning the timing and circumstances of injury and the identity of the perpetrator frequently cannot be inferred from medical evidence alone.
Intracranial injury in AHT frequently includes subdural hematoma (typically bilateral over the cerebral convexities or in the interhemispheric fissure) and subarachnoid hemorrhage. Displacement of the brain in relation to the skull and dura mater ruptures bridging vessels, and compression against the cranial bones produces further damage. Neuroimaging may also show intracranial edema, ischemia, or contusion in the acute stage and atrophy in later stages. These findings are thought to result from repetitive, abrupt acceleration-deceleration of the child’s head as it whiplashes back and forth during the shaking episode. Some authorities, citing the frequency with which patients with AHT also show evidence of having received blows to the head, think that impact is an essential component, although in many cases no sign of impact is found.
The most common ocular manifestation of AHT, present in approximately 80% of cases, is retinal hemorrhage. These hemorrhages can be seen in all layers of the retina and may be unilateral or bilateral. They are found most commonly in the posterior pole but often extend to the periphery (Fig 27-4). Vitreous hemorrhage may also develop, usually as a secondary phenomenon resulting from migration of blood from a preretinal hemorrhage into the vitreous. Occasionally, the vitreous becomes almost completely opacified by dispersed hemorrhage within a few days of injury. Retinal hemorrhages in shaken infants cannot be dated with precision and usually resolve over a period of weeks to months. Vitrectomy should be considered if there is a risk of amblyopia due to persistent vitreous hemorrhage.
Some eyes show evidence of retinal tissue disruption in addition to hemorrhage. Full-thickness perimacular folds in the neurosensory retina, typically with circumferential orientation around the macula that creates a craterlike appearance, are highly characteristic. Splitting of the retina (traumatic retinoschisis), either deep to the nerve fiber layer or superficial (involving only the internal limiting membrane), may create cavities of considerable extent that are partially filled with blood, also usually in the macular region (Fig 27-5). Full-thickness retinal breaks and detachment are rare. Retinal folds usually flatten out within a few weeks of injury, but schisis cavities can persist indefinitely.
Figure 27-4 Extensive retinal hemorrhages in a 4-month-old infant suspected to have been violently shaken.
(Courtesy of Sophia Ying Fang, MD.)
Figure 27-5 Traumatic retinoschisis with perimacular folds (arrow).
(Courtesy of Ken K. Nischal, MD.)
A striking feature of AHT is the typical lack of external evidence of trauma. The ocular adnexa and anterior segment may appear entirely normal. Occasionally, the trunk or extremities show bruises representing the imprint of the perpetrator’s hands. In a minority of cases, broken ribs or characteristic metaphyseal fractures of the long bones result from forces generated during shaking. It must be kept in mind, however, that these patients may have been subjected to other forms of abuse.
When extensive retinal hemorrhage accompanied by perimacular folds and schisis cavities is found in association with intracranial hemorrhage or other evidence of trauma to the brain in an infant, AHT can usually be diagnosed with confidence regardless of other circumstances. Severe accidental head trauma (eg, sustained in a fall from a second-story level or in a motor vehicle collision) is not frequently accompanied by retinal hemorrhage, and hemorrhage is not extensive when present. Retinal hemorrhage is rare and has never been documented to be extensive following cardiopulmonary resuscitation by trained personnel. Severe, fatal, acute head-crush injury rarely causes hemorrhagic retinopathy with perimacular folds, which can be differentiated from AHT by the associated injuries.
Extensive retinal hemorrhage without other ocular findings strongly suggests that intracranial injury has been caused by AHT, but alternative possibilities such as a coagulation disorder must be considered as well. Retinal hemorrhages resulting from birth trauma are common in newborns, but they seldom persist beyond the age of 1 month. Other possible causes of retinal hemorrhage in children include anemia, hypertension, acutely increased intracranial pressure, leukemia, meningitis, glutaricaciduria, and retinopathy of prematurity.
American Academy of Ophthalmology, Hoskins Center. Clinical Statement. Abusive Head Trauma/Shaken Baby Syndrome—2015. San Francisco: American Academy of Ophthalmology; 2015. Available at https://www.aao.org/clinical-statement/abusive-head-traumashaken-baby-syndrome.
Christian CW, Block R; Committee on Child Abuse and Neglect; American Academy of Pediatrics. Abusive head trauma in infants and children. Pediatrics. 2009;123(5):1409–1411.
Maguire SA, Watts PO, Shaw AD, et al. Retinal haemorrhages and related findings in abusive and nonabusive head trauma: a systematic review. Eye (Lond). 2013;27(1):28–36.
In one large study, 29% of children with AHT died of their injuries. Poor visual and pupillary responses were correlated with a higher risk of mortality. Survivors often had permanent impairment ranging from mild learning disability and motor disturbances to severe cognitive impairment and quadriparesis. The most common cause of vision loss is cortical injury followed by optic atrophy. Dense vitreous hemorrhage, usually associated with deep traumatic retinoschisis, carries a poor prognosis for both vision and life.
Kivlin JD, Simons KB, Lazoritz S, Ruttum MS. Shaken baby syndrome. Ophthalmology. 2000;107(7):1246–1254.
Excerpted from BCSC 2020-2021 series: Section 10 - Glaucoma. For more information and to purchase the entire series, please visit https://www.aao.org/bcsc.