Abusive Head Trauma
Severe shaking of infants, a form of nonaccidental trauma, is the cause of abusive head trauma (formerly known as shaken baby syndrome). The typical baby with abusive head trauma is almost always younger than 1 year and is frequently younger than 6 months. The presenting sign of child abuse involves the eye in approximately 5% of cases. Any physician who suspects that child abuse might have occurred is required by law in every US state and Canadian province to report the incident to a designated government agency.
Figure 18-7 Avulsion of the optic nerve head. In this color fundus photograph, the nerve is obscured by hemorrhage, and a mixed vascular occlusion is present.
See BCSC Section 6, Pediatric Ophthalmology and Strabismus, for discussion of the multiple systemic symptoms associated with abusive head trauma. Ocular signs include
The retinal hemorrhages associated with abusive head trauma often have a hemispheric contour. They can begin to resolve very rapidly, so it is important to examine suspected cases on presentation. The retinopathy may resemble that observed in Terson syndrome or central retinal vein occlusion, neither of which is common in infants. Retinal hemorrhages may be caused by trauma, but they are not usually associated with typical accidents, such as falls in the home.
Vitrectomy for vitreous hemorrhage should be considered if amblyopia is likely to occur but may be deferred if a bright-flash ERG response shows loss of the b-wave, which is indicative of extensive retinal damage. Fluorescein angiography shows attenuated vasculature and avascularity of the periphery.
Matthews GP, Das A. Dense vitreous hemorrhages predict poor visual and neurological prognosis in infants with shaken baby syndrome. J Pediatr Ophthalmol Strabismus. 1996;33(4):260–265.
Pierre-Kahn V, Roche O, Dureau P, et al. Ophthalmologic findings in suspected child abuse victims with subdural hematomas. Ophthalmology. 2003;110(9):1718–1723.
Figure 18-8 Color fundus photographs from a patient with abusive head trauma causing pre-retinal and retinal hemorrhages. A, Image taken several days after hospital admission, by which time many of the smaller hemorrhages had started to resorb. B, Numerous hemorrhages are located on and within the retina, and regions of hemorrhagic retinoschisis are observed centrally. Because the baby was upright, the red blood cells sank down into a dependent position within the larger regions of hemorrhagic retinoschisis. Some of the hemorrhages were white centered, whereas others had reflections of the flash from the fundus camera.
(Used with permission from Spaide RF, Swengel RM, Scharre DW, Mein CE. Shaken baby syndrome. Am Fam Physician. 1990;41(4):1145–1152.)
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.