HOME: THE JOHN LAVERTY, JR. CASE-- FALSE SBS CHARGES, WRONGFUL CONVICTION & IMPRISONMENT

THE "SHAKEN BABY SYNDROME" MYTH: Why top scientists say it isn't possible to shake an infant hard enough to cause the symptoms used to diagnose SBS and the probable real causes

Retinal Hemorrhage Study  (separate page)

Shaken Baby Syndrome: Retinal Hemorrhages
The triad of symptoms used to diagnose SBS:

1. Diffuse Axonal Injury
2. Subdural Hematoma
3. Retinal Hemorrhages

Medical Dogma Without Supporting Science
The following article is an example of medical assumptions without supporting science or proven evidence of abuse. This is the way it works. Doctors accept the unproven theory that a specific amount of force is required to cause Retinal Hemorrhages in infants, ignoring the fact that these are found in newborns, often in the presence of Subdural Hemorrhages caused by non-tramatic forces, accidental injuries, and a number of medical causes unrelated to abuse or trauma.

The medical assumptions used as guidelines are "equal to a fall from a 2-story building or being unrestrained in a vehicle accident". So, if the caretaker can't provide documented evidence that the infant fell out of a window, was in an accident, or was videotaped or observed suffering from an accident this severe by an unrelated "reliable" witness, then the symptoms are assumed to be caused by child abuse no matter what the caretaker says, including cases where the symptoms came on after a vaccination, the infant was found in a crib or bassinet unresponsive with no external sign of trauma, fell or was dropped from a short distance, and there was no history of abusive behavior or the expectation that the accused would harm an infant.

"Abusive" or "Non-accidental" head trauma is usually assumed where accidental trauma remains undocumented. Even though emergency pediatric physicians are instructed to consider Differential Diagnosis (other causes of the same symptoms) in these cases, other causes are rarely even considered and almost never tested for to eliminate medical causes, which results in RH being put into two categories:

Proven accident or assumed abuse.

Assumed abuse then becomes listed as something describing non-accidental injury--the current term is "Abusive Head Trauma" in studies and legal cases. And when they refer to "proven" or "documented" cases of non-accidental injury, that usually means there is no proof of accidental injury and caretakers have been forced to sign plea bargains to avoid the threat of an assured longer sentence if they go to trial.

At present there are no reliably witnessed cases of shaking which have produced the symptoms associated with Shaken Baby Syndrome/Abusive Head Trauma. There have, however, been documented cases of shaking which produced no injury.

http://www.aao.org/aao/news/eyenet/pediatrics/pediatrics_jul.htm

Pediatrics
Recognize and Report Shaken Baby Syndrome
By Lori Schena, Contributing Writer

It is a scenario that occurs every day in ERs across the country. Paramedics or parents rush in a child who is not breathing, lethargic, comatose or experiencing seizures. The trauma team, after examining the baby, calls in the attending ophthalmologist to confirm what they may suspect: shaken baby syndrome, the leading cause of death in child abuse cases in the United States.

Why is the expertise of an ophthalmologist so sought after? Because retinal hemorrhages are a telltale sign of SBS. Ophthalmic expertise is necessary to make a diagnosis; moreover, accurate documentation may prove vital evidence in a court of law.

Defining the Syndrome
“The term ‘shaken baby syndrome’ was only coined in the last 25 or 30 years,” said Monte D. Mills, MD, chief of ophthalmology at Children’s Hospital of Philadelphia. “Physicians began to realize that retinal hemorrhage was an important feature of the syndrome, which in turn helped to better identify the problem.”

“Shaken baby syndrome” has evolved into “shaken impact baby syndrome” because in many cases, the child is shaken and then thrown, said Sean P. Donahue, MD, associate professor of ophthalmology, pediatrics and neurology at Vanderbilt University.

Cerebral damage caused by the impact of hitting an immobile object is also afeature of SBS—and in fact, the syndrome is characterized by symptoms that include brain swelling (see “Who, Where, What and Why”).

Differential Diagnosis
Ophthalmologists are usually called in as consultants to help support the diagnosis of SBS, said Michael X. Repka, MD, professor of ophthalmology and pediatrics at Johns Hopkins University. “The diagnosis is suspected by the pediatric, trauma or intensive care team. And the ophthalmic findings, when present, are not subtle, but rather obvious.”

One of the striking things about retinal hemorrhage and SBS is that this clinical sign in toddlers is relatively unusual. The differential diagnosis for retinal hemorrhage in this age group includes leukemia, low blood platelets and clotting disorders, said Dr. Repka.

Dr. Donahue added, “Other problems can cause retinal hemorrhages, but those are typically very different and the underlying clinical setting is also different. History and clinical examination, along with the retinal hemorrhage, helps in making the SBS diagnosis.” Conversely, he said, the absence of retinal hemorrhages does not exclude the diagnosis of SBS. Yet the presence of retinal hemorrhage in a suspicious situation makes the diagnosis very likely.

In the famous case of the British nanny and the death of Matthew Eappen

One Ophthalmologist’s Story
Perhaps one of the most well-known cases of supposed SBS occurred in 1997, when British au pair Louise Woodward was found guilty of second-degree murder in the death of 8-month-old Matthew Eappen in Massachusetts. A judge later reduced the charge to involuntary manslaughter, sentenced the nanny, then 19, to time served and sent her home to England. In the incident, prosecutors reported that Ms. Woodward admitted to shaking Matthew and to dropping him on the floor and tossing him on a bed. State medical examiners said Matthew hit the floor with the “force equivalent to a fall from a second-story window.” Matthew spent four days on life support before dying.

Matthew’s mother, Deborah S. Eappen, MD, is an ophthalmologist practicing with Harvard Vanguard Medical Associates in Boston. This tragic experience has prompted her to start a foundation for her son (http://www.mattyeappen.org) and to speak across the country about diagnosing SBS and documenting the clinical findings. She spoke to her Academy colleagues at the Mid-Year Forum in Washington, D.C., this spring, and one literally could hear a pin drop as she told her story.

Dr. Eappen notes that she does not remember actually learning about SBS during her residency at Tufts University in the early 1990s. “It simply wasn’t a topic that was taught. In fact, while there is more awareness about SBS today, it still represents a taboo subject, and oftentimes physicians would rather find some other explanation for retinal hemorrhage than child abuse. However, this retinal hemorrhage is distinctive—not even severe motor vehicle accidents cause this type of bleeding.”

Documentation Is Essential
Dr. Eappen stressed that ophthalmologists are on the “front lines” in terms of detecting child abuse and reporting any suspected cases—a position reiterated by Dr. Mills, who said, “It is important for ophthalmologists to accurately document and report these cases so that they don’t happen again.”

Dr. Eappen added that ophthalmologists have a responsibility to write not just “retinal hemorrhage” on their reports but the diagnosis of SBS (if it is suspected). “Think about it,” she told the Mid-Year Forum meeting attendees: “If we see diabetic retinopathy, we don’t write ‘retinal hemorrhage.’ We name the underlying cause. And when we see retinal hemorrhage as part of SBS, we need to call it what it is.”

Dr. Donahue also pointed out the importance of documenting the extent and location of the retinal hemorrhages, with photography if possible. Ophthalmologists also may be subpoenaed to testify in these cases. He advised, “Make sure you work with child abuse experts in your medical center, who can help incorporate additional findings of the examination and look for other indicators of trauma and abuse.”

Dr. Mills emphasized, “Ophthalmologists can’t just walk away from these children after the diagnosis and documentation. They will need long-term follow-up care and may require low-vision evaluations, treatment for amblyopia or vitreous surgery.”

Dr. Eappen called for the Academy to treat SBS as it does any other life-threatening diagnosis. “We need enhanced education, specific documentation and access to relevant pediatric literature. As ophthalmologists, we must all be able to provide optimal care for our most vulnerable patients—our babies. If we miss SBS once, we may not get another chance.”

(One of the pathologists who testified for the prosecution in this case has since reversed his opinion and stated that he couldn't say how the baby died. And the nanny stated under oath that she did not shake or slam the baby down, but rather found him unresponsive in his crib. This happened at age 81/2 months, which probably meant he was vaccinated at an 8 months, and this would fall within the time frame of the known 28 day period following vaccination that extreme and sometimes fatal adverse events take place.) http://www.cnn.com/US/9710/23/nanny.trial/index.html

Retinal Hemorrhages have other causes

http://www.sbsdefense.com/Assumption_5.htm

False Assumption
Retinal hemorrhages only come from "Shaken Baby Syndrome" or nonaccidental trauma.

Truth:
Retinal hemorrhages can be found in a myriad of different scenarios (child birth, CPR, coagulation disorders or any scenario that gives you a sudden increase in intracranial pressure). Retinal hemorrhages cannot be pathologically interpreted or dated with any accuracy. Retinal hemorrhages are generally caused by a sudden increase in intracranial pressure.

Prosecutors and proponents of Shaken Baby Syndrome assert that retinal hemorrhages are pathognomonic for (i.e. diagnostic of) Shaken Baby Syndrome. In fact, retinal hemorrhages are found in a myriad of different conditions, most of which result in a sudden increase in intracranial pressure. A human head is a closed space, with limited spare room for things like bleeding and swelling. Therefore, when the brain has reached its cranial capacity, but is still increasing in mass, it becomes compressed and pushes down toward the only escape route- the foramen magnum. The mechanisms behind the respiratory arrest or death in "SBS" cases are also the result of increased intracranial pressure.

Citations

1. Kaur B, & Taylor D. (1990) Current Topic: Retinal Hemorrhages. Arch. Dis. Child 65:1369 - 1372.

2. Goetting MG, Sowa B (1990). Retinal hemorrhage after cardiopulmonary resuscitation in children: an etiologic reevaluation. Pediatrics 85:585-588.

3. Nelson, L. Disorders of the Eye. In: Textbooks of Pediatrics. Behrman, R., Kliegman, R., Arvin, A. Fifteenth Edition. W.B. Saunders Company (Philadelphia). 1996. pgs. 1790-1797.

4. Elner SG, Elner VM, Arnall M, Albert DM.(1990) Ocular and associated systematic findings in suspected child abuse. A necropsy study. Arch Ophthal 108: 1094-1101.

5. Spitz and Fisher: Medicological Investigation of Death. Supra

6. Hess, A. Scurvy Past and Present. J.P. Lippincott Company. Philadelphia and London. 1920.

7. Gutman, F. (1983). Evaluation of a Patient with Central Vein Occlusion. American Academy of Ophthalmology. 90(5) 481-483.

8. Iijima H, Gohdo T, Imai M, & Tsukahra S. (1998) Thrombin-Anti-thrombin III Complex in Acute Retinal Vein Occlusion. American Journal of Ophthalmology 126(5): 677-682.

9. Biousse, V., Mendicino, M., Simon, D. and Newman, N. (1998). The Ophthalmology of Intracranial Vascular Abnormalities. American Journal of Ophthalmology 125(4):527-544.

10. Budenz DL, Farber MG, Mirchandani HG, Park H, Rorke LB (1994). Ocular and optic nerve hemorrhages in abused infants with intracranial injuries. Ophthalmol 101:559-565.

11. Devin F, Roques G, Disdier P, Rodor F, Weiller P.J, (1996). Occlusion of central retinal vein after hepatitis B vaccination. The Lancet Vol. 147: 1626.

12. Boucher,M.C. et. al. (1998) The Photo Gallery of Clinical Opthamology: Bilatera Serous Retinal detachments associated with Goodpasters's syndrome. Canadian Journal of Opthamology 33:46-47.

13. Matson, Neurosurgery of Infancy and Childhood.

 

http://www.google.com/search?q=thrombocytopenia+%2B+retinal+hemorrhage (37,100 hits)

Massive bilateral vitreoretinal hemorrhage in patient with chronic ...
thrombocytopenia [4]. The retinal hemorrhages were gen-. erally flame-shaped, but were occasionally either subhya-. loid or had broken through the internal ...
www.springerlink.com/index/WU362673512801QW.pdf

http://www.eyepathologist.com/disease.asp?IDNUM=310350
Contributor: Gordon K. Klintworth
Hemorrhages in the retina have many causes (including diabetic retinopathy [retinopathy - diabetic], hypertensive retinopathy [retinopathy - hypertensive], physical trauma, bleeding diathesis and increased intracranial pressure). The clinical appearance of the hemorrhage depends on the location of the hemorrhage within the retinal layers. Hemorrhage in the nerve fiber layer spreads between axons and causes a flame-shaped or splinter appearance on funduscopy. Deep retinal hemorrhages tend to be round. When located between the retinal pigment epithelium and Bruch's membrane, blood appears as a dark mass and clinically resembles a melanoma.

http://www.drhull.com/Enchanter/H/hemorrhage_retinal.html
hemorrhage, retinal
Retinal hemorrhage means bleeding onto the surface of the retina (visual receptor of the eye) caused by rupture of the tiny blood vessels that lie on the surface of the retina. Retinal hemorrhage indicates increased pressure within the skull. This may result from head trauma and bleeding, whether accidental or intentional (child abuse). It was once believed to be pathognomonic of so-called shaken baby syndrome, but this is no longer thought to be true by the forensic pathology community.

http://pediatrics.aappublications.org/cgi/content/full/115/1/192-a
PEDIATRICS Vol. 115 No. 1 January 2005, pp. 192 (doi:10.1542/peds.2004-2150)
Retinal Hemorrhages in Accidental and Nonaccidental Injury: In Reply
Kirsten Beheld, MD
Kathleen Streusel, MD
John Eventual, MD
Charles Duncan, MD
Yale University School of Medicine,
New Haven, CT 06504

In Reply.—

We thank Dr Lieder for his comments regarding our article.1 The types of retinal hemorrhages seen in the 7 children in our study with accidental head injury, along with the mechanism of injury and type of brain injury, are as shown below:

* 1-month-old: witnessed 3-foot fall out of father's arms as he was lying in bed; acute right epidermal hemorrhage and skull fracture; right single intra retinal hemorrhage

* 4-month-old: fell 3 feet out of sibling's arms; skull fracture: left intraretinal hemorrhages in the center of the retina, not extending to the periphery

* 4-month-old: witnessed 4-foot fall out of mother's arms; head hit table; acute right intracranial hemorrhage and skull fracture; right intraretinal hemorrhages around optic disk and arcades

* 8-month-old: witnessed 2-foot fall out of mother's arms as she was lying on a couch; acute left epidural hemorrhage and skull fracture; left single intraretinal hemorrhage

* 8-month-old: witnessed 3-foot fall off a bed; acute right subdural hemorrhage; bilateral intraretinal hemorrhages, each of which were small, in the center of the retina, and did not extend to the periphery

* 9-month-old: witnessed fall downstairs in walker; acute right subdural hemorrhage and right frontal skull fracture; right single intraretinal hemorrhage

* 10-month-old: crawling in driveway, head run over by car backing out, witnessed by other adults; intracranial air with orbital fracture; left intraretinal hemorrhages in the center of the retina not extending to the periphery

We appreciate the controversy that exists regarding the diagnosis of abusive head injury in young infants to which Dr Lueder alludes. It is important to note that in the cases of accidental head injury that were accompanied by retinal hemorrhages, there was a clear history of head trauma that was given by the caregivers when the child first presented for care. It is also noteworthy that the types of retinal hemorrhages present in children with accidental head injury were distinctly different from those present in children with abusive head injury in that they were confined to the intraretinal layer, did not cover the macula, and did not extend to the periphery of the retina.* We hope that our study serves to clarify some of the clinical issues that are raised when evaluating young children with head trauma.

REFERENCE
1. Bechtel K, Stoessel K, Leventhal JM, et al. Characteristics that distinguish accidental from abusive injury in hospitalized young children with head trauma.
Pediatrics. 2004;114 :165 –168

http://pediatrics.aappublications.org/cgi/content/abstract/85/4/585
PEDIATRICS Vol. 85 No. 4 April 1990, pp. 585-588
Retinal Hemorrhage After Cardiopulmonary Resuscitation in Children: An Etiologic Reevaluation
MARK G. GOETTING MD1 and BONNIE SOWA MD1

1 Department of Pediatrics, Henry Ford Hospital, Detroit, Michigan

Retinal hemorrhage detected after cardiopulmonary resuscitation has important medical, social, and legal implications. When a child is brought to the hospital in circulatory arrest, these hemorrhages raise the question of preceding trauma, frequently child abuse.1 Several authors have suggested that retinal hemorrhage may be virtually pathognomonic of child abuse.2,3 We have questioned this belief because our experience, as well as that of others,4,5 suggests that retinal hemorrhage may result from resuscitative efforts. We therefore undertook a prospective study to evaluate whether cardiopulmonary resuscitation can cause retinal hemorrhage.

MATERIALS AND METHODS

During a 4-month period, all children admitted to the Pediatric Critical Care Medicine Service who underwent cardiopulmonary resuscitation were considered for inclusion in the study.

http://www.ncbi.nlm.nih.gov/sites
1: Am J Forensic Med Pathol. 1990 Mar;11(1):79-82.
Retinal hemorrhage in an infant after cardiopulmonary resuscitation.
Weedn VW, Mansour AM, Nichols MM.

Department of Pathology, University of Texas Medical Branch, Galveston 77550.

Unexplained retinal hemorrhages in infants are usually indicative of child abuse. We present the case of an infant with retinal hemorrhages following cardiopulmonary resuscitation, who had not been abused. Cardiopulmonary resuscitation should be added to the list of causes of retinal hemorrhages in infants and children.

PMID: 2305754 [PubMed - indexed for MEDLINE]

http://www.wrongdiagnosis.com/r/retinal_detachment/book-diseases-3a.htm
Retinal Hemorrhage
Hemorrhages in the retina represent a broad range of ocular manifestations of systemic disease and/or trauma. The most important diagnosis to discover is nonaccidental trauma. Recognition of the pattern of hemorrhaging,* coupled with patient characteristics, history, and physical examination leads to the proper workup and diagnosis. An eye consultation will serve well in streamlining the evaluation and maximizing intervention.

Differential Diagnosis

* It is critical to realize that hemorrhages do not progress but represent altered structure, and as such may affect acuity
* Nonaccidental trauma must be the first etiology considered
* Pigmented lesions of the retina including choroidal nevi, congenital hypertrophy of the retinal pigment epithelium, retinal pigment epithelial hyperplasia
* Diabetic retinopathy is characterized by dot/blot, flame, preretinal, vitreous hemorrhages
* Hypertensive retinopathy is typically accompanied by signs of hypoxia, e.g., cotton wool spots and optic disc swelling
* May be associated with any systemic vascular disease or collagen vascular disease (e.g., systemic lupus erythematosus)
* Vein occlusion (Retinal arteries and veins can become blocked by a blood clot or substances (such as fat or plaque) that get stuck in the blood vessels. This is usually caused by an underlying disorder such as glaucoma, hypertension, diabetes, coagulation disorders, atherosclerosis, or hyperlipidemia.)
–Occlusion of a central vein may involve the entire retina, occlusion of one branch vein involves a section of the retina
* Peripheral retinal hemorrhaging may be associated with vascular insufficiency due to carotid stenosis
* May be associated with optic disc swelling
* Traumatic truncal injury may create intraretinal hemorrhages called Purtscher lesions
* Intracranial hemorrhage may dissect forward to surround optic nerve (Terson phenomenon)
* Blood dyscrasias, anemias, leukemias, sickle cell, ocular sarcoidosis, Behçet disease, Eales disease may cause retinopathy
* If sudden loss of vision is associated, wet macular degeneration, macular hemorrhage of histoplasmosis, preretinal hemorrhage, or vitreous hemorrhage may be the etiology
* Retinal vascular tumors, which may have an associated neurologic aneurysm
* HIV retinopathy presents with hemorrhage as first sign but may progress to involve and destroy vision

Workup and Diagnosis

* History
–Evaluate status of known systemic diseases; e.g., hypertension, diabetes
–Investigate for undiagnosed systemic disease: Hypertension, diabetes, carotid occlusion, cardiac anomalies, blood disorders, HIV

* Physical exam
–Visual acuity: Acuity is compromised if the hemorrhage lies within the foveal area
–Pupillary evaluation: Look for Marcus Gunn pupil
–Extraocular muscle evaluation for diplopia (may be associated with diabetes)
–Confrontation visual fields are indicated in all cases
–Perform a dilated fundus evaluation
* Labs
–CBC, differential, lipid profile, ANA, sickle cell, ACE, serum calcium

* Studies
–Ultrasonography, fluorescein angiography, ocular CT may be performed in conjunction with an ophthalmology consultation
–If secondary to a retinal vascular tumor, orbital and brain imaging with and without contrast is indicated with a neurologic consultation

Retinal hemorrhage in the young child: a review of etiology, predisposed conditions, and clinical implications
Authors: Gayle M.O.; Kissoon N.; Hered R.W.; Harwood-Nuss A.
Journal of Emergency Medicine, Volume 13, Number 2, 4 March 1995 , pp. 233-239+286(7)
Publisher: Elsevier

http://www.greenjournal.org/cgi/content/abstract/81/5/688
Obstetrics & Gynecology 1993;81:688-694
© 1993 by The American College of Obstetricians and Gynecologists

Obstetric correlates of neonatal retinal hemorrhage
MC Williams, RA Knuppel, WF O'Brien, A Weiss, WN Spellacy, and M Pietrantoni

OBJECTIVE: To determine whether maternal or fetal factors, other than vacuum-assisted delivery, play a role in neonatal retinal hemorrhage, and whether correlates are similar in retinal hemorrhage after spontaneous vaginal delivery.

METHODS: A cross-section of assisted deliveries at an urban hospital (n = 156) over 7 months were compared with contemporaneous spontaneous vaginal deliveries (n = 122). A subset of assisted deliveries (n = 87) was prospectively randomized to forceps or vacuum-assisted delivery by sealed envelope. Maternal and neonatal biometric data were collected, and Apgar scores, umbilical artery blood gas analysis, and neonatal ophthalmologic evaluations were performed.

RESULTS: Moderate to severe retinal hemorrhage was found in 18% of spontaneous, 13% of forceps, 28% of vacuum-assisted, and 50% of sequential vacuum and forceps-assisted deliveries. Fetal distress (P < .008), vacuum-assisted delivery (P < .02), decreased birth weight for gestation (P < .004), umbilical artery pH less than 7.20 (P < .004), and second stage of labor less than 30 minutes (P < .05) were most closely associated with increased degrees of retinal hemorrhage. Maternal parity, preeclampsia, length of labor, and head circumference were not correlated with retinal hemorrhage. Vacuum-assisted delivery among low birth weight infants (P < .0001), short second stage of labor (P < .006), fetal acidosis (P < .045), and sequential use of vacuum and forceps for assisted delivery (P < .005) formed a logistic model that correctly predicted 81% of moderate to severe retinal hemorrhage cases. Logistic analysis of the randomized assisted deliveries gave similar results.

CONCLUSIONS: Maternal and fetal factors other than vacuum-assisted delivery are significant correlates of moderate to severe retinal hemorrhage. Vacuum-assisted delivery among small for gestational age infants is closely correlated with moderate to severe retinal hemorrhage.

S. Herr, M. C. Pierce, R. P. Berger, H. Ford, and R. D. Pitetti
Does Valsalva Retinopathy Occur in Infants? An Initial Investigation in Infants With Vomiting Caused by Pyloric Stenosis
Pediatrics, June 1, 2004; 113(6): 1658 - 1661.

M Mei-Zahav, Y Uziel, J Raz, N Ginot, B Wolach, and P Fainmesser
Convulsions and retinal haemorrhage: should we look further?
Arch. Dis. Child., May 1, 2002; 86(5): 334 - 335.

A. Polito, K.-G. Au Eong, M. X. Repka, and D. J. Pieramici
Bilateral Retinal Hemorrhages in a Preterm Infant With Retinopathy of Prematurity Immediately Following Cardiopulmonary Resuscitation
Arch Ophthalmol, June 1, 2001; 119(6): 913 - 914.

C. DiScala, R. Sege, G. Li, and R. M. Reece
Child Abuse and Unintentional Injuries: A 10-Year Retrospective
Arch Pediatr Adolesc Med, January 1, 2000; 154(1): 16 - 22.

A. Odom, E. Christ, N. Kerr, K. Byrd, J. Cochran, F. Barr, M. Bugnitz, J. C. Ring, S. Storgion, R. Walling, G. Stidham, and M. W. Quasney
Prevalence of Retinal Hemorrhages in Pediatric Patients After In-hospital Cardiopulmonary Resuscitation: A Prospective Study
Pediatrics, June 1, 1997; 99(6): e3 - e3.

S Sandramouli, R Robinson, M Tsaloumas, and H E Willshaw
Retinal haemorrhages and convulsions
Arch. Dis. Child., May 1, 1997; 76(5): 449 - 451.

http://general-medicine.jwatch.org/cgi/content/full/1990/504/4
RETINAL HEMORRHAGES DO NOT ALWAYS INDICATE CHILD ABUSE
Journal Watch (General), May 4, 1990; 1990(504): 4 - 4.

Retinal hemorrhage in a child who requires resuscitation is considered a potential marker of child abuse, and some authors believe it is pathognomonic of abuse. Goetting and Sowa undertook a four-month prospective study of children who required chest compression during resuscitation, but who had no medical condition known to be associated with retinal hemorrhage and no evidence of physical abuse.

Of the 20 children who met these criteria, two had retinal hemorrhages. One child was a two-year-old victim of an accidental drowning, and the other was a six-week-old diagnosed with sudden infant death syndrome. Skeletal survey and autopsy ruled out trauma in both cases. The authors also report a nine-year-old boy who had two cardiac arrests caused by asthma. There were no retinal hemorrhages after these episodes, but two hemorrhages were detected after a third resuscitation.

The mechanism of retinal hemorrhage is believed to be increased intrathoracic pressure caused by chest compression during resuscitation attempts, which in turn increases retinal venous pressure. Child abuse must always be suspected in a child with cardiopulmonary arrest and retinal hemorrhage, but it must be remembered that abuse is not the only cause.— RAD

Goetting MG; Sowa B. Retinal hemorrhage after cardiopulmonary resuscitation in children: an etiologic reevaluation. Pediatrics 1990 Apr 85 585-588.

http://www.ajcn.org/cgi/content/abstract/22/5/559
American Journal of Clinical Nutrition, Vol 22, 559-567, Copyright © 1969 by The American Society for Clinical Nutrition, Inc.

Ocular Lesions in Scurvy

http://www.ajcn.org/cgi/content/abstract/22/5/559
American Journal of Clinical Nutrition, Vol 22, 559-567, Copyright © 1969 by The American Society for Clinical Nutrition, Inc.
Ocular Lesions in Scurvy
JAMES HOOD 1 and ROBERT E. HODGES 1

1 From The Department of Internal Medicine, University Hospitals, Iowa City, Iowa

Despite the recorded rarity of ocular vascular lesions in human scurvy, conjunctival lesions appeared during deprivation of ascorbic acid in five of nine volunteers who participated in two studies of experimental scurvy in man, three of four men in the first study and two of five men in the second. The ocular lesions often appeared early in the development of clinical scurvy and were first noted after deprivation of ascorbic acid for 74-95 days.

These lesions varied from minute bulbar conjunctival hemorrhages and varicosities to a large subconjunctival hemorrhage accompanied by palpebral petechial hemorrhages, and conjunctival congestion.

http://www.jpands.org/vol11no1/clemetson.pdf
C. Alan B. Clemetson, M.D.
ABSTRACT

Caffey is often cited as the source of the diagnosis of "shaken
baby syndrome" (SBS). Once the "classic" findings attributed to SBS
are identified, it is rare for a differential diagnosis to be considered.
Caffey focused on radiologic findings, but while he was aware
of the possible diagnosis of scurvy, the radiologic signs of infantile
scurvy may not have had sufficient time to develop. Other findings
in his cases were compatible with scurvy due to toxic histaminemia,
which can cause capillary fragility, retinal petechiae, and subdural
hematoma. Although dietary vitamin C deficiency is very rare today
in our country, both vitamin C deficiency and toxic histaminemia
can accompany systemic infection. Toxic histaminemia may also
occur following immunizations.

http://www.blackwell-synergy.com/doi/abs/10.1111/j.1365-4632.2007.02856.x?journalCode=ijd
International Journal of Dermatology
Volume 46 Issue 2 Page 194-198, February 2007
To cite this article: Margarita Larralde PhD, MD, Andrea Santos Muñoz MD, Paula Boggio MD, Vanesa Di Gruccio MD, Isaac Weis MD, Adolfo Schygiel MD (2007)
Scurvy in a 10-month-old boy

www.blackwell-synergy.com/doi/pdf/10.1111/j.1365-4632.2007.02856.x
Subscription needed for full text
File Format: PDF/Adobe Acrobat
clinical presentation of infantile scurvy resembles child abuse. Indeed, they share several features, such as mucosal and skin. bleeding, retinal hemorrhage .

http://www.blackwell-synergy.com
Pediatrics International
Volume 45 Issue 6 Page 758, December 2003
To cite this article: C Alan B Clemetson (2003)
Child abuse or Barlow's disease?
doi:10.1111/j.1442-200X.2003.01805.x
Subsciption needed

http://books.google.com
Sudden Death in Infancy, Childhood and Adolescence: Retinal hemorrhages..

http://tinyurl.com/2leevs Book: Clinical Preventive Medicine--Chapter: Manifestations of Vitamin Deficiencies (p.719) Vitamin C deficiency--hemorrhages in eyelids, conjunctiva, anterior chamber, and retina, proptosis in infantile scurvy

http://tinyurl.com/2d25ny
Clinical Orthopaedics & Related Research. 432:49-56, March 2005.
Caviglia, Horacio MD, PHD *; Garrido, Cecilia Pascual MD +; Palazzi, Federico Fernandez MD ++; Meana, Nestor Vallejos MD [S]
Within text....
Clinical Orthopaedics and Related Research - Fulltext: Volume (432 ...
Kato K: Critique of the roentgen signs of a infantile scurvy. .... Kao SC: Magnetic resonance imaging evaluation of neonates with retinal hemorrhages. ...
www.corronline.com/pt/re/corr/fulltext.00003086-200503000-00007.htm

http://tinyurl.com/2bqu45 --Book: Diseases of the eye and disorders of speech in childhood: hemorrhage of the lids (p.69)

http://www.google.com/search?q=retinal+hemorrhage%
Subdural Hematoma in Children
File Format: PDF/Adobe Acrobat
(within text)...variant of infantile scurvy (Barlow disease). Although he again argues that vascular fragility may led to SDH and retinal hemorrhages during the normal ...
www.springerlink.com/index/vnnx29066n8q2j34.pdf

http://www.freemendez.org/dispute.html (The Shaken Baby Syndrome theory is a source of controversy in the medical field. Here we have the medical establishment debating its very existance.)

http://www.cincinnatichildrens.org/svc/alpha/c/child-buse/tools/retinal-hemorrhage.htm

http://www.sbsdefense.com/Assumption_5.htm (vaccinations)

Review of Retinal Hemorrhages

Authored by Kathi Makoroff, M.D.

The Child Abuse and Neglect Team of The Mayerson Center for Safe and Healthy Children at Cincinnati Children's Hospital provides the following clinical update of literature on retinal hemorrhages resulting from shaken baby syndrome.

Does Accidental Injury Result in Retinal Hemorrhages?
Alario, et al., Johnson, et al. and Elder, et al. all performed prospective studies to determine if children who sustain accidental head injuries have retinal hemorrhages.

Combining the three studies, a total of 215 children were examined. Two children (0.93%) had retinal hemorrhages; both of these children were involved in fatal or serious motor vehicle accidents. Buys, et al. and Duhaime, et al. examined children who sustained traumatic head injury.

Buys found that 3/78 children had retinal hemorrhages; all three children were determined to have suffered non-accidental head injury after full multidisciplinary work-up. Duhaime found retinal hemorrhages in 10/100 patients <24 months who were admitted with head injury. Nine patients with retinal hemorrhages were felt by the authors to have suffered abusive head trauma. The other patient with retinal hemorrhages was involved in a motor vehicle accident.

Luerssen, et al. examined a database of 811 pediatric patients who were admitted to the hospital following traumatic brain injury. Retinal hemorrhages were detected in 27 patients. Twenty-two of these patients were felt by the authors to have suffered abusive head injury; one patient was involved in a motor vehicle accident and four patients suffered falls.

Christian, et al. reports three cases of retinal hemorrhages occurring after serious household accidental trauma. In the three patients, aged 13 months, 9 months and 7 months, the retinal hemorrhages were localized to the posterior pole.

Betz, et al. examined different groups of traumatic and non-traumatically head injured patients to compare a morphometrical analysis of the eyes. Two adult patients who suffered significant trauma (fall from stairs and a motor vehicle accident) had retinal hemorrhages, and all of the patients who were diagnosed with shaken baby syndrome had retinal hemorrhages. None of the patients with non-traumatic head injury had retinal hemorrhages.

Are Retinal Hemorrhages Caused by Cardiopulmonary Resuscitation?
Kanter, et al., Goetting, et al., and Odom, et al. all performed prospective studies to evaluate whether cardiopulmonary resuscitation (CPR) can cause retinal hemorrhages in children.

They studied a total of 117 patients. Nine patients had retinal hemorrhages: one patient had a single retinal hemorrhage following 75 minutes of CPR; another patient had multiple small punctate hemorrhages after 60 minutes of CPR.

Four patients were determined by the authors to have been abused based on additional findings. Another patient was involved in a motor vehicle accident, and one had significant hypertension. The final patient was a drowning victim; it is notable that no other reports of similar retinal hemorrhages following drowning can be found.

Weedn, et al., Kramer, et al., and Bacon, et al. each describe a single case report of an infant or child with retinal hemorrhages following cardiopulmonary resuscitation. The authors felt that these patients did not suffer non-accidental traumatic brain injury. In all three cases, however, the reviewer wonders if non-accidental traumatic brain injury was completely excluded.

Gilliland and Lukenbach performed a postmortem study on 169 infants and children to examine if resuscitation is associated with retinal hemorrhages. Seventy patients had retinal hemorrhages after receiving resuscitation attempts, and the majority of these patients had head injuries as the cause of death. Importantly, however, the nature and cause of the head injury was not specified.

Fackler et al. used an animal model to determine if CPR causes retinal hemorrhages in piglets. They performed CPR on six piglets for 50 minutes. No retinal hemorrhages were found following the resuscitation of these six piglets even with measurements of right atrial mean pressures of 74 ± 12 mm Hg and mean sagittal sinus pressures of 42 ± 6 mm Hg.

Are Retinal Hemorrhages Caused by Seizures?
Tyagi et al., and Sandramouli et al. performed similar studies to evaluate the likelihood that seizures alone will cause retinal hemorrhages in children. Combining the two studies, a total of 65 children who had recently had a seizure were examined with a dilated indirect fundiscopic examination. None of the children had retinal hemorrhages.

Do Retinal Hemorrhages Follow Meningitis?
Fraser et al. reports a case of a 12 year old with meningococcal meningitis who was found to have a large subretinal and vitreous hemorrhage of the left eye. The authors propose that obstruction of the central retinal vein caused retinal venous hypertension and the hemorrhage.

Kennedy describes a 4-month-old with meningococcal meningitis and disseminated intravascular coagulation. The infant had a small number of retinal nerve fiber hemorrhages in the posterior pole of both eyes. The author suggests that the hemorrhages were due to disseminated intravascular coagulation.

Are There Other Causes of Retinal Hemorrhages?
Clark et al. report a case of a 4 year old who had a spinal cord arteriovenous malformation and presented with bilateral retinal hemorrhages and papilledema. McLellan et al. present a case of a 6 week old with a ruptured intracranial arterial aneurism who also presented with bilateral retinal hemorrhages.

Pollack and Tychsen examined a random sample of infants and children after they had received extracorporeal membrane oxygenation. Five patients were found to have retinal hemorrhages; four of the five were neonates. The hemorrhages were all described as single or few dot or flame hemorrhages.

Shiono et al. describes two older patients with von Willebrand's syndrome. One patient (19 years old) had vitreous hemorrhages only, but the second patient (13 years old) had retinal, subretinal and vitreous hemorrhages.

What is the Significance of Unilateral Retinal Hemorrhages?
Drack et al. describes four cases of documented child abuse in which the children had extensive preretinal or retinal hemorrhages in one eye only.

All of the children had indirect ophthalmoscopy performed by an ophthalmologist. Tyagi et al. similarly describes three cases of unilateral retinal hemorrhages in children who the authors felt sustained non-accidental head injury.

Paviglianti and Donahue describe three infants who were found to have unilateral retinal hemorrhages and ipsilateral cranial hemorrhages. All three cases were "strongly suspicious of nonaccidental trauma".

Wilkinson et al. correlated retinal hemorrhages with neurological outcome in shaken baby syndrome. Three of fourteen patients (21%) in their series had unilateral retinal hemorrhages. Kivlin et al. examined the ophthalmologic findings with shaken baby syndrome at one medical center. Of the retinal hemorrhages that were identified by the ophthalmologists, 11/76 (14%) were unilateral.

Do Neonates Have Retinal Hemorrhages?
Sezen et al., Planten al., Baum et al., Levin et al., Schenker et al.., and Emerson et al. all performed studies looking at the incidence of retinal hemorrhages in neonates and also to see if the delivery technique influences the incidence of retinal hemorrhages.

In all of the studies that looked at delivery technique, the highest incidence was seen following delivery with vacuum extraction and the lowest incidence was seen following cesarean section. Sezen et al. and Baum et al. determined the incidence of retinal hemorrhages when neonates were examined within one week of birth.

The incidences were 14.3% and 15.5% respectively. Planten et al., Levin et al. and Schenker et al examined neonates within 24 hours of birth. The incidence of retinal hemorrhages in these studies ranged from 19.2% to 37.3%.

Sezen et al. additionally looked at the time to resolution of the hemorrhages. Hemorrhages identified as flame shaped resolved within five days. Round, red, deep hemorrhages usually disappeared within 21 days except in one case in which the hemorrhage did not resolve until 6 weeks after birth.

Emerson et al. examined neonates within 30 hours of birth and found the incidence of retinal hemorrhages to be 34%. Most of the hemorrhages were gone by 2 weeks of age; one subretinal hemorrhage persisted up to six weeks after birth.

Smith et al. randomly selected 46 neonates without perinatal problems for dilated retinal examination. Ten infants were found to have retinal hemorrhages. These ten infants also had a brain MRI looking for evidence of intracranial injury. Only eight of the scans were satisfactory but none of the neonates showed evidence of intracranial injury on MRI.

Skalina et al. examined the incidence of retinal hemorrhages in newborn infants with systemic hypertension (defined as mean arterial pressure >70mmHg on at least three separate days). Eight patients had retinal hemorrhages; one infant had splinter hemorrhages which were still visible 10 weeks later.

Beratis et al. investigated whether maternal smoking during pregnancy causes retinal abnormalities in the newborn. They used two groups of neonates matched for mode of delivery and gestational size; the neonates were grouped according to whether their mothers smoked during pregnancy or not (self-report).

There was an increased frequency of retinal hemorrhages seen in neonates of mothers who smoked during pregnancy when compared to infants of mothers who did not smoke during pregnancy.

Does Purtscher retinopathy occur in children?
Tomasi and Rosman report two cases of children who had ecchymosis of the chest and were also found to have retinal hemorrhages.

The authors define Purtscher retinopathy as following a sudden compression of the thoracic cage. The two children in these case reports did not have head imaging, so it is difficult to conclude that thoracic compression is the cause of the hemorrhages.

Does Terson syndrome occur in children?
Kuhn, et al. performed two studies examining vitreous hemorrhages and subarachnoid and subdural hemorrhages in adults and children.

The second study which examined the incidence of intraocular hemorrhages with subarachnoid hemorrhages did not include children. The incidence of Terson syndrome in children, therefore, could not be determined from this study. Interestingly, all of the children in the first study who underwent vitrectomy for vitreous hemorrhages had subdural hemorrhages.

What are the Outcomes of Infants and Children with Retinal Hemorrhages?
Matthews and Das examined the relationship of retinal and vitreous hemorrhages and neurological outcomes in five infants with shaken baby syndrome. Three of the five infants had a poor neurological outcome. Wilkinson et al. also looked at the relationship between retinal hemorrhages and neurological outcomes in fourteen infants and children with shaken infant syndrome. There was a borderline statistical significance between the presence of retinal hemorrhages and the neurological outcome.

Kivlin et al. examined clinical and ophthalmological findings in children who were diagnosed with shaken baby syndrome. They found that the presence and bilaterality of retinal hemorrhages indicated a worse prognosis for survival.

Han and Wilkinson examined six children 12 - 55 months following a shaking injury. There was significant visual morbidity seen in these six cases. In addition, three of the children had significant neurological disabilities. McCabe and Donahue performed a retrospective chart review of 30 patients who were diagnosed with shaken baby syndrome. They found that decreased vision in these patients was due to retinal scarring, optic atrophy and cortical visual impairment.

Article Summaries

Does Accidental Injury Result in Retinal Hemorrhages?

Christian CW, Taylor AA, Hertle R, Duhaime AC. Retinal hemorrhages due to accidental household trauma. J Pediatrics 1999;135:125-127.

Objectives:
To describe cases of retinal hemorrhages occurring after serious accidental trauma.

Methods:
3 case reports of unintentional household trauma resulting in retinal hemorrhages.

Case 1

* Mechanism: 13 month old fell down 13 concrete steps in a walker
* Symptoms: Immediate loss of consciousness
* Findings: Scalp and thigh bruise; nasal abrasion. Acute right parieto-temporal subdural and enlarged extra-axial space with minor mass effect. Skeletal survey normal
* Retinal Findings: Unilateral (right) pre-retinal and intra-retinal hemorrhage; localized retinal edema in the posterior pole
* Outcome: Normal findings on ophthalmology follow-up at 3, 11, 24 months

Case 2

* Mechanism: 9 month old was being supported and swung by father; fell back 1-2 feet hitting occiput
* Symptoms: Cried then transiently unresponsive with seizure activity. Glasgow Coma Score (GCS) = 4
* Findings: Acute subdural and/or subarachnoid hemorrhage over the left parieto-occipital area with midline shift; Skeletal survey normal
* Retinal Findings: Multiple intraretinal flame shaped hemorrhages and round intraretinal hemorrhages in the posterior pole of left eye. Also 2 small posterior vitreous hemorrhages along the posterior pole. Foveal edema.
* Outcome: Normal neurological exam at follow-up at 3, 6 months.

Case 3

* Mechanism: 7 month old fell through a stair rail onto concrete basement floor, landing on her head
* Symptoms: No LOC; Glasgow Coma Score (GCS) = 7
* Findings: Large right parieto-frontal subdural hemorrhage with midline shift. Diastatic fracture of coronal suture; linear fracture of temporal bone; right cerebral contusion also noted operatively. Skeletal survey normal
* Retinal Findings: Unilateral (right) subretinal and intraretinal hemorrhages in the posterior pole; also preseptal cellulitis
* Outcome: Normal neurological exam and ophthalmology exam at follow-up

Conclusions:

* Intracranial bleeding and retinal hemorrhage may occur secondary to household accidental trauma. Reports of this are infrequent.
* There were differences between retinal findings in these three patients compared to typical retinal findings seen in patients with non-accidental head injury. In these cases, the retinal hemorrhages were:
    o Isolated to the posterior pole
    o Had no peripheral involvement
    o Not associated with retinal folds or retinal detachment

Alario A, Duhaime T. Do retinal hemorrhages occur with accidental head trauma in young children? AJDC 1990;144:445. (Abstract only)

Objectives:
To determine if retinal hemorrhages occur from common accidents.

Methods:
Prospective study of 50 children <24 months of age with well-documented accidental head trauma.

Ophthalmologists performed an ophthalmologic exam on patients within 24 hours of presentation of accidental head trauma to look for retinal hemorrhages.

Results:
Mean age of patients was 11.4 months. Retinal hemorrhages were not found in any of the 50 children.
Mechanism of injury: n (%)
Fall down stairs (19/26 in walkers) 26 (52%)
Fall <= 4 feet 15 (30%)
Fall >= 10 feet 4 (8%)
Impact from moving object 2 (4%)
MVA 3 (6%)

Outcomes:
All children recovered quickly without any neurologic sequelae.

Conclusion:
Retinal hemorrhages were not found in the young children who sustained mild to moderate head injury as a result of common accidental injury in this series.

Johnson DL, Braun D, Friendly D. Accidental head trauma and retinal hemorrhages. Neurosurgery. 1993;33(2):231-4.

Objective:
To determine if retinal hemorrhages occur with accidental injuries, including accidental injuries that cause skull fractures and/or intracranial hemorrhages.

Methods:
Head injured children who also had skull fractures and/or intracranial hemorrhages were examined by an ophthalmologist. Exclusion criteria included children with suspected child abuse and with gunshot wounds to the head.

Results:
Median age was 4.5 years (52 children were less than 2 years of age). Retinal hemorrhages were found in 2/140 children (1.4%) (hemorrhages are not described). Both children were involved in side-impact MVAs:

* One child died (no autopsy information)
* One child additionally had an ipsilateral cerebral concussion and sub-arachnoid hemorrhage

Mechanisms of injury n (%)
MVA 55 (39%)
Assault 13 (6%)
Other 8 (5%)
Falls: 70 (50%)
<5 feet 17 (24%)
5-10 feet 11 (16%)
Stairs 17 (24%)
Falls from buildings 12 (17%)
Playground 13 (19%)

Conclusion:
Retinal hemorrhages were noted in <2% of accidental closed head injury and only following serious injury.

Elder JE, Taylor RG, Klug GL. Retinal hemorrhage in accidental head trauma in childhood. J Pediatr Child Health 1991;27:286-289.

Objective:
To study the incidence of retinal hemorrhages in children who sustained known accidental trauma.

Methods:
25 children admitted with significant head injury (defined as injury that resulted in loss of consciousness, confusion or obtunded mental state) had a dilated indirect fundoscopic examination by an ophthalmologist within 6 days of injury. (72% of patients were examined within 3 days of injury). Children with suspected non-accidental trauma were excluded.

Results:
Median age was 5.6 years (only 16% were <2 years of age). No children had evidence of retinal hemorrhages.

Conclusion:
Another study that shows that retinal hemorrhages are not a common finding following accidental closed head injury. These children, notably, were older, on average, than infants diagnosed with shaken baby syndrome.

Buys YM, et al. Retinal findings after head trauma in infants and young children. Ophthalmology 1992;99(11):1718-1723.

Objectives:
To see if retinal hemorrhages in children who sustained head injuries is pathognomonic for child abuse.

Methods:
Children between 4-36 months who sustained head trauma within the preceding 48 hours had a dilated indirect fundoscopic exam by an ophthalmologist. Patients with systemic diseases that are associated with retinal hemorrhages were excluded. Patients were assigned to accidental or non-accidental group after full multidisciplinary work-up:

* 75 were determined to be accidental
* 3 were determined to be non-accidental
* 1 was indeterminate (and was not included in the statistical analysis)

Results:
Mean age was 16.1 months (range 1.1-35.2 months). All children in the accidental head injury group had a normal fundoscopic examination. 3/3 children in the non-accidental group had retinal hemorrhages:

Patient Retinal Hemorrhage Description
1: single dot intraretinal hemorrhage in the posterior pole of right eye
2: extensive bilateral nerve fiber layer, subhyaloid and vitreous hemorrhages and a left retinal detachment
3: bilateral subhyaloid and nerve fiber layer hemorrhages

Conclusion:
Retinal hemorrhages were found in all three children in the non-accidental head injury group but in none of the 75 children with accidental head injury.

Duhaime AC, Alario AJ, Lewander WJ, et al. Head injury in very young children: mechanisms, injury types, and ophthalmologic findings in 100 hospitalized patients younger than 2 years of age. Pediatrics 1992; 90:179-185.

Objectives:
To analyze the mechanism, injury type and ophthalmologic findings in young children who sustain head injury.

Methods:
100 consecutively admitted head-injured patients 24 months of age or younger (diagnosis as determined at discharge or autopsy) were prospectively studied. All patients underwent ophthalmologic exam by ophthalmologists or ED physicians. Radiologic evaluations were performed as clinically indicated.

Abuse was determined by an algorithm which the authors feel provides a conservative estimate: Determination is based on a combination of findings indicating the presence of either:

1. unexplained or healing long bone fractures
2. injuries unequivocally caused by mechanical trauma with no history of trauma,
3. a history of forces considered by the authors to be mechanically insufficient to cause a particular injury, or
4. changing or developmentally incompatible history

Results:
Retinal hemorrhages were found in 10/100 patients:

* 9/10 were in patients that were found to have inflicted injuries (abuse)
* One patient was involved in an MVA

Reported Mechanism of Injury:
Accidental Abuse
Number 76 24
Mean Age (months) 9.0 8.7
Falls
<4 feet 26 8
>4 feet 21 0
Down stairs 10 0
Down stairs in walker 8 0
MVA 9 0
No history 0 14
Admitted assault 0 2
Impact by moving object 2 0

Conclusion:
Retinal hemorrhages were not seen in trivial accidental head injuries in this study.

Betz P, Puschel K, et al. Morphometrical analysis of retinal hemorrhages in the shaken baby syndrome. Forensic Sci Internat 1996;78:71-80.

Objective:
To investigate whether a morphometrical analysis of eyes can differentiate between accidental and non-accidental head injury.

Methods:
Patient Groups:

* Accidental head injury; n=24 (ages 2 months-73 years)
* Non-traumatic intracranial bleeding; n=6
* Intravital brain death; n=2
* SIDS; n=10
* Shaken baby syndrome; n=7

Area of retinal hemorrhage was determined using a 100-square grid fitted on an eyepiece of a microscope.

Area fraction = number of squares covered by retinal hemorrhages/total number of squares covered by retinal layers

Results:

* Accidental head injury: Retinal hemorrhages were seen in 2/24 patients:
1. 35 year old who fell from stairs; had skull fracture, SDH and DAH
    o "spot-like hemorrhages in one eye, not in all layers"
    o Retinal area = 3.33%
2. 56 year old in a traffic accident; had skull fracture, SDH and DAH and brain contusion
    o RH in one eye
    o Retinal area = 1.18%
* Non-traumatic intracranial bleeding: No patients had retinal hemorrhages
* Intravital brain death: No patients had retinal hemorrhages
* SIDS: No patients had retinal hemorrhages; (all patients in this group received CPR)
* Shaken baby syndrome: All patients had retinal hemorrhages (7 patients)
    o Six patients had massive retinal hemorrhages involving all layers of both eyes
    o One patient had extensive retinal hemorrhages in one eye only
    o Retinal area range: 19.2-73.2%

Conclusions:

* Morphometrical analysis can contribute to the differentiation between shaken baby syndrome and accidental injuries
* The detection of extensive retinal bleeding can indicate a violent traumatic event

Luerssen TG, Huang JC, McLone DG. Retinal hemorrhages, seizures, and intracranial hemorrhages: relationships and outcomes in children suffering traumatic brain injury. Concepts Pediatr Neurosurg 1991;11:87-94.

Objective:
To look at the relationship of retinal hemorrhages and seizures as clinical indicators of pediatric traumatic brain injury.

Methods:
Data was collected in cases of pediatric traumatic brain injury requiring admission to the hospital.

Results:
811 patients in database. Mean age was 4.4 years. Retinal hemorrhages were detected in 27 patients (but were not described):
Mechanism of injury n
MVA 1
Fall 4
Abuse 22

Conclusion:
Retinal hemorrhages were more commonly seen in children who were found to have been abused in this study.

Are Retinal Hemorrhages Caused by Cardiopulmonary Resuscitation?

Kanter RK. Retinal hemorrhage after cardiopulmonary resuscitation or child abuse. J. Pediatr 1986;108:430-432.

Objective:
To determine the extent to which retinal hemorrhage is a complication of cardiopulmonary resuscitation (CPR).

Methods:
Direct fundiscopic examinations without use of mydriatics was performed in patients who had received cardiopulmonary resuscitation (CPR). Non-survivors were examined immediately after death. Survivors were examined within 2 days except for one patient who was not examined until 84 hours following CPR.

If retinal hemorrhages were detected, work up for occult trauma was done including CT, skeletal radiographs, physical examination and history.

Results:
54 total patients were examined:

* 20 patients were <12 months of age
* 10 patients were 12 - 23 months of age
* 24 patients were >24 months of age

6 patients had retinal hemorrhages:

* 4 patients also had bruising on head/face (4 patients) or subdural hematomas (2 patients) or brain edema (3 patients). (skeletal radiographs were all negative)

These patients were determined by the authors to have been abused (ages of these patients: 1 month, 5 months, 18 months, 2 years).

* 1 patient was hit by car.

* 1 patient (age 18 months) had no evidence of trauma but had arterial hypertension (190/120 mm Hg) and seizures.

Conclusion:
In this small patient sample, the majority of children with retinal hemorrhages following cardiopulmonary resuscitation were felt by the authors to have been abused based also on other physical findings. Another child suffered significant accidental trauma, and one child had no history of trauma but had significant hypertension. The retinal hemorrhages are not described.

Goetting MG, Sowa B. Retinal jhemorrhage after cardiopulmonary resuscitation in children: an etiologic reevaluation. Pediatrics 1990;85:585-588.

Objective:
Prospective study to evaluate whether CPR can cause retinal hemorrhages.

Methods:
Children who underwent CPR and met the following criteria:

* Had chest compressions
* Had no evidence of preceding trauma
* Had no history of conditions associated with RH (seizures, hypertension, bleeding disorders)

The children had direct fundiscopic examination performed by a pediatric neurologist. Positive findings were confirmed by two additional examiners. (Pharmacologic dilatation was used only "when necessary")
Results:

20 children met the above criteria. Median age was 2 years (range: 2 weeks-17 years). Causes of cardiopulmonary arrest:

* sepsis (5 patients)
* SIDS (5 patients)
* near-drowning (3 patients)
* asthma (3 patients)
* poisoning (2 patients)
* asphyxia (1 patient)
* aspiration (1 patient)

Two children (10%) had retinal hemorrhages:
Patient 1 was a two year old drowning victim who had CPR for 40 minutes. Had multiple bilateral large retinal hemorrhages. Platelet number, coagulation studies, skeletal survey and autopsy were normal.

Patient 2 was a 6 week old admitted for 36 hours with possible sepsis (cause of death was SIDS). Had 75 minutes of CPR. Had a "single fresh retinal hemorrhage 0.3 disc diameters (dd) in size at 1.2 dd temporal to the right disc" Skeletal survey and autopsy were normal.

Additional case (detected after the study period):
9 year old with 2 episodes of arrest from asthma. Minutes before his third arrest had no retinal hemorrhages. Had CPR for 12 minutes then 2 retinal hemorrhages were seen in the left fundus.

Conclusions:

* This study illustrates that although retinal hemorrhages are frequently associated with head trauma in children, other causes must be excluded.
* The description of retinal hemorrhages in patient 1 may not be dissimilar to those seen in shaken infants. It is notable that we have found no other reports of retinal hemorrhages like these following drowning.

Gilliland MGF, Luckenbach MW. Are retinal hemorrhages found after resuscitation attempts? Am J Forensic Med Path 1993;14:187-192.

Objective:
To examine the hypothesis that resuscitation causes retinal hemorrhages.

Methods:
169 infants and children had a postmortem examination were included:

* 131 had resuscitation attempts lasting a minimum of 30 minutes
* 38 had not received such vigorous attempts or no resuscitation attempts.

90% of patients were <3 years; mean age was 17 months.

Results:
99 patients did not have retinal hemorrhages:

* 70 of these 99 had resuscitation attempts lasting a minimum of 30 minutes

70 patients had retinal hemorrhages:

* 61 of these 70 patients had resuscitation attempts lasting a minimum of 30 minutes:
    o 56 patients had head injuries as the cause of death
    o 3 patients had CNS disease as the cause of death
    o 1 patient had sepsis as the cause of death
* 1 patient had an undetermined cause of death (came from household with two prior deaths and confirmed abuse)
    o 9 had not received such vigorous attempts or no resuscitation attempts:
    o 6 patients had head injuries as the cause of death
    o 1 patient had CNS disease as the cause of death
    o 2 patients had an undetermined cause of death

Conclusion:
Most of the patients in this series who were found on postmortem examination to have retinal hemorrhages had head injuries as the cause of death. It is not discussed which of these patients were felt to have suffered non-accidental head injury.

Odom A, Christ E, Kerr N, et al. Prevalence of retinal hemorrhages in pediatric patients after in-hospital cardiopulmonary resuscitation: a prospective study. Pediatrics 1997;99(6).

Objective:
To determine the prevalence of retinal hemorrhages after inpatient cardiopulmonary resuscitation (CPR) in patients hospitalized for non-traumatic illnesses.

Methods:
43 patients (total of 45 resuscitation attempts) who received CPR > 1 minute and survived. Exclusion criteria:

* patients who had evidence of trauma
* patients with suspected child abuse
* patients with seizures or near-drowning
* patients who had retinal hemorrhages documented before CPR
* patients who had CPR performed out-of-hospital

Dilated fundus examinations that visualized the retina to the equator was performed by pediatric ophthalmolgists within 96 hours of CPR.

Age range: 1 month-15.8 years; mean 23.2 months
84% of patients were <2 years old

Results:
One patient (1 month old) had retinal hemorrhages:

* Had 60 minutes of chest compressions via open cardiac massage
* PT/PTT: 22.9/78; Plts=91,000
* Retinal findings: multiple small punctate hemorrhages bilaterally

Conclusion:
No patients with a normal platelet count and normal coagulation studies had retinal hemorrhages following cardiopulmonary resuscitation in this study.

Fackler JC, Berkowitz ID, Green WR. Retinal hemorrhages in newborn piglets following cardiopulmonary resuscitation. AJDC 1992;146:1294-1296.

Objective:
To determine whether conventional CPR causes retinal hemorrhages in piglets.

The pig is an appropriate model for ocular research because the retinal capillary networks of swine and humans are similar in size and distribution throughout the retinal layers. However the pig has no central retinal artery and major retinal vessels lie superficially.

Methods:
6 two week old piglets weighing 3.5-4.5 kg underwent CPR for 50 minutes with 20% displacement of AP chest diameter. Measurements of right atrial and sagital sinus pressures were obtained during CPR. Following CPR, the pigs were euthanized and the eyes were examined for gross and microscopic changes.

Results:
No retinal hemorrhages were found. Sagital sinus and right atrial pressures were elevated above baseline and remained elevated throughout CPR.

Conclusion:
There was no evidence of retinal hemorrhages in a piglet model of cardiopulmonary resuscitation in these six piglets.

Weedn VW, Mansour AM, Nichols MM. Retinal hemorrhage in an infant after cardiopulmonary resuscitation. Am J Forensic Med Path 1990;11:79-82.

Objectives:
To describe a case report with retinal hemorrhages following cardiopulmonary resuscitation in an infant who the authors felt was not abused.

Case report:
4 month old suffered scalding burns to upper body (face, neck, hands and back) and the oral airway. The history supplied by mother was that the 2 year old sibling turned on the hot water faucet. The patient had 45 minutes of CPR and died. The autopsy showed:

* Several large patches of retinal hemorrhages situated in the nerve fiber layer in the equator and posterior pole of both eyes.
* Marked edema of the brain without subdural or subarachnoid hemorrhages
* There was no report of skeletal radiographs

Conclusion:
This one case report suggests that retinal hemorrhages in the posterior poles could result from prolonged CPR, but the reviewer wonders if non-accidental trauma was completely excluded as a diagnosis in this case.

Kramer K, Goldstein B. Retinal hemorrhages following cardiopulmonary resuscitation. Clin Pediatr 1993;32:366-368.

Objective:
To report the occurrence of retinal hemorrhages following vigorous CPR in a 17 month old child.

Case Report:
17 month old presents with severe dehydration from vomiting, diarrhea and fever. Initial fundiscopic examination by the attending pediatrician (local hospital) was normal without retinal hemorrhages. Had respiratory arrest and underwent 60 minutes of CPR. Transferred to a children's hospital where another fundiscopic examination revealed: bilateral multiple scattered intraretinal and subhyaloid hemorrhages throughout the posterior poles and mid-periphery.

CT of the head showed diffuse cerebral edema without evidence of trauma. Skeletal survey was normal.

Conclusion:
This one case report suggests that retinal hemorrhages could occur as a consequence of vigorous and prolonged resuscitation attempts. The author found no evidence of shaking in this case although this reviewer recognizes that shaking can never be entirely eliminated as a possible cause.

Bacon CJ, Sayer GC, Howe JW. Extensive retinal hemorrhages in infancy-an innocent cause. BMJ 1978;1(6108):281.

Objective:
To report the existence of retinal hemorrhages in an infant who the authors felt was not abused.

Case Report:
2 month old was found pale and limp by father. Mother "slapped him repeatedly on the back to try and revive him". He survived and was found to have "extensive fresh haemorrhages in the nerve-fiber layer of both fundi". Coagulation studies and platelet count and CSF cytology were all normal. There was no report of skeletal radiographs or head CT.

Conclusion:
This one case report suggests that retinal hemorrhages could occur as a consequence of thoracic compression, but non-accidental trauma was never excluded in this patient.

Are Retinal Hemorrhages Caused by Seizures?

Tyagi AK, Scotcher S, Kozeis N, Willshaw HE. Can convulsions alone cause retinal hemorrhages in infants? Br J Ophthalmol 1998;82:659-660.

Objective:
To evaluate the likelihood that seizures alone will cause retinal hemorrhages in children under the age of 2 years.

Methods:
32 children <2 years of age who just had a seizure were evaluated with a dilated indirect fundiscopic exam by an ophthalmologist within 48 hours of presentation. Mean age of patients was 12.2 months; age range was 1 - 23.5 months.

Exclusion criteria: patients with a history of associated head trauma and who received cardiopulmonary resuscitation.

Results:
No children had retinal hemorrhages.

Conclusion:
Seizures alone are unlikely to cause retinal hemorrhages in children under the age of 2 years.

Sandramouli S, Robinson R, Tsaloumas M, Willshaw HE. Retinal hemorrhages and convulsions. Arch Dis Child 1997;76:449-451.

Objective:
To evaluate the likelihood that seizures alone will cause retinal hemorrhages in children.

Methods:
33 children who were admitted after having a seizure were evaluated with a dilated indirect fundiscopic exam by an ophthalmologist within 48 hours.

One child was excluded for having absence seizures only.

Age range was 4 months-14 years; mean age was 46.9 months.
Thirteen children (41%) were less than 2 years of age

Three children were admitted in status epilepticus.

Results:
No children had retinal hemorrhages.

Conclusion:
Seizures alone are unlikely to cause retinal hemorrhages in children.

Do Retinal Hemorrhages Follow Meningitis?

Fraser SG, Horgan SE, Bardavio J. Retinal hemorrhages in meningitis. Eye 1995;9:659-660.

Case report:
12 y.o. female admitted with Meningococcal meningitis. She complained of blurred vision and on day # 6 of illness was found to have a large subretinal and a vitreous hemorrhage of the left eye. Clotting studies were normal.

8 weeks later she had a small residual foveal hemorrhage. The authors propose that retinal venous hypertension brought on by obstruction of the central retinal vein may have been the source of the hemorrhage.

Kennedy CJ. Sectorial iris infarction caused by meningococcal septicaemia. Aust N Z J Ophthalmol 1995;23:149-151.

Case report:
4 month old with Meningococcal meningitis, sepsis and disseminated intravascular coagulation. Petechial and purpuric skin rash was present.

The posterior pole of both eyes had a small numder of retinal nerve fiber hemorrhages. There was a mild left uveitis and a small subconjunctival hemorrhage was present in the conjunctiva of the right eye.

The author proposes that the occular hemorrhages in this case are due to disseminated intravascular coagulation.

Are There Other Causes of Retinal Hemorrhages?

Clark RSB, Orr RA, Atkinson CS. Retinal hemorrhages associated with spinal cord arteriovenous malformation. Clin Pediatrics 1995;:281-283.

Objective:
To report a case of a ruptured arteriovenous malformation as a cause of retinal hemorrhages.

Case report:
4 y.o. presents with loss of consciousness and generalized tonic-clonic seizures. Had bilateral retinal hemorrhages and papilledema. Head CT showed acute subarachnoid and intracerebral hemorrhages. Cerebral angiogram was negative but spinal cord MRI showed a large spinal cord arteriovenous malformation at T9-L2.

The authors presume that the cause of retinal hemorrhages in this case is a sudden increases in intracranial pressure that is transmitted through the optic nerve sheath through the subarachnoid communication in the optic canal.

 

Pollack JS, Tychsen L. Prevalence of retinal hemorrhages in infants after extracorporeal membrane oxygenation. Am J Ophthalmol 1996;121:297-303.

Objective:
To determine the prevalence of retinal hemorrhages in infants and children after venoarterial ECMO.

Methods:
Thirty-seven (18% of 202 patients who underwent ECMO) patients were chosen randomly by a neonatologist for eye examination following ECMO. Patients were examined within 30 days (average 16 days) of ECMO.

Results:
Five patients were found to have (unilateral) retinal hemorrhages (13%):

* 4/5 were neonates examined an average of three weeks after birth:
o descriptions of retinal hemorrhages:
+ Patient 1: "single dot hemorrhage located posterior to the equator"
+ Patient 2: "two extamacular dot hemorrhages in the right eye"
+ Patient 3: "three dot hemorrhages located outside the macula in the left eye"
+ Patient 4: "single extrafoveal dot hemorrhage in the macula"
* One patient was 21 months old:
o description of retinal hemorrhage:
+ "small (<1 disc diamerter) intraretinal flame-shaped hemorrhage located near the optic disk in the left eye"

Eight patients in the series had cerebral hemorrhages but none of these eight had retinal hemorrhages. Presence of retinal hemorrhages did not correlate with mortality.

Conclusion:
In this small series of patients, retinal hemorrhages were not seen commonly in patients following ECMO. It is notable that the majority of patients with retinal hemorrhages following ECMO (4/5) were neonates.

Shiono T, Abe S, Watabe T, et al. Vitreous, retinal and subretinal hemorrhages associated with von Willebrand's syndrome. Arch Clin Exp Ophthalmol 1992;230:496-497.

Objective:
To describe retinal hemorrhages in patients with von Willebrand's syndrome.

Two case repots:
Patient 1: 13 year old female presents with spotted vision OS. Opththalmoscopic examination revealed vitreous, peripapillary retinal and subretinal hemorrhages in right fundus. Found to have decreased activities of Factor VIII and von Willebrand's factor.

Patient 2: 19 year old with vitreous hemorrhages in both eyes and decreased activities of Factor VIII and von Willebrand's factor.

Conclusion:
These case reports demonstrate that retinal and vitreous hemorrhages can be seen in patients with von Willebrand's syndrome.

McLellan NJ, Prasad R, Punt J. Spontaneous subhyaloid and retinal hemorrhages in an infant. Arch DisChild 1986;61:1130-1132.

Objective:
To describe a case of retinal hemorrhages occuring with a ruptured intracranial arterial aneurism.

Case Report:
6 week old presented with left sided seizures, full fontanelle, extensive bilateral retinal hemorrhages and a large right subhyaloid hemorrhage.

Hb=8.5g/dL
PT/PTT, Plts, WBC normal
Skeletal survey normal

CT Scan showed a large right intracerebral hemorrhage

Angiography showed an aneurysm of the right middle cerebral artery

Conclusion:
Intracranial bleeding secondary to a ruptured cerebral aneurism can mimic the symptoms seen in shaken baby syndrome.

What is the Significance of Unilateral Retinal Hemorrhages?

Drack AV, Petronio J, et al. Unilateral retinal hemorrhages in documented cases of child abuse. Amer J Ophthalmol 1999; 128:340-344.

Objective:
To describe 4 cases of documented child abuse in which the children had extensive preretinal or retinal hemorrhages in one eye only.

Methods:
In all four cases " an adult caretaker was found responsible for shaking, choking or squeezing the child". Indirect ophthalmoscopy was performed by an ophthalmologist in all cases.

Case 1: 6 month old

* CT scan: Cerebral infarction
* Fundiscopic exam: "Multiple diffuse dot/blot retinal hemorrhages, some with white centers"; several preretinal hemorrhages" in the left fundus
* Other findings: Ecchymosis of the left upper eyelid and left side of neck
* Adult caretaker prosecuted for grabbing and shaking the infant by the neck

Case 2: 5 month old

* Brain MRI: Small right subdural hematoma
* Fundiscopic exam: "Diffuse intraretinal hemorrhages in the posterior pole in the right eye including white-centered hemorrhages, preretinal hemorrhages and hemorrhages into the vitreous near the optic nerve"
* Other findings: Old rib fracture
* Adult caretaker admitted to shaking the baby

Case 3: 17 month old

* Brain MRI: Bilateral subdurals, R>L
* Fundiscopic exam: "Diffuse intraretinal hemorrhages many with white centers throughout the posterior pole in the right fundus"
* Other findings: Ecchymosis around right eye and bruises on left face and right arm
* Adult caretaker had shaken the child

Case 4: 6 month old

* Brain MRI: Bilateral subdurals
* Fundiscopic exam: "Preretinal hemorrhage over left macula with several other intraretinal hemorrhages throughout the posterior pole"
* Other findings: Bilateral rib fractures and left tibia fracture
* Adult caretaker tried to calm infant during inconsolable crying and "perhaps did not know his own strength"

Conclusion:
Unilateral retinal hemorrhages occurred in these four cases where adult caretakers admitted to or were prosecuted for child abuse or shaking.

Tyagi AK, Willshaw HE, Ainsworth JR. Unilateral retinal hemorrhages in non-accidental injury. Lancet 1997;349:1224.

Objective:
To describe three cases of unilateral retinal hemorrhages in children sustaining non-accidental injury.

Case 1: 5 week old

* Retinal Findings: "Extensive retinal hemorrhage and a dense premacular hemorrhage in the right eye".
* CT Findings: Cerebral edema; subdural hemorrhages

Case 2: (No age reported)

* Retinal findings: Unilateral retinal hemorrhages (not described)
* CT findings: Cerebral edema; subdural hemorrhages Other findings: Fractures of differing ages

Case 3: (no age reported)

* Retinal findings: Unilateral retinal hemorrhages (not described)
* CT findings: Cerebral edema; subdural hemorrhages Other findings: Humerus metaphyseal fracture

Conclusion:
Unilateral retinal hemorrhages occurred in these three cases which the authors felt were consistent with non-accidental injury.

Paviglianti JC, Donahue SP. Unilateral retinal hemorrhages and ipsilateral cranial bleeds in nonaccidental trauma. JAAPOS 1999; 3:383-384.

Objective:
To describe three patients with unilateral retinal hemorrhages and ipsilateral cranial hemorrhages in which non-accidental trauma was "strongly suspicious"

Results:
Case 1 2 3
Age/sex/race 5mo/m/w 4w/f/w 10 mo/m/w
History To ED after sz. Intermittent sz in ED To ED multiple apneic episodes To ED after fall from bed at home
Ocular findings OD numerous intra and pre retinal hemorrhages near optic nerve, extending past the arcades. OS normal OD numerous pre- and subretinal hemorrhages near optic nerve, extending past the arcades. OS normal OS multiple intraretinal rh. OD normal
Neuroimaging CT acute and subacute SDH near R frontal convexity, with mass effect and midline shift CT SAH over the right frontal convexity and r sylvian fissure CT small epidural heme underlying the left convexity
Skeletal imaging normal normal normal

Conclusion:
Unilateral retinal hemorrhages occurred in these three patients who the authors felt had sustained non-accidental trauma.

What are the Outcomes of Infants and Children with Retinal Hemorrhages?

Matthews GP, Das A. Dense vitreous hemorrhages predict poor visual and neurological prognosis in infants with shaken baby syndrome. J Pediatr Ophthalmol Strabismus 1996;33:260-265.

Objective:
To examine the relationship between the presence and extent of vitreous hemorrhages and neurological outcome findings in infants with shaken baby syndrome.

Methods:
5 patients with shaken baby syndrome (SBS) were examined. SBS was diagnosed when infants or children had evidence of intraocular hemorrhages, with subdural or subarachnoid hemorrhages and a history of suspected child abuse. All patients underwent pars plana vitrectomy for removal of vitreous hemorrhages.

Results:
Patient Age at Injury Ocular findings CT/MRI Neurological outcome findings
1 7 months Dense vitreous hemorrhages (OU). Intraoperative findings (IO): large multiple retinal holes and ischemia (OU) Occipital infarct; subarachnoid hemorrhage Chronic vegetative state; hypertonic; expired 5 months after injury
2 8 months Dense vitreous hemorrhages (OU) IO: large multiple retinal holes (OU) Right frontal, temporal, parietal subdural Left hemiparesis; seizures; no neurologic improvement
3 5 months Dense vitreous hemorrhages (OU) IO: :macular holes (OU); giant retinal tear (OS) Bilateral subdural hemorrhage; diffuse cerebral edema; atrophy Spasticity; seizures; no neurologic improvement
4 3 months Intraretinal hemorrhages (OD); subhyaloid macular hemorrhage (OS) IO: retina attached; no holes Right frontal intracranial hemorrhage with ischemia and edema; subdural hematoma Neurologically improved
5 4.5 months Subhyaloid and intraretinal hemorrhage (OU) IO: retina attached; no holes Bilateral frontal subdural hemorrhage Neurologically improved

Conclusion:
The presence of vitreous hemorrhages in these infants with shaken baby syndrome suggested a poor neurological outcome in three of the five infants.

Han DP, Wilkinnson WS. Late ophthalmic manifestations of the shaken baby syndrome. J Pediatr Ophthalmol Strabismus 1990;27:299-303.

Objective:
To describe the ophthalmologic findings and complications in children months after an initial shaking episode.

Methods:
Six children were examined 12-55 months following a shaking injury. Patients underwent a dilated direct and indirect fundiscopic exam as well as visual acuity testing and other tests by an ophthalmologist.

Results:
Age at Injury Age at F/U CT findings Intraoccular hemorrhage Final Visual Acuity Associated Findings Causes of visual loss
20 months 6.2 yrs. Right subdural hemorrhage Bilateral subhyaloid hemorrhage 20/50 OD
20/20 OS Macular fold
8.5 months 1.8 yrs. Diffuse atrophy Unilateral (OD) subhyaloid or vitreous hemorrhage Unable to maintain gaze (OD) Macular folds
4 months 3.2 yrs. Subarachnoid hemorrhage; diffuse edema Bilateral subhyaloid or vitreous hemorrhage Poor fixation (OU) Severe MR Bilateral occipital lobe infarction
3 months 2.4 yrs. Right occipital hematoma; diffuse edema;subarachnoid hemorrhage Unilateral subhyaloid or vitreous hemorrhage No fixing/ following (OU) Severe MR Occipital lobe atrophy
10 months 4.0 yrs. Bilateral occipital infarction; bilateral subarachnoidhemorrhage Bilateral subhyaloid or vitreous hemorrhage No fixing/ following (OU) Bilateral occipital lobe infarction
9 months 1.8 yrs. Right subarachnoid; bilateral prefrontal subdural hemorrhage Bilateral subhyaloid hemorrhage Steady maintained gaze Left hemiparesis (not mentioned)

Conclusion:
There was significant visual morbidity associated with these 6 cases of shaken baby syndrome.

McCabe CF, Donahue SP. Prognostic indicators for vision and mortality in shaken baby syndrome. Arch Ophthalmol 2000;118:373-377.

Objective:
To determine the prognostic indicators for vision and mortality in patients who were diagnosed with shaken baby syndrome.

Methods:
Retrospective chart review of 30 patients. Mean age of patients at injury was 9.3 months (range: 1-39 months)

Results:
Follow-up: 20/22 living children received follow-up examinations for a mean of 6.7 months (range 1-36 months).

1. Retinal hemorrhages resolved in
* 7 patients 1 month following injury
* 5 patients 2 months following injury
* 4 patients 3 months following injury
* 2 patients 4 months following injury
* 1 patient at the 9 month visit
* 1 patient at the 11 month visit
* (not all patients had monthly visits, so this represents the maximum time)
2. Twelve patients (40%) were able to fix and follow (fix and follow vision) initially.
* Ten (83%) retained fixed and follow vision
* Two (17%) lost this vision
3. Eighteen patients (60%) presented without fix and follow vision in at least 1 eye:
* Eight died.
* Of the remaining 10 patients: 7 (70%) gained fix and follow vision, and 3 (30%) never had improvement in their vision
4. After resolution of retinal hemorrhages, 6/22 patients had poor vision in at least one eye:
* Two patients had optic atrophy
* One patient had retinal fibrosis,
* One patient had retinal scaring/traumatic cataract
* Two patients had cortical visual impairment

Conclusion:
Decreased vision in these patients at follow-up was due to retinal scarring, optic atrophy and cortical visual impairment.

Kivlin JD, Simons KB, Lazoritz S, Ruttum MS. Shaken Baby Syndrome. Ophthalmology 2000;107:1246-1254.

Objective:
To examine clinical and autopsy ophthalmological findings and outcome results in children who were diagnosed with shaken baby syndrome.

Methods:
Retrospective review of the eye examinations or histological examination of patients <3 years of age with shaken baby syndrome (shaken baby syndrome was determined based on the presence of subdural hemorrhages, characteristic fractures and lack of supporting history).

Results:
Eighty three percent of 111 patients diagnosed as having SBS and who had an ophthalmology consult had retinal hemorrhages.

Thirty six (29%) patients died:

* Lack of visual response and poor pupillary response proved to be strongly associated with demise.
* The presence of retinal hemorrhages correlated with death

Visual outcome was assessed in 68 survivors:
Mean follow-up was 21 months (range: 1 month-7years)
Causes of impairment Number
Bilateral (19 patients)
Cerebral alone 11
Cerebral + optic atrophy 1
Cerebral + retinal injury 2
Cerebral + high myopia 1
Retinal injury + homoonymous 1
Hemianopsia (HH)
HH alone 3

Unilateral (2 patients)
Retinal/optic nerve injury 1
Stabismic amblyopia 1

Conclusions:

* Presence and bilaterality of retinal hemorrhages gave a worse prognosis for survival in patients with shaken baby syndrome.
* Most patients with visual impairment following shaken baby syndrome had cortical impairment.

Wilkinson WS, Han DP, Rappley MD, Owings CL. Retinal hemorrhage predicts neurologic injury in the shaken baby syndrome. Arch Ophthalmol 1989;107:1472-1474.

Objectives:
To find characteristics of retinal hemorrhages that will identify infants at risk for severe intracranial injury from the shaken baby syndrome.

Methods:
Fourteen cases of shaken baby syndrome were identified (shaken baby syndrome was defined by the presence of intraoccular hemorrhage and intracranial injuries in the absence of external signs of head trauma). Mean age was 5.5 months.

All patients had a head CT and a fundiscopic exam (fundiscopic exam was within 72 hours of injury and performed by an ophthalmologist).

* "Initial neurologic score" was determined from the clinical examination and CT findings.
* "Late neurologic score" was based on the presence of motor or cognitive delay, seizure activity or residual focal defect and the presence of hydrocephalus or substance loss on CT.
* "Retinopathy score" was determined from the type and extent of occular hemorrhage.

Results:
There was a significant correlation between retinopathy score and the initial neurologic injury score. There was a borderline statistical significance between retinopathy score and late neurologic injury score. Younger patients had higher retinopathy scores.

Conclusion:
The severity of retinal hemorrhages predicts the severity of initial neurological injury in this series of patients with shaken baby syndrome.

Do Neonates Have Retinal Hemorrhages?

Smith WL, Alexander RC, Judisch GF, et al. Magnetic Resonance Imaging Evaluation of Neonates with Retinal Hemorrhages. Pediatrics 1992;89: 332-333.

Objective:
To determine if there is a relationship between retinal hemorrhages acquired at birth and concurrent intracranial injuries.

Methods:
Full-term neonates without perinatal problems and normal Apgar scores were selected randomly and had dilated retinal examination by pediatric ophthalmologist (n=46).

Ten infants had retinal hemorrhages. All 10 infants had a brain MRI: 8/10 were satisfactory scans.

Results:
None of the neonates showed evidence of intracranial injury on MRI.

Conclusion:
In this group of full-term neonates without perinatal complications and with normal Apgar scores, retinal hemorrhages were not associated with intracranial bleeding.

Sezen F. Retinal hemorrhages in newborn infants. Brit J Ophthalmol 1970;55:248-253.

Objective:
To determine the incidence and causes of retinal hemorrhages (RH) in newborn infants.

Methods:
1238 newborn infants were examined for retinal hemorrhages with dilated direct ophthalmoscopy:

* 709 infants were examined within the first 24 hours
* 304 infants were examined within 25-48 hours
* 225 infants were examined between 72-120 days

Results:
178 infants had retinal hemorrhages (14.3%)
Hours after birth Percentage of infants with Retinal Hemorrhages
1-24 18.9
24-48 12.5
72-120 2.6

Delivery technique Number Number with RH (%)
Vacuum extraction 62 25 (40.3)
Forceps 9 3 (33.3%)
Cesarean section 125 1 (0.8%)
Spontaneous 1042 147 (14.2)

15/61 of infants born premature had retinal hemorrhages (24.6%).

Types of hemorrhages seen:

* Flame shaped hemorrhage: occasionally disappeared within 24 hours; usually within 3 days and sometimes remained as long as 5 days.
* Round, red, deep hemorrhages: usually disappeared after 14-21 days; in one case, the retinal hemorrhages disappeared 6 weeks after birth.

Conclusions:

* Mode of delivery influences the incidence of retinal hemorrhages in newborn infants with the highest incidence seen in infants following vaccum extraction delivery and the lowest following cesarean sections.
* Retinal hemorrhages secondary to birth usually resolve within 5 days of life if they are flame shaped and within 21 days if they are deep hemorrhages.

Planten JT, v d Schaaf PC. Retinal hemorrhage in the newborn. Ophthalmologica 1971;162:213-222.

Objective:
To see if there is a relationship between the course of labor and retinal hemorrhages in neonates.

Methods:
Study 1. Once a week all infants born within that week were examined with direct dilated ophthalmoscopy (n=329 infants)
Study 2: All infants born within 24 hours were examined with direct dilated ophthalmoscopy (n=222 infants)
(examiners were blinded to the mode of delivery)

Results:
Study 1: Twenty-four infants had retinal hemorrhage (7%)
Type of delivery Number of neonates Number with RH (%)
Spontaneous 244 19 (8%)
Vacuum extraction 22 3 (14%)
Forceps 25 1 (4%)
Cesarean section 36 1 (3%)
Version and extraction 2 0

(13 patients were examined on the first day of life, 4 patients were examined on the second day of life, 2 patients were examined on the third day of life, 3 patients were examined on the forth day of life, 1 patient was examined on the fifth day of life, 1 patient was examined on the sixth day of life)

Study 2: Fifty infants had retinal hemorrhages (23%).
Type of delivery Number of neonates Number with RH (%)
Spontaneous 154 34 (22%)
Vacuum extraction 23 5 (21%)
Forceps 20 8 (40%)
Cesarean section 36 2 (6%)
Breech presentation 13 1 (7.6%)

Conclusion:
The incidence of retinal hemorrhages in newborn infants is influenced by mode of delivery with the highest incidence following forceps assisted delivery and the lowest incidence following cesarean section.

Baum JD, Bulpitt CJ. Retinal and conjunctival hemorrhage in the newborn. Arch Dis Child 1970;45:344-349.

Objective:
To study the incidence of retinal and conjunctival hemorrhages in the newborn in relation to etiologic factors.

Methods:
230 infants were examined within a few days of birth with dilated indirect ophthalmoscopy.

Results:
Thirty-three infants had retinal hemorrhages (15.5%) when all infants examined within the first week of life were included.

Retinal hemorrhages were bilateral in 20/33 of cases. In the 13 unilateral cases the hemorrhages were "smaller and less extensive".
Age at examination Number of infants seen %with retinal hemorrhages
0-12 hours 39 31%
0-24 hours 100 20%
0-48 hours 152 17%
0-120 hours 210 15.5%

Type of delivery Number Number with retinal hemorrhages (%)
Spontaneous vertex 109 24 (22%)
Breech 8 1 (13%)
Cesarian section 23 3 (13%)
Forceps 12 4 (33%)
Vacuum extraction 1 1 (100%)

There was no significant difference between infants with retinal hemorrhages and without retinal hemorrhages when infants were compared according to:

* sex distribution
* race
* birthweight
* relation to gestational age
* mode of delivery
* need for positive pressure ventilation during resuscitation
* maternal parity

No relation was established between retinal hemorrhages and asphyxia.

Conclusion:
Retinal hemorrhages were found in 15.5% of infants who were examined in the first week of life. No factor was found to be significantly associated with retinal hemorrhages in neonates.

Levin S, Janive J, Mintz M, et al. Diagnostic and prognostic value of retinal hemorrhages in the neonate. Obstretics and Gynecology 1980;55:309-314.

Objective:
To investigate whether the course of pregnancy and management of delivery influences the incidence of retinal hemorrhages in neonates.

Methods:
410 infants were examined within 24 hours of birth by an ophthalmologist with dilated direct ophthalmoscopy.

Results:
150 infants (37.3%) had retinal hemorrhages.
Mode of delivery Number of infants with retinal hemorrhages (%)
Spontaneous 118 (38.9)
Vacuum extraction 16 (44.4%)
Forceps 8 (28.6%)
Vacuum extraction and Forceps 4 (57.1)
Cesarean section 4 (12.1)

Other studies:
Author Time from delivery to exam % of infants with RH
Baum, 1970 24 hours 20%
Bergen, 1976 24 hours 35
Giles, 1960 24 hours 36
McKeown, 1941 18-24 hours 50.5
Noorden, 1973 24 hours 24.5
Schenker, 1966 24 hours 19.2
Sezen, 1971 24 hours 18.9
Present study 24 hours 37.3

Conclusion:
37.3% of infants examined within 24 hours of birth had retinal hemorrhages in this study. Mode of delivery influences the incidence of retinal hemorrhages (the incidence is lower in infants delivered by cesarean section).

Schenker JG, Gombos GM. Retinal hemorrhage in the newborn. Obstret Gynecol 1966;27:521-523.

Objective: To study the relationship between type of labor and the fundiscopic changes in newborn infants.

Methods:
317 newborns were evaluated with dilated ophthalmoscopy within 24 hours of birth. The examination results were correlated with the case history of each delivery.

Results:
Sixty-one infants (19.2%) had retinal hemorrhages.
Mode of delivery Number Number with Retinal Hemorrhages (%)
"Normal" 244 42 (17.3)
Cesarean Section 20 0
Forceps 16 5 (31)
Vacuum extraction 25 13 (52)
Breech 12 1 (8.3)

Resolution:

* In 20 neonates the retinal hemorrhages resolved within 3 days
* In 35 neonates, the retinal hemorrhages resolved within 8 days
* In 6 neonates, the retinal hemorrhages persisted beyond 8 days

Conclusion:
Retinal hemorrhages occur in infants following birth and are more common when forceps or vacuum extraction is used. Most retinal hemorrhages in neonates disappear within 8 days.

Beratis NG, Varvarigou A, Katsibris J, Gartaganis SP. Vascular retinal abnormalities in neonates of mothers who smoked during pregnancy. J Pediatr 2000;136:760-766.

Objective:
To investigate whether maternal smoking during pregnancy causes retinal abnormalities in the newborn.

Methods:
162 term neonates whose mothers smoked during pregnancy were examined by one ophthalmologist during the second or third day of life

* 135 births were by spontaneous delivery
* 27 births were by elective cesarean section

* 112 infants were appropriate for gestational age (AGA)
* 30 infants were small for gestational age (SGA)
* 20 infants were large for gestational age (LGA)

162 term neonates whose mothers did not smoke during pregnancy were examined by one ophthalmologist during the second or third day of life = controls.

* 135 births were by spontaneous delivery
* 27 births were by elective cesarean section

* 112 infants were AGA
* 30 infants were SGA
* 20 infants were LGA

Inclusion criteria:

* Clear amniotic fluid
* No signs of fetal distress
* Healthy infants
* Apgar scores >= 7
* Mothers who did not:
o have preeclampsia
o have diabetes
o have hypertension
o use illicit drugs

Results:
# of Newborns of Smoking Mothers # of Newborns of Non-smoking Mothers p
Retinal Hemorrhages (all) 36 18 .0007
Flame-shaped RH 14 7 .029
Dot and Blot RH 33 17 .0005
Both Flame and Dot/Blot 16 9

There was a significant positive correlation between the number of cigarettes smoked per day and the severity of the retinal hemorrhages (determined by extent of retinal area occupied by the hemorrhage)

Resolution of retinal hemorrhages in all infants occurred by the third month of life.

Conclusion:
There was an increased frequency of retinal hemorrhages seen in neonates of mothers who smoked during pregnancy when compared to infants of mothers who did not smoke during pregnancy (smoking information was ascertained by self-report).

Skalina MEL, Annable WL, Kliegman RM, Fanaroff, AA. Hypertensive retinopathy in the newborn infant. J Pediatr 1983;103:781-786.

Objective:
To report the incidence of retinal changes in newborn infants with systemic hypertension.
Methods:

* 23 patients observed to have systemic hypertension were examined with dilated indirect ophthalmoscopy.
* Hypertension was defined as mean arterial blood pressure >70mm Hg on at least three separate days.
* The mean onset of hypertension was10.7 days of life (range: birth-52 days).
* Patients were examined only after their medical condition had stabilized or improved (mean or range of days is not given).

Results:
Eleven infants had retinal abnormalities (2 infants died). Of those that had hemorrhages:

* 4 had splinter hemorrhages (and these were still visible at 1 ½ months of life or later)
* 2 had dot/blot hemorrhages
* 2 had exudates

One child with splinter hemorrhages still had evidence of them at 10 weeks following the first examination.

Conclusion:
Retinal hemorrhages are seen in infants with systemic hypertension. The time to resolution of the retinal hemorrhages in one child was longer than what is expected with neonates.

Emerson MV, Pieramici DJ, Stoessel KM, et al. Incidence and rate of disappearance of retinal hemorrhage in newborns. Ophthalmology 2001;108:36-39.

Objective: To determine the incidence of and rate of disappearance of neonatal retinal hemorrhages.

Methods:
Consecutive healthy newborns (as determined by the pediatrics service) were examined within 30 hours of birth.

Dilated indirect ophthalmoscopy was performed. If retinal hemorrhages were detected, indirect ophthalmoscopy was repeated every 2 weeks until hemorrhage was no longer detected.

Examination was by a fellowship trained retinal specialist.

Results:
149 newborns were enrolled

* Retinal hemorrhages were detected in 50/149 (34%) of newborns
* 26 newborns (52%) had bilateral retinal hemorrhages
* 9/12 (75%) of infants born by vacuum-assisted delivery had retinal hemorrhages
* 40/120 (33%) of infants born by spontaneous vaginal delivery had retinal hemorrhages
* 1/15 (7%) of infants born by cesarean section had retinal hemorrhages
* 0/2 (0%) of infants born by forceps-assisted delivery had retinal hemorrhages

17 of 50 patients were lost to follow-up (34%)

Of the remaining 33 patients:

* At two weeks after birth, the retinal hemorrhages had disappeared in 28 patients (85%)

Of the 4 patients (out of 5) that returned for follow-up at 4 weeks after birth:

* One patient had a single subretinal hemorrhage; this hemorrhage was not detected 6 weeks after birth

Conclusions:

* The incidence of retinal hemorrhages in this study (34%) is consistent with reported values from other studies.
* In this study, the incidence of retinal hemorrhages in newborns is highest for infants born by vacuum-assisted delivery and lowest for infants born by cesarean section.
* In this series, most retinal hemorrhages disappeared by 2 weeks of age; one subretinal hemorrhage persisted up to 6 weeks after birth

Does Purtscher Retinopathy Occur in Children?

Tomasi LG, Rosman NP. Purtscher retinopathy in the battered child syndrome. Am J Dis Child 1975;129:1335-1337.

Objective:
To describe two cases of children with chest injury and retinal hemorrhages.

Purtscher Retinopathy: hemorrhagic retinal angiopathy with preretinal, retinal hemorrhages and retinal exudates and decreased visual acuity. It follows compression of the thorax which results in an increase in intravascular pressure to the head and eyes. Most reported cases have been in adults. (author's definition)

Methods:
Two cases reports

Case 1:

* 18 week old presented with bruises on right hemithorax; bruises also on right cheek, buttock, thigh and left foot.
* Bilateral retinal hemorrhages were present and retinal exudates were seen in the left fundus.
* No imaging was performed, but
* Patient had two bilateral subdural taps; the first was negative and the second had 3cc of slightly xanthochromic fluid.

Case 2:

* 23 month old presented with bruises on neck and chest circumferentially; also had bruising on the face, buttocks and legs.
* Preretinal hemorrhages were seen bilaterally; subhyaloid fluid level and exudates were seen in the right fundus.
* No imaging was performed.

Conclusion:
Although these two children had chest wall bruising indicating possible thoracic compression, it is impossible to conclude that an increase in intravascular pressure from thoracic compression was the cause of the retinal hemorrhages because head imaging was not performed.

Does Terson Syndrome Occur in Children?

Kuhn F, Morris R, Witherspoon CD, Mester V. Terson syndrome. Results of vitrectomy and the significance of vitreous hemorrhage in patients with subarachnoid hemorrhage. Ophthalmology 1998;105:472-477.

Objective:
(study A) To determine if vitrectomy is effective for Terson syndrome.
(study B) To determine the incidence of vitreous hemorrhages in patients with subarachnoid hemorrhages.

Terson syndrome: when subarachnoid or subdural hemorrhages are followed by intraoccular hemorrhages (presumably from intracranial pressure impeding the venous outflow from the eye). (author's definition)

Methods:
(study A) Retrospective chart review of 27 patients who had vitectomy performed . All patients had a subarachnoid or subdural hemorrhage. 4 patients were children (3 were <1 year of age). All 4 children had subdural hemorrhage.

(study B) Prospective study to examine the eyes of 100 patients undergoing neurosurgery for subarachnoid hemorrhages. Unsure if any patients were children.

Results:
(study B) Intraocular hemorrhages were found in 17 eyes of 100 patients with ruptured cerebral aneurysms resulting in subarachnoid hemorrhages.

Conclusion:
Because there were no known pediatric patients in Study B, the incidence of Terson syndrome in children cannot be estimated from this study. Four children with subdural hemorrhages also had vitreous hemorrhages that required vitrectomy (this meets the author's definition of Terson syndrome).

http://www.sbsdefense.com/Retinal_Hemorrhages.htm

Retinal Hemorrhages are small hemorrhages on the back of the eye. Most experts do not agree as to the pattern, number, location or type of retinal hemorrhages that point to a diagnosis of SBS or other nonaccidental trauma. The mechanism(s) behind retinal hemorrhages in infancy in the context of alleged head trauma are unknown. Most research points to a mechanism involving rapid increases in intracranial pressure, cerebral venous spasm or increased venous pressure, and possibly hypoxia. Most studies do not support a mechanical etiology. The presence or absence of retinal hemorrhages and/or its characteristics is often used by prosecution doctors to determine whether or not the case is nonaccidental trauma. This is not a reliable mechanism. Sometimes, the retinal hemorrhages are accompanied by nerve sheath damage or bleeding in the subdural space of the optic nerve. This finding has been considered an indicator of a greater degree of damage. Other times, the hemorrhages are referred to as dot-and-blot hemorrhages or petechiae. These are thought to suggest a lesser degree of force. Retinal hemorrhages in SBS cases are most often bilateral.

http://www.bmj.com/cgi/content/full/328/7442/754

Perimacular retinal folds from childhood head trauma (accidental)

A forensic autopsy showed no direct trauma to the orbits or eyes. There were prominent bilateral scalp contusions with soft tissue and intramuscular haemorrhage, symmetrical parietal skull fractures with coronal sutural diastasis, and a lacerated dura mater with extrusion of brain and blood. In addition to bilateral subdural and subarachnoid haemorrhages, a thin epidural haematoma partially covered the frontoparietal, calvarial lamina interna. The brain showed bilateral cortical contusions, severe cerebral oedema, and diffuse anoxic-ischemic injury. Postmortem ocular examination showed haemorrhages of the optic nerve sheaths with subdural haemorrhage greater than subarachnoid haemorrhage. Both eyes had extensive retinal haemorrhages with perimacular retinal folds (fig 2). Retinoschisis and peripapillary intrascleral haemorrhages were evident, and the retinal haemorrhages extended from the posterior pole to the ora serrata affecting the preretinal, intraretinal, and subretinal layers.

From the trial of Alan B Yurko   Retinal Hemorrhages following hepatitis B. vaccination

Exhibits:
(14) Brezin A, Massin-Korobelnik P., Boudin M., Gaudric A., Lehoang P., Acute Posterior Multifocal Placoid Pigment Epitheliopathy After Hepatitis B Vaccine, Archives of Ophthalmology 1995:133:297-200.

(15) Cogan D., Immunosuppression and Eye Disease, American Journal of Ophthalmology 1977:83(6):777-788.

(16) Rochat C., Immunological Profiles in Patients with Acute Retinal Necrosis. Graefe's Archives of Clinical Experimental Ophthamology 1996:234:547-552.

(17) Ribera EF, Polyneuropathy associated with administration of hepatitis B vaccine. New England Journal of Medicine 1983:309:615-615.

(18) Brezin A, Visual loss and eosinophilia after recombinant hepatitis vaccine. Lancet 1993:342:563-564.

(19) Granel B, Disdier P, Devin F, et al. Occlusion of the central retinal vein after vaccination against viral hepatitis B with recombinant vaccines: 4 cases. Presse Med 1977:26:62-65.
(End of exhibits)

Retinal Hemorrhages
"Experts" arrive at one conclusion--2 catagories: witnessed, documented accidents or assumed abuse

Once again, there is no stated criteria about how "inflicted injury" cases were determined, other than what we know--lack of documented evidence of accidental injury or medical causes. ONE OTHER THING STANDS OUT--the belief that symptoms are different in cases of accidental or inflicted injury. In point...there are no clinical signs which point to the origin of an injury as being accidental or non-accidental. The physiology of the body is constant. The same amount of force whether inflicted or accidental will produce the same result, and that is without even factoring in medical causes.

http://www.whale.to/vaccine/dynamic.html "In a letter written to a court in 2008, expert Injury Biomechanics Researcher: Chris Van Ee, PhD explains that "...while many in the medico-legal communities have debated these injury causation mechanisms, the Court is advised that most medical doctors are not trained in our scientific discipline and do not access our databases nor study our peer-reviewed research." He   goes on to assure the court that biomechanics tackles "Inconvenient Truths" that "some have ignored or distorted" head on." "Intentionally impacting a 0- to 2-year-old child’s head against a hard surface could easily cause fatal brain injuries that would mimic those of a fall and today’s science cannot distinguish accidental from non-accidental impacts of falls of similar magnitude, barring extraordinary signs, e.g., grip marks or eye-witness accounts."

"The other possible causes for hemorrhages in this age child can be investigated and eliminated." The problem is, once the triad of symptoms believed to be diagnostic of SBS are found, other causes are NOT investigated and eliminated.

Thinking "dirty"--If you find retinal hemorrhages, assume Shaken Baby Syndrome.

More on retinal hemorrhage: thrombocytopenia, associated with vaccines, drugs, and unknown other causes.

Vaccine-induced THROMBOCYTOPENIA journal articles (a small sample from http://scholar.google.com)

• OBJECTIVES: Adverse events and positive re-challenge of symptoms reported in the scientific literature and to the Vaccine Adverse Event Reporting System (VAERS) following hepatitis B vaccination (HBV) were examined. METHODS: The VAERS and PubMed (1966-2003) were searched for autoimmune conditions including arthritis, rheumatoid arthritis, myelitis, optic neuritis, multiple sclerosis (MS), Guillain Barré Syndrome (GBS), glomerulonephritis, pancytopenia/thrombocytopenia, fatigue, and chronic fatigue, and Systemic Lupus Erythematous (SLE) following HBV. RESULTS: HBV was associated with a number of serious conditions and positive re-challenge or significant exacerbation of symptoms following immunization. There were 415 arthritis, 166 rheumatoid arthritis, 130 myelitis, 4 SLE, 100 optic neuritis, 101 GBS, 29 glomerulonephritis, 283 pancytopenia/thrombocytopenia, and 183 MS events reportedfollowing HBV A total of 465 positive re-challenge adverse events were observed following adult HBV that occurred sooner and with more severity than initial adverse event reports. A case-report of arthritis occurring in identical twins was also identified. CONCLUSIONS: Evidence from biological plausibility, case-reports, case-series, epidemiological, and now for positive re-challenge and exacerbation of symptoms, and events in identical twins was presented. One would have to consider that there is causal relationship between HBV and serious autoimmune disorders among certain susceptible vaccine recipients in a defined temporal period following immunization. In immunizing adults, the patient, with the help of their physician, should make an informed consent decision as to whether to be immunized or not, weighing the small risks of the adverse effects of HBV with the risk of exposure to deadly hepatitis B virus.

• 1: N Y State J Med. 1972 Feb 15;72(4):499.Links
  Thrombocytopenia associated with rubella vaccination.
  Bartos HR.

• PEDIATRICS Vol. 89 No. 2 February 1992, pp. 318-324
  

  The Ricochet of Magic Bullets: Summary of the Institute of Medicine Report, Adverse Effects of Pertussis and Rubella Vaccines
  Christopher P. Howson PhD1 and Harvey V. Fineberg MD, PhD1

  1 From the Institute of Medicine of the National Academy of Sciences, Washington, DC. Dr Howson is Deputy Director of the Division of International Health of the Institute of Medicine and Dr Fineberg is dean of the Harvard School of Public Health, Boston, MA.

  On July 3, 1991, the National Academy of Sciences' Institute of Medicine (IOM) released a reported entitled, Adverse Effects of Pertussis and Rubella Vaccines,1 in response to a congressional request to review evidence about a set of serious adverse events and immunization with pertussis and rubella vaccines. The request originated in the 1986 National Childhood Vaccine Injury Act (Public Law 99-660), whose primary purpose was to establish a federal compensation scheme for persons potentially injured by a vaccine; Section 312 of Public Law 99-660 called for the IOM review.

  Over the course of its 20-month study, the 11-member interdisciplinary committee constituted by IOM to conduct the review examined altogether 18 adverse events for pertussis vaccine—infantile spasms; hypsarhythmia; aseptic meningitis; acute encephalopathy; chronic neurologic (permanent brain) damage; deaths classified as sudden infant death syndrome (SIDS); anaphylaxis, autism; erythema multiforme or other rashes; Guillain-Barré syndrome (polyneuropathy); peripheral mononeuropathy; hemolytic anemia; juvenile diabetes; learning disabilities and hyperactivity; protracted inconsolable crying or screaming; Reye's syndrome; shock and "unusual shock-like state" with hypotonicity, hyporesponsiveness, and short-lived convulsions (usually febrile); and thrombocytopenia—and 4 adverse events for rubella vaccine—acute arthritis; chronic arthritis; radiculoneuritis and other neuropathies; and thrombocytopenic purpura. In conducting its review, the committee recognized that its charge was to focus on questions of causation and not broader topics, such as cost-benefit or risk-benefit analyses of vaccination.

  This summary begins with a brief history of events leading to the IOM study, then reviews the methods used by the committee to evaluate the evidence, summarizes the committee's conclusions for these adverse events, and offers directions for future investigation of adverse events in connection with widely used health interventions, such as vaccination.
  Submitted on November 5, 1991
  Accepted on November 21, 1991

• Hepatitis and death following vaccination with 17D-204 yellow fever vaccine - all 3 versions »
  RC Chan, DJ Penney, D Little, IW Carter, JA … - The Lancet, 2001 - Elsevier
  ... to by: Rarity of adverse effects after 17D ... on Jan 31, he developed thrombocytopenia,
  clotting abnormalities ... not support previous yellow fever vaccination in our ...

• Comment on:
  Lancet. 1994 Nov 5;344(8932):1293.

  Thrombocytopenia reported in association with hepatitis B and A vaccines.
  Meyboom RH, Fucik H, Edwards IR.

 

http://tinyurl.com/4z2za8

Drug-Induced THROMBOCYTOPENIA

http://www.neurology.org/cgi/content/abstract/54/6/1240

Neurologic complications in immune-mediated heparin-induced thrombocytopenia
C. Pohl, MD, U. Harbrecht, MD, A. Greinacher, MD, I. Theuerkauf, MD, R. Biniek, MD, P. Hanfland, MD and T. Klockgether, MD

From the Departments of Neurology (Drs. Pohl and Klockgether), Transfusion Medicine (Drs. Pohl, Harbrecht, and Hanfland) and Pathology (Dr. Theuerkauf), Rheinische Friedrich Wilhelms Universität, Bonn; Institute of Immunology and Transfusion Medicine (Dr. Greinacher), Ernst Moritz Arndt Universität Greifswald; and the Rheinische Landesklinik Bonn (Dr. Biniek), Bonn, Germany.

Address correspondence and reprint requests to Dr. C. Pohl, Department of Neurology, University of Bonn, Sigmund-Freud-Straße, D-53105 Bonn, Germany; e-mail: c.pohl@uni-Bonn.de

OBJECTIVE: To evaluate neurologic complications in patients with immune-mediated heparin-induced thrombocytopenia (HIT) with respect to incidence, clinical characteristics, outcome, and therapy.

METHODS: One hundred and twenty consecutive patients with immune-mediated HIT were recruited over a period of 11 years and studied retrospectively for the occurrence of neurologic complications. Diagnosis of HIT was based on established clinical criteria and confirmed by detection of heparin-induced antibodies using functional and immunologic tests.

RESULTS: Eleven of the 120 patients (9.2%) presented with neurologic complications; 7 suffered from ischemic cerebrovascular events, 3 from cerebral venous thrombosis, and 1 had a transient confusional state during high-dose heparin administration. Primary intracerebral hemorrhage was not observed. The relative mortality was much higher (Chi-square test, p < 0.01) in HIT patients with neurologic complications (55%) as compared to patients without neurologic complications (11%). The mean platelet count nadir in neurologic patients was 38 ± 25 x 109/l on average, and was lower in patients with fatal outcome compared to those who survived (21 ± 13 x 109/l versus 58 ± 21 x 109/l; p < 0.05, Wilcoxon test). In three patients neurologic complications preceded thrombocytopenia. There was a high coincidence of HIT-associated neurologic complications with other HIT-associated arterial or venous thrombotic manifestations.

CONCLUSION: Neurologic complications in HIT are relatively rare, but associated with a high comorbidity and mortality. HIT-associated neurologic complications include cerebrovascular ischemia and cerebral venous thrombosis. They may occur at a normal platelet count

 

BELOW: Inconclusive study. Also, doctors world-wide disagree on whether there
is a specific pattern of retinal hemorrhage found in assumed SBS cases.

Prevalence of Retinal Hemorrhages in Pediatric Patients After In-hospital Cardiopulmonary: Pediatrics

http://pediatrics.aappublications.org/cgi/content/full/99/6/e3

PEDIATRICS Vol. 99 No. 6 June 1997, pp. e3 (doi:10.1542/peds.99.6.e3)

Copyright ©1997 by the American Academy of Pediatrics
ELECTRONIC ARTICLE:
Prevalence of Retinal Hemorrhages in Pediatric Patients After In-hospital Cardiopulmonary Resuscitation: A Prospective Study

Amy Odom*, Elizabeth Christ*, Natalie Kerrpar , Kathryn Byrdpar , Joel Cochran¶, Fredrick Barr*, Mark Bugnitz*, John C. Ring*, Dagger , Stephanie Storgion*, Robert Walling§, Gregory Stidham*, and Michael W. Quasney*, #

From the * Divisions of Critical Care, Dagger Cardiology, and § Ambulatory Care, Department of Pediatrics, # Crippled Children's Foundation Research Center, par Department of Ophthalmology, Le Bonheur Children's Medical Center, University of Tennessee, Memphis, Tennessee and ¶ Department of Pediatrics, Medical University of South Carolina, Charleston, South Carolina.

ABSTRACT
INTRODUCTION
METHODS AND MATERIALS
RESULTS
DISCUSSION
ACKNOWLEDGMENT
ABBREVIATIONS
REFERENCES

ABSTRACT

Objective. Child abuse occurs in 1% of children in the United States every year; 10% of the traumatic injuries suffered by children under 5 years old are nonaccidental, and 5% to 20% of these nonaccidental injuries are lethal. Rapid characterization of the injury as nonaccidental is of considerable benefit to child protection workers and police investigators seeking to safeguard the child care environment and apprehend and prosecute those who have committed the crime of child abuse. Physically abused children present with a variety of well-described injuries that are usually easily identifiable. In some cases, however, particularly those involving children with the shaken baby syndrome, obvious signs of physical injury may not exist. Although external signs of such an injury are infrequent, the rapid acceleration-deceleration forces involved often cause subdural hematomas and retinal hemorrhages, hallmarks of the syndrome. Frequently, retinal hemorrhages may be the only presenting sign that child abuse has occurred. Complicating the interpretation of the finding of retinal hemorrhages is the belief by some physicians that retinal hemorrhages may be the result of chest compressions given during resuscitative efforts. The objective of this study is to determine the prevalence of retinal hemorrhages after inpatient cardiopulmonary resuscitation (CPR) in pediatric patients hospitalized for nontraumatic illnesses in an intensive care unit.

Design. Prospective clinical study.

Setting. Pediatric intensive care unit.

Patients. Forty-three pediatric patients receiving at least 1 minute of chest compressions as inpatients and surviving long enough for a retinal examination. Patients were excluded if they were admitted with evidence of trauma, documented retinal hemorrhages before the arrest, suspicion of child abuse, or diagnosis of near-drowning or seizures. All of the precipitating events leading to cardiopulmonary arrest occurred in our intensive care unit, eliminating the possibility of physical abuse as an etiology.

Interventions. None.

Measurements. Examination of the retina was performed by one of two pediatric ophthalmologists within 96 hours of CPR. The chart was reviewed for pertinent demographic information; the platelet count, prothrombin time, and partial thromboplastin time proximate to the CPR were recorded if they had been determined.

Results. A total of 43 pediatric patients hospitalized with nontraumatic illnesses survived 45 episodes of inpatient CPR. The mean age was 23 months (range, 1 month to 15.8 years), and 84% of the patients were under 2 years old. The majority of the patients (44%) were admitted to the intensive care unit after surgery for congenital heart disease, and another 21% were admitted for respiratory failure. The mean duration of chest compressions was 16.4 minutes ± 17 minutes with 58% lasting between 1 and 10 minutes. Five patients had chest compressions lasting >40 minutes, and two patients had open chest cardiac massage. All patients survived their resuscitative efforts. Ninety-three percent of patients had an elevated prothrombin time and/or partial thromboplastin time while 49% were thrombocytopenic. Sixty-two percent of the patients had low platelet counts and an elevated prothrombin time and/or partial thromboplastin time. Small punctate retinal hemorrhages were found in only one patient.

Conclusions. Retinal hemorrhages are rarely found after chest compressions in pediatric patients with nontraumatic illnesses, and those retinal hemorrhages that are found appear to be different from the hemorrhages found in the shaken baby syndrome. Despite the small number of patients in this prospective study, we believe that these data support the idea that chest compressions do not result in retinal hemorrhages in children with a normal coagulation profile and platelet count. A larger number of patients should be evaluated in a prospective multi-institutional study to achieve statistical significance in a nondescriptive study. retinal hemorrhages, CPR, shaken baby syndrome, child abuse, coagulopathy.

INTRODUCTION

Child abuse occurs in 1% of children in the United States every year; 10% of the traumatic injuries suffered by children younger than 5 years are nonaccidental, and 5% to 20% of these nonaccidental injuries are lethal.1,2 Rapid characterization of the injury as nonaccidental is of considerable benefit to child protection workers and police investigators seeking to safeguard the child care environment and apprehend and prosecute those who have committed the crime of child abuse. Physically abused children present with a variety of well-described injuries that are usually easily identifiable.2 However, in some cases, particularly those involving children with the shaken baby syndrome, obvious signs of physical injury may not exist.3 Although external signs of such an injury are infrequent, the rapid acceleration-deceleration forces involved often cause subdural hematomas and retinal hemorrhages, hallmarks of the syndrome. Frequently, retinal hemorrhages may be the only presenting sign that child abuse has occurred.

Several studies have documented that retinal hemorrhages occur in a large percentage of child abuse cases, especially those resulting from shaken baby syndrome.5 Some physicians believe these lesions are pathognomonic for nonaccidental injury.5,11,12 Other physicians, however, have suggested that chest compressions performed during cardiopulmonary resuscitation (CPR) may cause retinal hemorrhages.13,14 This is supported by one prospective study14 and several anecdotal case reports. However, in nearly all cases the cardiopulmonary arrest was unwitnessed, and therefore, the etiology of the arrest is not accurately known. Furthermore, coagulation studies and platelet counts have not always been documented in these reports, and thus, the possible propensity for bleeding in these patients was not completely evaluated.

The still unanswered questions about the relationship between retinal hemorrhages and CPR have obvious medical, legal, and social implications. The physician caring for the child presenting with retinal hemorrhages must decide whether these lesions were caused by physical abuse or resulted from chest compressions given by care givers or emergency personnel. This study was undertaken to help elucidate a possible association between chest compressions performed during in-hospital CPR and retinal hemorrhages in pediatric patients admitted to the hospital for nontraumatic illnesses.

METHODS AND MATERIALS
The Pediatric Intensive Care Unit at Le Bonheur Children's Medical Center is a 20-bed medical/surgical unit and a separate 12-bed transitional care unit for technology-dependent children. There are approximately 1500 children with a wide variety of illnesses admitted to the two units per year. Approval of the study was obtained from the Institutional Review Board. Children between 0 to 16 years admitted between November 1994 and September 1996 to the pediatric intensive care unit or transitional care unit who subsequently required 1 minute or more of chest compressions after cardiopulmonary arrest were enrolled in the study. Patients were excluded from the evaluation if admission diagnosis included evidence of trauma, suspected child abuse, near-drowning, or seizures. Patients with documented retinal hemorrhages before CPR or who had CPR performed out-of-hospital were also excluded from the study. No postmortem fundoscopic examinations were performed.

Dilated fundus examinations were performed at the bedside by one of two pediatric ophthalmologists within 96 hours of the arrest and chest compressions. The posterior pole and midperipheral retina to the equator were visualized. The number, size, and type of retinal hemorrhages were recorded.

Coagulation studies, including a prothrombin time (PT) and partial thromboplastin time (PTT), and platelet counts were performed near the time of the CPR for many patients at the discretion of the attending physician. The patient's age, admission diagnosis, history of retinopathy of prematurity, etiology of arrest, length of chest compressions, coagulation studies results, platelet counts, and ophthalmological examination findings were recorded. A descriptive analysis was performed on the data.

RESULTS
Forty-three patients survived chest compressions lasting >1 minute between November 1994 and September 1996. Their ages ranged from 1 month to 15.8 years (mean = 23.2 months) (Table 1). The majority of the patients were between 1 month and 2 years (36/43). Admission diagnoses of the eligible patients are shown in Table 1, and included congenital heart defects (19/43), respiratory failure due to pneumonia, asthma, apnea, or bronchiolitis (9/43), sepsis (4/43), cardiomyopathy (4/43), congenital diaphragmatic hernia (3/43), necrotizing enterocolitis (1/43), bronchopulmonary dysplasia admitted after placement of an intraventricular shunt for hydrocephalus secondary to an intraventricular hemorrhage (1/43), arteriovenous malformation (1/43), and vein of Galen aneurysm with congestive heart failure (1/43). Two patients, one with a diaphragmatic hernia and one with a cardiomyopathy each had two episodes of chest compressions and were evaluated by the ophthamologists after each episode. Thus, the total number of cardiopulmonary arrests after which retinal examinations were performed was 45.

Table 1. Characteristics of Patients Evaluated for Retinal Hemorrhages After Chest Compressions
[View Table]

The precipitating events for each of the 45 cardiopulmonary arrests are shown in Table 2. A plugged or dislodged endotracheal or tracheostomy tube was determined to be the cause in 11 of 45 arrests requiring chest compressions. Other precipitating events included respiratory failure secondary to apnea, bronchspasm, or aspiration (8/45), arrythmias (5/45), hyperkalemia (5/45), tension pneumothorax or hydrothorax (3/45), cardiac tamponade (2/45), sepsis (2/45), and primary myocardial ischemia (1/45). In 7 of 45 episodes of cardiopulmonary arrest, the precipitating event was indeterminate.

Table 2. Precipitating Events for 45 Cardiopulmonary Arrests Requiring Chest Compressions of Patients Evaluated for Retinal Hemorrhages
[View Table]

Mean CPR interval was 16.4 ± 17 minutes and ranged from 1 minute to 60 minutes (Table 3). The majority of the episodes of chest compressions lasted for 1 to 10 minutes (26/45), although 6 of 45 lasted 11 to 20 minutes, 8 lasted 21 to 40 minutes, and 5 lasted for >40 minutes (Table 3). Two patients in our study had open chest cardiac massage during their resuscitation. Ophthalmologic examinations performed by pediatric ophthalmologists within 96 hours of the chest compressions revealed multiple small punctate retinal hemorrhages bilaterally after 1 of the 45 episodes of chest compressions (Table 3). These hemorrhages were different than those observed in the shaken baby syndrome.

Table 3. Chest Compressions in Pediatric Intensive Care Unit Patients and the Prevalence of Retinal Hemorrhages
[View Table]

Coagulation studies were performed near the time of the arrest in 29 of the 45 episodes of chest compressions (Table 4). Either the PT or PTT was elevated in 27 of these 29 episodes (93%). Platelet counts were evaluated in 41 of the 45 episodes. Fewer than 2 × 105 platelets/µL were found in 20 of these 41 episodes (49%). Both platelet count and PT or PTT were abnormal in 29 episodes of chest compressions with 18 (62%) of these patients having abnormal values for both measurements.

Table 4. Coagulation Profiles and Platelet Counts Near the Time of Chest Compressions of Patients Evaluated for Retinal Hemorrhages
[View Table]

DISCUSSION
Chest compressions during CPR elevates intrathoracic pressure, and the mechanism by which elevated intrathoracic pressure results in retinal hemorrhages was postulated by Gilkes and Mann.15 Blunt trauma to the thorax leads to a rise in intrathoracic pressure and an increased central venous pressure. This increased central venous pressure can result in retinal hemorrhages in two possible ways. First, the increased central venous pressure may be directly transmitted to the retinal venous system. Second, the increased central venous pressure can result in an elevated intracranial pressure that has been suggested to cause retinal hemorrhages.16,17 However, there is little direct evidence that the increased intrathoracic pressures with chest compressions during CPR result in retinal hemorrhages. Furthermore, no large scale prospective studies have been done to evaluate the association of retinal hemorrhages after chest compressions when the etiology of the arrest is definitively nontraumatic.

Whether or not retinal hemorrhages can be caused by chest compressions obviously has important medical, legal, and social implications. The consequences of misdiagnosing child abuse and attributing retinal hemorrhages to CPR can have devastating consequences for the child and other children in the care of the abuser. However, wrongly accusing a care giver of child abuse can be equally disastrous. The physician caring for the child presenting with retinal hemorrhages must decide if these ocular lesions were caused by physical abuse or the result of chest compressions that care givers or emergency personnel may have given the child. Thus, it is important to determine if retinal hemorrhages are found after chest compressions given during resuscitative efforts.

In our study, one 1-month-old patient was found to have retinal hemorrhages after chest compressions. This patient had 60 minutes of chest compressions that were done via open chest cardiac massage. Her PT was 22.9 seconds, PTT was 78 seconds, and her platelet count was 91 000 platelets/µL. These retinal hemorrhages were also morphologically different from the retinal hemorrhages observed in the shaken baby syndrome in that they were numerous, small punctate hemorrhages. Retinal hemorrhages were not found after any other of the 44 episodes of chest compressions, despite a majority of these patients also having a coagulopathy and/or thrombocytopenia. A second patient of the same age also had prolonged open chest cardiac massage, elevated PT and PTT and decreased platelets. This patient had no retinal hemorrhages on examination by the pediatric ophthalmologists. Thus, we find no patients with normal coagulation studies and platelet counts who have retinal hemorrhages after chest compressions. Furthermore, retinal hemorrhages are a rare finding after chest compressions in patients with a coagulopathy or a low platelet count and are atypical of retinal hemorrhages seen in shaken baby syndrome.

Although the numbers are limited, other studies also support this conclusion. Kanter18 performed a prospective study on 54 children who underwent chest compressions. Six of the 54 children had retinal hemorrhages. In five of these patients, trauma or child abuse was the precipitating event of the cardiac arrest, although the sixth patient had seizures and severe arterial hypertension. Both of these conditions are known risk factors for the development of retinal hemorrhages.19,20 Kanter18 concluded that trauma should be assumed when retinal hemorrhages are found and that retinal hemorrhages should not be attributed to CPR alone. Our study differs in that all arrests occurred in the intensive care unit whereas the patients in Kanter's study occurred outside of the hospital. In addition, the events leading up to the arrest were witnessed, and all patients survived their resuscitations.

Gilliland and Luckenbach21 microscopically examined at autopsy the retina of 169 children who underwent prolonged resuscitative efforts. Seventy children had retinal hemorrhages, and the etiology of all but one were attributed to illnesses with which retinal hemorrhages have been associated. The cause of the cardiac arrest for the one patient with retinal hemorrhages who died despite chest compressions was listed officially as undetermined. This child came from a home in which two other pediatric deaths had occurred and episodes of abuse had been documented. Thus, these authors concluded that their data did not support the idea that retinal hemorrhages are caused by CPR.

However, some reports have suggested that chest compressions given during resuscitative attempts can result in retinal hemorrhages.13,14, 22 Although one of these reports is a prospective evaluation of children who received CPR, most reports are anecdotes in which the arrests were not witnessed by anyone but the care giver. In fact, in the prospective study, one of the two arrests occurred out-of-hospital although the cause of the in-hospital arrest was unwitnessed and the diagnosis of sudden infant death was made.14 In most of these cases, intentional injury cannot be entirely ruled out. In most cases coagulation studies were not done. One case report describes an 17-month-old female infant who was evaluated for probable adenoviral gastroenteritis who had no retinal hemorrhages on her initial examination by an attending pediatrician.13 This patient experienced a respiratory arrest and required approximately 60 minutes of chest compressions. She was transported to another hospital and on evaluation had multiple scattered intraretinal and subhyloid hemorrhages. Her PT and PTT were normal, but her platelet count was low at 167 000/µL. This patient is similar to our one patient who had retinal hemorrhages in that both received chest compressions for about 60 minutes and both were thrombocytopenic. Of the other four patients in our study who had chest compressions for >40 minutes, two were thrombocytopenic, and all had elevated coagulation studies, but none of them had retinal hemorrhages. Thus, in cases with prolonged chest compressions, thrombocytopenia may be a risk factor for the development of retinal hemorrhages.

This study has the following limitations. First, the number of patients reported in this study is small. An adequate number of patients would require a multiinstitutional study. Second, a direct causal effect of chest compressions on retinal hemorrhages cannot be practically assessed using this approach. Pre-arrest fundoscopic examinations would need to be performed on every patient admitted to our unit, but this would be impractical because of the large volume of patients admitted to our unit. However, we believe that the approach used in this study will determine if there is an association of retinal hemorrhages with chest compressions and perhaps identify risk factors for developing retinal hemorrhages after chest compressions. Third, we did not examine the retina of children who did not survive their CPR. The frequency of retinal hemorrhages in this population of children may differ from the frequency seen in children who survive their resuscitation and may warrant further study.

In summary, we evaluated the fundi of 43 children after 45 episodes of chest compressions. All of the precipitating events leading to cardiopulmonary arrest occurred in our intensive care unit, eliminating the possibility of physical abuse as an etiology. Despite coagulopathies in the majority of the cases, retinal hemorrhages were found in only one patient who underwent an open chest cardiac massage and had an extensive coagulopathy. No retinal hemorrhages were found in the patients who had normal coagulation studies or only abnormal PT/PTT or an abnormal platelet count. Despite the small numbers of patients in this prospective study, we believe that these data support the idea that chest compressions do not result in retinal hemorrhages in children with a normal coagulation profile and platelet count. Furthermore, retinal hemorrhages are an infrequent finding in children with abnormal coagulation studies and low platelet counts. A larger number of patients should be evaluated in a prospective multiinstitutional study to achieve statistical significance in a nondescriptive study.

ACKNOWLEDGMENT
This project was supported by the Methodist Hospitals Foundation.

FOOTNOTES

Received for publication Nov 4, 1996; accepted Jan 14, 1997.

Reprint requests to (M.W.Q.) Division of Critical Care, Department of Pediatrics, Le Bonheur Children's Medical Center, 50 N. Dunlap, Memphis, TN 38103.

ABBREVIATIONS

CPR, cardiopulmonary resuscitation. PT, prothrombin time. PTT, partial thromboplastin time.

REFERENCES

1. Schmitt BD, Krugman RD. Abuse and neglect in children. In: Behrman RE, Vaughan VC, eds. Nelson's Textbook of Pediatrics. 14th ed. Philadelphia, PA: WB Saunders; 1992:79-83
2. Reece RM, Grodin MA Recognition of nonaccidental injury. Pediatr Clin North Am. 1985; 32:41-61 [Medline][Medline]
3. Riffenburgh RS, Sathyavagiswaran L Ocular findings at autopsy of child abuse victims. Ophthalmology 1991; 98:1519-1524 [Medline][Medline]
4. Wilkenson WS, Han DP, Rappley MD, Retinal hemorrhage predicts neurologic injury in the shaken baby syndrome. Arch Ophthalmol. 1989; 107:1472-1474[Abstract]
5. Caffey J On the theory and practice of shaking infants: its potential residual effects of permanent brain damage and mental retardation. Am J Dis Child. 1972; 124:161-169 [Medline][Medline]
6. Levy I, Wysenbeek YS, Nitzan M, Occult ocular damage as a leading sign in the battered child syndrome. Metab Pediatr Syst Ophthalmol. 1990; 13:20-22
7. Giangiacomo J, Barkett KJ Ophthalmoscopic findings in occult child abuse. J Pediatr Ophthalmol Strabismus. 1985; 22:234-237 [Medline][Medline]
8. Eisenbrey AB Retinal hemorrhage in the battered child. Childs Brain 1979; 5:40-44 [Medline][Medline]
9. Hadley MN, Sonntag VKH, Pekate HL, The infant whiplash-shake injury syndrome: a clinical and pathologic study. Neurosurgery. 1989; 24:536-540 [Medline][Medline]
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