NON-ACCIDENTAL
INJURIES & THE EYE
For more information please contact: denisstark@eyedr4kids.com
DENIS STARK
PAEDIATRIC OPHTHALMOLOGIST
Jessica Blvd, Minyama
QLD, AUSTRALIA
Visible injuries from direct injury are perhaps the ones that spring immediately to mind when speaking of non-accidental injuries to the eye. These I will consider briefly:
External Injuries
Periocular
ecchymoses
Conjunctival Haemorrhage
Hyphaema
2.Internal
Subluxation of lens
Cataract formation
Vitreous Haemorrhage
Retinal Detachment
Optic Atrophy
Cataract Subluxated Lens
Optic Atrophy & Macular DAMAGE FOLLOWING SHAKING.
3. Sexually transmitted disease
Conjunctivitis -Chlamydia, Gonorrhoea
4. Munchausen Syndrome by Proxy
Conjunctival or Corneal trauma- Mechanical, Chemical
OCCULT EYE INJURIES
Retinal Haemorrhages. These can be very extensive.
They are most predominant at the posterior pole.
They may be intraretinal, preretinal, subhyaloid or vitreal. They may obscure the retinal structures.
Papilloedema may or may not be present.
These occur in the very small infants.
Often there is a history of altered consciousness.
The infant is often seen in the intensive care unit and often requires life support systems.
There is often no external evidence of Trauma.
The pupils should be dilated to allow a full examination of the Fundi to be made
Gilkes first described retinal Haemorrhages in abused children.
Caffey in 1972 coined the term "Whiplash Shaken Infant syndrome".
This has become known as The Shaken Baby Syndrome.
These infants are usually less than18 months of age
Whiplash Shaken Baby Syndrome
Retinal Haemorrhages
Intracranial Haemorrhages
Long Bone Signs
Few External Injuries
Retinal haemorrhages are found in up to 80% of patients with suspected shake injury (Duhaime et al). There is some discussion whether shaking alone will cause these injuries or whether the injury is a combination of shaking and impact injury - Shaken and Slamming Injury. The picture of Retinal Haemorrhages with no history of very severe trauma should be treated as strong evidence of a SHAKEN BABY. The associated presence of retinal folds I have seen only in cases of non-accidental trauma.
Shaken Baby Syndrome
History of Altered ConsciousnessUsually intracranial Haemorrhage
Cerebral Oedema
Retinal Haemorrhage 80%
Duhaime et al J Neurosurg66:409-415, 1987
Two Typical Stories
Monica: Admitted 7 Dec 1995 at age 18 months.
Admitted to hospital –unconscious, marked brain swelling, retinal haemorrhages.
Died.
Cobie: examined 9/12/95. Died age 5 weeks
Unconscious, marked brain swelling, limited interhemispheric & subdural haemorrhage, severe retinal haemorrhages with retinal folds
Coroner found cause of death Head injury-no charge.
What causes these haemorrhages? Probably a combination of mechanisms.
The Cerebral Injury
Relatively heavy head + weak neck muscles.
Poor control of the head + brain has space to move in the skull.
Acceleration and deceleration forces + shearing forces.
Brain injury. Cerebral Oedema +/- Haemorrhages.
increased pressure in the retinal veins
Retinal Haemorrhages.
Compression of the chest
Raised Central Venous Pressure
Increased orbital venous pressure
Raised intraocular venous pressure:
Retinal Haemorrhages
Acceleration/Deceleration forces within the Eye
Partial Vitreous Detachment
Retinal haemorrhages and Retinal Folds
What forces cause such Haemorrhages in Adults.
Hydrostatic Pressure System
Rapid Changes in Velocity- Pilots in supersonic aircrafts.(Lyle 1957)
Bungee jumping (Filipe et al J internat ophth 18(6):359-60,1994-5
What can cause these Haemorrhages and Retinal changes in an infant?
1.Shaking Injuries
2.Birth Trauma
3.Subarachnoid or Subdural Haemorrhages
4.Blood Dyscrasias or bleeding disorders
2. Retinal Haemorrhages of the Newborn
Related to birth trauma
40% Vacumn extraction
33% Forceps Delivery
14% Spontaneous
1% Caesarian Section
These resolve within 7-10 days. No sequelae.
Note the following history:
D’s History
Age- 3months Admitted Hospital, NSW- Convulsing, Subdural Haematoma, Retinal Haemorrhages. Age- 3months Admitted Hospital, NSW- Convulsing, Subdural Haematoma, Retinal Haemorrhages.
Question: ? Retinal Haemorrhages =Birth Haemorrhages
? Subdural secondary to Birth Trauma
Discharged.
Age- 7months Readmitted. Convulsing, Fresh subdural haemorrhage,limb fractures. Permanent Brain damage.
3. Subdural or subarachnoid Haemorrhages
Terson’s Syndrome- Retinal haemorrhages associated with large Subarachnoid haemorrhages.
Subdural Haematoma - papilloedema , I feel, should be present.
Factors often blamed but rarely the Cause:
1.Accidental Head Injury- retinal haemorrhages occur rarely in association with accidental injury and is associated with extraordinary force.1.Accidental Head Injury- retinal haemorrhages occur rarely in association with accidental injury and is associated with extraordinary force.
(Johnson et al Neurosurgery. 33(2):231-4,1995
Minor falls are not a cause. (Helfer, Duhaime et al)
2.Cardiopulmonary Resuscitation:2.Cardiopulmonary Resuscitation:
Not a cause for retinal haemorrhages
Kanter J paed 1986;108;430-2
The difficulty in these cases is to obtain incontrovertible evidence that the trauma was NON-ACCIDENTAL. It is important to remember that the retinal haemorrhages that occur in many of these cases occur only with very severe force and in the absence of such history represent direct evidence of SHAKEN BABY SYNDROME.
But more information regarding these haemorrhages is required. For while it is my opinion and of many others that the haemorrhages in these babies are unique in character, There are enough gaps in our knowledge for a clever counsel to twist the facts to confuse the issue.
What is needed:
Establish the true incidence of Eye Damage in Shaken baby Syndrome.
Provide data of relationship of retinal haemorrhages and brain injury-
Examine children with accidental head injury to establish pattern of eye findings.
Ascertain mechanism of causation of retinal haemorrhages.
Educate medical and legal profession regarding the significance of these retinal haemorrhages.
The Significance of retinal haemorrhages.
They represent definite evidence of severe injury.
33% Die
33% Recover fully
33% Recover with major handicaps.
Remember:
"The act of shaking/slamming is so violent that competent individuals observing the shaking would recognise it as dangerous" Amer Acad Paediatrics
