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Other useful references

The following is a summary of the systematic review findings up to the date of our most recent literature search. If you have a specific clinical case, we strongly recommend you read all of the relevant references as cited and look for additional material published outside our search dates.


Retinal Imaging

  • The use of RetCam imaging to record retinal findings facilitates accurate quantification of the retinal features present and the opportunity for further opinions 1,2,3

  • There is a recorded instance of RetCam potentially contributing to retinal haemorrhage in the newborn 4; however, in a recent prospective study of 50 eyes in 25 children 60 minutes after a retcam examination for retinopathy of prematurity, none had developed retinal haemorrhage 5

  • MRI scan of the brain may include images of the eye. If this involves GRET2 sequences 6, or the use of susceptibility weighted imaging  7 it may reveal retinal haemorrhages
  • Hand-held spectral domain optical coherence tomography, with 8 or without 9 electroretinography may be of value in defining retinal features

Subconjunctival haemorrhages

  • These are thought to occur in infants with prolonged coughing or haematological disorders. Two studies report their presence in child abuse 10,11. There have been no large-scale studies of this association.

Examination and recording of retinal findings

  • Recent studies have evaluated tools to improve the standardised recording of retinal findings in suspected abusive head trauma 12-16
  • In a study of 72 children undergoing examination by ophthalmologists and non-ophthalmologists, non-ophthalmologists were correct in their findings in 44% of cases; they had no false-positives but retinal haemorrhages were present in the 13% of cases they missed 17. This highlights the importance of an appropriate examination technique.

Indications for ophthalmological examination in suspected abuse

  • An assessment of the value of retinal examination in children with suspected abuse but no intracranial injury 18

Updated UK national guidance

This relates to the ophthalmological examination and assessment of children with suspected physical abuse, including a standardised examination pro forma based on our validated reporting tool 19,20


Pathophysiology of Retinal Haemorrhages

  • A finite element infant eye model indicates that shaking could generate sufficient force to cause retinal haemorrhage 20

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  1. Sturm V, Landau K, Menke MN. Optical coherence tomography findings in Shaken Baby syndrome. American Journal of Ophthalmology. 2008;146(3):363-368 [Pubmed]
  2. Nakagawa TA, Skrinska R. Improved documentation of retinal hemorrhages using a wide-field digital ophthalmic camera in patients who experienced abusive head trauma. Archives of Pediatrics and Adolescent Medicine. 2001;155(10):1149-1152 [Pubmed]
  3. Muni RH, Kohly RP, Sohn EH, Lee TC. Hand-held spectral domain optical coherence tomography finding in shaken-baby syndrome. Retina. 2010;30(4 Suppl):S45-50. [Pubmed]

  4. Adams GG, Clark BJ, Fang S, Hill M. Retinal haemorrhages in an infant following RetCam screening for retinopathy of prematurity. Eye. 2004;18(6):652-653 [Pubmed citation only]
  5. Azad RV, Chandra P, Pal N, Singh DV. Retinal haemorrhages following Retcam screening for retinopathy of prematurity. Eye. 2005;19(11):1221, author reply 1221-2 [Pubmed]
  6. Altinok D, Saleem S, Zhang Z, Markman L, Smith W. MR imaging findings of retinal hemorrhage in a case of nonaccidental trauma. Pediatric Radiology. 2009; 39(3):290-292 [Pubmed]
  7. Zuccoli G, Panigrahy A, Haldipur A, Willaman D, Squires J, Wolford J, Sylvester C, Mitchell E, Lope LA, Nischal KK, Berger RP. Susceptibility weighted imaging depicts retinal hemorrhages in abusive head trauma. Neuroradiology. 2013;55(7):889-93 [Pubmed]

  8. Nakayama Y, Yokoi T, Sachiko N, Okuyama M, Azuma N. Electroretinography combined with spectral domain optical coherence tomography to detect retinal damage in shaken baby syndrome. Journal of AAPOS. 2013;17(4):411-413 [Pubmed]

  9. Scott AW, Farsiu S, Enyedi LB, Wallace DK, Toth CA. Imaging the infant retina with a hand-held spectral-domain optical coherence tomography device. American Journal of Ophthalmology. 2009;147(2):364-373.e2 [Pubmed]

  10. Spitzer SG, Luorno J, Noël LP. Isolated subconjunctival hemorrhages in nonaccidental trauma. Journal of AAPOS: American Association for Pediatric Ophthalmology and Strabismus. 2005; 9(1):53-56 [Pubmed]
  11. DeRidder CA, Berkowitz CD, Hicks RA, Laskey AL. Subconjunctival hemorrhages in infants and children: a sign of nonaccidental trauma. Pediatric Emergency Care. 2013;29(2):222-226 [Pubmed]

  12. Ng WS, Watts P, Lawson Z, Kemp A, Maguire S. Development and validation of a standardized tool for reporting retinal findings in abusive head trauma. American Journal of Ophthalmology. 2012;154(2):333-339 [Pubmed]
  13. Fleck B, Tandon A, Jones P, Mulvihill A, Minns R. An inter-rater reliability study of a new "zonal classification for reporting the location of retinal hemorrhages in childhood for clinical, legal and research purposes". British Journal of Ophthalmology. 2010;94(7):886-890. [Pubmed]

  14. Mulvihill AO, Jones P, Tandon A, Fleck BW, Minns RA. An inter-observer and intra-observer study of a classification of RetCam images of retinal haemorrhages in children British Journal of Ophthalmology. 2011;95(1):99-104 [Pubmed]

  15. Bhardwaj G, Jacobs MB, Martin FJ, Donaldson C, Moran KT, Vollmer-Conna U, Mitchell P, Coroneo MT. Grading system for retinal hemorrhages in abusive head trauma: clinical description and reliability study. Journal of AAPOS. 2014;18(6):523-528 [Pubmed]

  16. Levin AV, Cordovez JA, Leiby BE, Pequignot E, Tandon A. Retinal hemorrhage in abusive head trauma: finding a common language. Transactions of the American Ophthalmological Society. 2014;112:1-10 [Pubmed]

  17. Morad Y, Kim YM, Mian M, Huyer D, Capra L, Levin AV. Nonophthalmologist accuracy in diagnosing retinal hemorrhages in the shaken baby syndrome. Journal of Pediatrics. 2003;142(4):431-434 [Pubmed]
  18. Li S, Mitchell E, Fromkin J, Berger RP. Retinal hemorrhages in low-risk children evaluated for physical abuse Archives of Pediatrics and Adolescent Medicine. 2011;165(10):913-917 [Pubmed]

  19. Watts P, Child maltreatment guideline working party of the Royal College of Ophthalmologists, UK. Abusive head trauma and the eye in infancy. Eye. 2013, 27(10): 1227-1229 [Pubmed]

  20. Hans SA, Bawab SY, Woodhouse ML.Graefes Archive for Clinical and Experimental Ophthalmology. A finite element infant eye model to investigate retinal forces in shaken baby syndrome. 2009;247(4):561-71 [Pubmed]


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