Regarding: Ocular Coherence Tomography in Shaken Baby Syndrome

Abstract

I read with interest the article by Sturm and associates, 1 Sturm V. Landau K. Menke M.N. Optical coherence tomography findings in Shaken Baby syndrome. Am J Ophthalmol. 2008; 146: 363-368 Abstract Full Text Full Text PDF PubMed Scopus (60) Google Scholar which notes one “theory of vitreoretinal traction from repeated acceleration-deceleration postulates a direct mechanical effect of the shaking or impact itself” and indicates the optical coherence tomography (OCT) findings in cases of presumed Shaken Baby syndrome (SBS) lend support for this. However, as they correctly pointed out, “Preretinal blood applies pressure on the vitreous body leading to an indentation and localized vitreous detachment with consecutive vitreoretinal traction in the surrounding area.” Thus, it is the hemorrhage, not the proposed vitreous traction caused by shaking, that causes the configuration of the schisis cavity and retinal folds seen on OCT. This was assumed by Madarov and associates 2 Madjarov B. Hilton G.F. Brinton D.A. Lee S.S. A new classification of the retinoschises. Retina. 1995; 15: 282-285 Crossref PubMed Scopus (22) Google Scholar and again postulated by Emerson and associates. 3 Emerson M.V. Jakobs E. Green W.R. Ocular autopsy and histopathologic features of child abuse. Ophthalmology. 2007; 114: 1384-1394 Abstract Full Text Full Text PDF PubMed Scopus (60) Google Scholar These OCT findings have been previously published in adults with premacular hemorrhages. 4 Shukla D. Naresh K.B. Kim R. Optical coherence tomography in Valsalva retinopathy. Am J Ophthalmol. 2005; 140: 134-136 Abstract Full Text Full Text PDF PubMed Scopus (53) Google Scholar , 5 Meyer C.H. Mennel S. Rodrigues E.B. Schmidt J.C. Persistent premacular cavity after membranectomy in Valsalva retinopathy evident by optical coherence tomography. Retina. 2006; 26: 116-118 Crossref PubMed Scopus (34) Google Scholar These hemorrhages can occur either between the vitreous and the internal limiting membrane (ILM) (true “preretinal” or subhyaloid hemorrhages) or between the ILM and the nerve fiber layer (NFL) (sub-ILM) or both. 6 Srinivasan S. Kyle G. Subinternal limiting membrane and subhyaloid haemorrhage in Terson syndrome: the macular ‘double ring’ sign. Eye. 2006; 20: 1099-1101 Crossref PubMed Scopus (26) Google Scholar If the blood is between the vitreous and the ILM, the vitreous elevates the ILM. If the blood is between the ILM and the NFL, the ILM elevates the NFL. The blood obscures the visible retinal vessels, proving it is superficial to the NFL, but clinically it is difficult, if not impossible, to tell which layer it is in. Emerson and associates 3 Emerson M.V. Jakobs E. Green W.R. Ocular autopsy and histopathologic features of child abuse. Ophthalmology. 2007; 114: 1384-1394 Abstract Full Text Full Text PDF PubMed Scopus (60) Google Scholar noted all their cases to be sub-ILM. Sturm's cases appear to also be sub-ILM, the structure identified as epiretinal membrane (ERM) most likely being the ILM. (ERMs are indeed “epi,” ie, on top of, the retina and take some time to form.) ReplyAmerican Journal of OphthalmologyVol. 147Issue 3PreviewWe thank Dr Gardner for his interest in our article. He raised the crucial question regarding the underlying pathophysiology of characteristic ocular findings in Shaken Baby syndrome (SBS) such as retinal hemorrhages, retinoschisis, and retinal folds. Full-Text PDF