Extensive Retinal Hemorrhages Research Articles

Shaken Baby Syndrome: Intending to Harm or Attempting to Help?

To describe the role of ophthalmologists in shaken baby syndrome evaluation. Case report. A 3.5-month-old girl was admitted to the Pediatrics Clinic with lethargy. The mother, who brought in the baby, claimed that the baby had fallen from her cradle 6 hours ago. Clinical examination showed signs of head injury. Ophthalmologic examination was requested and revealed extensive retinal hemorrhages bilaterally covering the whole fundus, and retrohyaloid hematoma in the right eye. Computerized tomography neuroimaging documented large subdural hematomas exerting force on the brain parenchyma. The sum of the results of the clinical and neuroimaging examination-retinal hemorrhages and subdural hematomas-was indicative of violent shaking of the baby. Coronal evaluation was unable to determine whether the baby was abused by her parents or whether she was accidentally hurt. Ophthalmologic examination is necessary to document shaken baby syndrome since it reveals the retinal hemorrhages which together with the neuroimaging findings are almost always present in such cases. However, even when all the signs of shaken baby syndrome are present, it is difficult and sometimes destructive for a parent to be falsely accused of abusing his or her own child.

Retinal folds and retinoschisis in accidental and non-accidental head injury

To report the similarity of retinal findings in an infant who sustained an accidental head injury and an infant with non-accidental head trauma. Two male infants sustained head injuries with skull fractures. Case 1 was an accidental head injury and case 2 was a non-accidental head injury. On examination, in case 1, there were four superficial retinal haemorrhages in the right fundus. The left eye had a haemorrhagic optic disc oedema with extensive retinal haemorrhages, retinal folds, and schitic cavities within the retina at the posterior pole. In case 2, the right fundus had a single blot haemorrhage at the posterior pole. The left fundus revealed optic disc haemorrhage and oedema with extensive retinal haemorrhages. There was a haemorrhagic retinoschisis with a retinal fold. The two cases, one with accidental and the other with non-accidental injury, demonstrate very similar ophthalmic findings. This supports the argument that there may be no retinal signs seen exclusively in non-accidental head injury.

Shaken baby syndrome without intracranial hemorrhage on initial computed tomography

We sought to describe the unique characteristics of children diagnosed with shaken baby syndrome (SBS) despite the absence of intracranial hemorrhage on cranial computerized tomography (CT) on hospital admission. Using an international e-mail-based listserv for professionals with an interest in child abuse, we identified and reviewed the charts of children hospitalized in different medical centers who were diagnosed with SBS although CT disclosed no signs of intracranial bleeding. Children with normal imaging were not included. Eight cases were identified. All children had cerebral edema in CT, which was severe on 7/8 cases (88%). All of these children had extensive retinal hemorrhage. The prognosis was poor; 5/8 infants died (63% mortality), and the rest had permanent neurologic damage. The diagnosis of SBS can be established even when CT at presentation does not demonstrate intracranial hemorrhage. We hypothesize that rapidly developing cerebral edema may cause increased intracranial pressure and tamponade that prevents the accumulation of intracranial blood. The prognosis in these cases is grave.

Manifestations of the shaken baby syndrome.

Retinal hemorrhages are the most common fundus finding in the shaken baby syndrome. They vary in type and location; no particular type is pathognomonic for the condition. Retinal hemorrhages are not needed to make a diagnosis of shaken baby syndrome. However, in a child under age 3 years, the presence of extensive bilateral retinal hemorrhages raises a very strong possibility of abuse, which must be investigated. The other possible causes for hemorrhages in this age child can be investigated and eliminated. The diagnosis of abuse should be made by someone particularly trained in this area, who can put together the entire picture of inadequate or changing history, fractures of various ages, particularly rib fractures, subdural hematoma of the brain, and retinal hemorrhages. Photographs of retinal hemorrhages are very helpful to child advocacy experts who take these cases to court.

DIFFUSE UNILATERAL HEMORRHAGIC RETINOPATHY ASSOCIATED WITH ACCIDENTAL PERINATAL STRANGULATION

To report an unusual case of diffuse retinal hemorrhage associated with strangulation in a neonate with a tightly wrapped nuchal cord around his neck at birth who was noted to have eyelid and subconjunctival petechial hemorrhages upon delivery. Clinical diagnostic examination as well as postmortem gross and histopathologic examination of ocular and central nervous system structures was performed. Funduscopic and gross pathologic examination of the eyes revealed extensive unilateral retinal hemorrhage of the right eye only. This was corroborated by histopathologic studies, which revealed unilateral diffuse hemorrhage throughout all nuclear layers of the retina with a particularly dense nerve fiber layer and sub-internal limiting membrane hemorrhage in the macula along with extraocular muscle and episcleral hemorrhage. Clinical, gross, and microscopic examination also revealed multiple areas of hemorrhage involving the right side of the brain and throughout the cerebellum. Although retinal findings in nonaccidental trauma are common, accidental strangulation retinopathy in neonates is a rare occurrence. To the authors' knowledge, this case is the only documented histopathologic study of hemorrhagic retinopathy associated with strangulation in the literature.

Intraocular hemorrhages associated with endoscopic spinal surgery

PURPOSE: To report the occurrence of intraocular hemorrhages in association with endoscopic spinal surgery. METHODS: Case report. RESULTS: A 40-year-old patient noted severe visual loss in both eyes after epidural endoscopy, epidurography, and endoscopic adhesiolysis. Ophthalmic examination showed a best-corrected visual acuity of RE: 20/800, and LE: counting fingers, and extensive subhyaloid, retinal, and subretinal hemorrhages in both eyes. The hemorrhages resolved over a period of 8 weeks and the best-corrected visual acuity improved to 20/40 in both eyes after 4 months. CONCLUSION: A syndrome of visual loss and intraocular hemorrhages after an endoscopic spinal procedure is studied.

Unilateral retinal hemorrhages in documented cases of child abuse

PURPOSE: To describe the occurrence of unilateral retinal hemorrhages in four cases of documented child abuse, including a case in which retinal hemorrhages were an incidental finding on routine examination. METHODS: Case reports. RESULTS: Three children, 5 to 17 months of age, with suspected child abuse had fundus examinations with a dilated pupil as part of their evaluation. An additional child, 6 months of age, received fundus examination with a dilated pupil as part of follow-up for regressed retinopathy of prematurity. Each of the four children had extensive retinal or preretinal hemorrhages in one eye only. Three of the four had ecchymoses on the ipsilateral face or neck. Two had evidence of bone fractures on skeletal surveys. All four had neuroimaging that documented cerebral hemorrhage or infarct. In all four cases an adult caretaker admitted shaking, choking, or squeezing the child. One child died. Two had resolution of retinal hemorrhage, whereas one required vitrectomy. All three had at least partial recovery of vision in the affected eye after amblyopia treatment. CONCLUSION: In cases of documented child abuse, unilateral retinal or preretinal hemorrhages may be present. Ophthalmologists should recognize that unilateral retinal or preretinal hemorrhages may be associated with child abuse.

Unilateral retinal haemorrhages in non-accidental injury

Retinal haemorrhages are often seen in infants with nonaccidental injury, particularly following severe shaking. The classic finding is of widespread multiple haemorrhages in both eyes which may be associated with subdural haemorrhage and rib or limb fractures. An incomplete or atyical pattern of presentation may lead to diagnostic uncertainty. We report three infants with non-accidental injury who presented with unilateral retinal haemorrhages. A 5-week-old boy (case 1) was brought to the casualty department because he had stopped feeding after being generally unwell for 2 days. The infant had several convulsions whilst in the casualty department and was admitted for further management. Computed tomography (CT) of the head showed diffuse cerebral oedema, subdural haemorrhages of differing ages, and contusion clefts in the frontal lobes. Skeletal survey and blood investigations were normal. Ocular examination revealed extensive retinal haemorrhages and a dense premacular haemorrhage in the right eye. The left eye was normal with no evidence of intraocular haemorrhage. 48 h after admission the parents reported having been involved in a road traffic accident 2 weeks earlier, during which their son had been secured in an infant support. No external injuries were reported by the parents at the time and therefore non-accidental injury was still considered to be the most likely unifying diagnosis. As a consequence of the presence of haemorrhage in only one eye the diagnosis was called into question and child protection was not instituted. Two more infants were admitted over the ensuing 4 months. In each case the clinical examination and investigations were diagnostic of non-accidental injury, but once again the retinal haemorrhages were unilateral. As a result of our experience and evidence from published research, the original medicolegal report in case 1 was modified. Brief details of the three infants are shown in the table. Intraocular haemorrhages are present in up to 89% of infants with non-accidental injury. They may follow a direct blow to the eye, severe chest compression, or severe shaking of the head. The mechanism of these haemorrhages is uncertain but is probably related to raised intraocular venous pressure due to a sudden rise in intracranial pressure or raised central venous pressure. One might expect retinal haemorrhages in patients with non-accidental injury to be bilateral due to the nature of the injury. Very few cases of unilateral retinal haemorrhages have been reported and this unilaterality has never been emphasised. Thus the possibility of unilateral retinal haemorrhages occurring in non-accidental injury is not widely recognised. Since retinal haemorrhages can present before other injuries become apparent we feel that in the age group at risk, non-accidental injury should be suspected even in cases of unilateral retinal haemorrhage, and the infant admitted for further evaluation. Although the intraocular haemorrhages have cleared in the three infants, the vision has returned to normal level in case 1 only, and remains greatly reduced in cases 2 and 3 due to associated optic nerve and occipital lobe injury. A good prognosis for visual recovery cannot be assured even if the initial signs of injury are limited to one eye.

Bilateral Papilledema With Retinal Hemorrhages in Association With Cerebral Venous Sinus Thrombosis and Paroxysmal Nocturnal Hemoglobinuria

To report a patient with paroxysmal nocturnal hemoglobinuria who complained of transient obscurations of vision and exhibited bilateral papilledema with retinal hemorrhages. Case report. Computed tomography did not demonstrate any abnormality but magnetic resonance imaging disclosed signs of cerebral venous sinus thrombosis. The patient was treated with subcutaneous low molecular weight heparin and intravenous corticosteroids. Symptoms improved within one week and ophthalmoscopic signs resolved within four months. Bilateral papilledema with extensive retinal hemorrhages may be a sign of cerebral venous sinus thrombosis, a reported devastating complication of paroxysmal nocturnal hemoglobinuria. Thus, any patient with suspected cerebral venous sinus thrombosis should undergo magnetic resonance imaging, even when results of computed tomography are normal.

Retinal Folds in the Shaken Baby Syndrome

We examined two children with presumed shaken baby syndrome. Both children suffered severe, indirect closed head trauma with intracranial hemorrhage, sharply increased intracranial pressure, and extensive neurologic damage. In addition to extensive retinal and preretinal hemorrhages, bilateral symmetric white ring-shaped retinal folds were seen encircling the macula outside the vascular arcades. These retinal folds may be a hallmark of shaking injuries in child abuse victims.

10 Cerebral handicap in full-term neonates related to the mechanical forces of labour

Sometimes the relationship between peripartum events and neonatal CNS injury is obvious: for example, following complete abruptio placentae or umbilical cord prolapse and occlusion with a delay of many minutes before delivery of the baby. These circumstances are, of course, rare in modern obstetrics. Usually, when a neonate develops neurological injury, a host of various potentially adverse peripartum factors are assumed to be the aetiology, but without definitive evidence. Among these latter factors are those we have focused on in this paper: the mechanical forces exerted on the fetal head during labour when the full-term fetus is in cephalic presentation. The mechanical events during the first stage of labour are reviewed, showing how uterine contractions result in cervical dilatation and descent and rotation of the fetal head. The consequences of these forces on the fetal intracranial pressure and blood flow are discussed: FHR remains normal up to a certain pressure threshold, above which decelerations occur. In other words, excessive pressures applied to the fetal head, either spontaneously (e.g. uterine tetany) or iatrogenically (e.g. traumatic forceps delivery or excessive fundal pressure) can increase fetal intracranial pressure to such a degree as to result in significant decreases in cerebral blood flow that are associated with fetal heart rate decelerations. Even when decelerations are simultaneous to contractions, decelerations cannot be considered as reflex and innocuous, as they are indeed associated with a decreasing cerebral blood flow. They must therefore be considered and evaluated in the management of labour. Cord compression and functional modifications of intervillous space by mechanical forces may further compromise the biological status of the fetus, leading to severe asphyxia. Neurological evaluation of the neonate within the first few days after delivery is currently the only way to provide the obstetricians with information on the possible consequences of an abnormal labour. The assessment of normality of the CNS in the neonate born at term, and its value in predicting late outcome are discussed. When abnormalities are detected after one or repeated assessments, abnormal neurological signs and symptoms are classified into three grades at the end of the first week. According to our data, a good correlation exists between this neonatal grading of cerebral dysfunction and late outcome. A careful evaluation of fetal head deformation, extensive caput succedaneum, and extensive retinal haemorrhages can help to interpret an abnormal labour retrospectively.(ABSTRACT TRUNCATED AT 400 WORDS)

Traumatic Retinoschisis in Battered Babies

Five infants who were victims of physical abuse had extensive bilateral retinal hemorrhages on initial evaluation and subsequently developed signs of permanent retinal damage. None showed external evidence of trauma to the eyes. Vitreous hemorrhage developed after a delay of several days or more in three cases that were followed closely from the time of the traumatic incident. In several eyes, apparent intraretinal blood-filled cavities were seen acutely in the macular region and elsewhere. Late scarring of the macula typically had a cystic or crater-like configuration. Electroretinography showed loss or reduction of the positive 13-wave with preservation of the negative A-wave in every case. We propose that splitting of the retina resulting from the direct mechanical effects of violent shaking was responsible for all of these findings.

NEUROLOGICAL MANIFESTATIONS IN ABUSED CHILDREN WHO HAVE BÉEN SHAKEN

Four infants with the 'shaken infant syndrome' are described. None had skull fractures and only one had a subdural hematoma. All had extensive retinal and pre-retinal hemorrhages. Follow-up computerized tomography showed severe brain atrophy, multiple hypodense areas and ventricular enlargement. Three of the patients suffered severe, permanent brain damage, with mental retardation, spasticity and blindness. It is suggested that the underlying pathogenesis of this syndrome is acutely increased intrathoracic pressure, transmitted into the head to cause multiple venous infarctions. Retinal and pre-retinal hemorrhages are cardinal features of this syndrome and their presence should raise the suspicion of this form of battering in the absence of the 'classical' signs of battering.

Whiplash shaking syndrome: Retinal hemorrhages and computerized axial tomography of the brain

Three cases of whiplash shaking injury of infants are presented. All children presented with seizures and had minimal signs of external injury. Examination of the retina revealed extensive retinal hemorrhages. These were missed on initial examination and were only discovered after pupillary dilatation. The presence of these palecentered retinal hemorrhages suggested the diagnosis of child abuse and skeletal surveys and thorough social histories confirmed the diagnosis. Despite extensive retinal hemorrhages, computerized axial tomography (C.T.) scan showed minimal inter-hemispheric bleeding. In contrast to the “Battered Child Syndrome,” all the findings in whiplash shaking syndrome of infants are subtle and demand an awareness, an index of suspicion and a thorough examination which may include extensive retinal examination following dilatation of the pupils. This latter examination is frequently not performed by family physicians and residents so that the syndrome may be missed. A fourth case is also discussed where shaking is admitted on initial presentation but said to be done for resuscitation. This poses an immense diagnostic dilemma to the pediatrician since in this case the child presented later with all the signs of physical abuse.

Clinical and Experimental Studies on Diabetic Renal Disorder

Control of diabetes mellitus in recent years has become less difficult even with complicated with infection, however, the general vascular disorders, especially diabetic nephropathy, as a result of long standing metabolic disturbance will present a serious problem in the prognosis of diabetes. In spite of voluminous reports on the subject appearing in foreign countries, our domestic reports have been limited to a few. Present investigation is the report on the behaviours of renal circulation and glucose reabsorption from renal tubules by means of measuring renal plasma flow (RPF), renal blood flow (RBF), glomerular filtration rate (GFR) and tubular reabsorptive mass (TmG) in 50 diabetic patients. Then an attempt was made to analize the relations between these findings with sex, age, severity, duration of the disorder, blood pressure, proteinuria, retinal finding and insulin sensitivity. In addition, renal biopsy was carried out on some of 50 diabetic cases. With the methods mentioned above diagnosis, severity, prognosis and etiology of the renal disorders have been studied. In brief, the disorders could be classified into three groups from the view point of glomerular function.1. A group with normal glomerular function. (with RPF. 410-600 ml/min, including cases with GFR over 90 ml/min and RPF between 400-410 ml/min) Among these cases, 58 percent belonged to this group. Many of them showed a short history of the disease with normal insulin sensitivity, negative proteinuria, normal blood pressure except a few cases of slight hypertension, and normal ophthalmoscopic finding except two cases which showed either high normal value or high value in TmG. Extremely high value of TmG were encountered in the cases of severe and moderately advanced diabetics. The GFR/TmG ratio showed low value in large number.2. A group with glomerular hyperfunction. (with RPF over 600 ml/min) Among these cases 16 percent belonged to this group. These cases were usually juvenile diabetics and no one was over the age of 50. This group showed a short history of the illness with increased resistance to insulin.Many cases of this group belonged to moderately advanced diabetes. Proteinuria and mild hypertension were seen in two of 8 cases. In two cases there were extensive retinal hemorrhages with renal hyperfunction and few histological finding of the kidney. This makes us to presume that the retinopathy has accrued prior to the onset of diabetic nephropathy. The TmG was elevated in all the case. It is very interesting that the TmG is elevated in all the severe and moderately severe diabetics with normal or hyperglomerular function.3. A group with glomerular hypofunction (with RPF below 410 ml/min) Among the cases 26 percent belonged to this group. This group showed the highest age in average and the longest duration of the disease in three groups. 84.6 percent of this group showed a history of more than 5 years.Many of these cases showed increased resistance to insulin, particularly cases with marked hypofunction of the glomeruli showed stronger resistance to insulin. Proteinuria was observed in all cases and hypertension as well as diabetic retinopathy were found in nearly all of them. TmG values was decreased in almost all cases exclusively to this group, and GFR/TmG ratio was decreased in all cases. Renal biopsy was carried out in cases showing remarkable hypofunction of glomeruli and revealed the nodular lesion or generalized hyalinization of the glomeruli as described by Kimmelstiel-Wilson.For the purpose of studying the causal relationship between diabetic nephropathy and pituitary-adrenocortical function, alloxan diadetic dogs were treated with ACTH, prednisolone and cortisone respectively and their renal function was investigated on the glomerular and tubular function. Furthermore, morphological studies of the kidney were carried out to see correlation between functional and strucural disorder.

THE PLACE OF COATS'S DISEASE AMONG THE DISEASES OF THE RETINA

The place of Coats's disease, called by Coats retinitis exsudativa (retinitis externa hemorrhagica), among the diseases of the retina is still an uncertain one. The difficulty of characterizing it as a distinct entity is due to the fact that the massive exudations which are characteristic of the disease occur also in the other well characterized diseases of the retina, such as disciform macular degeneration (Junius and Kuhnt) and angiomatosis of the retina (von Hippel), and with extensive retinal hemorrhages of any origin. The difficulty is still heightened by the differences of opinion among investigators as to the cause of the exudations. Coats himself considered them to be the result of the hemorrhages in the retina. He was in doubt about the origin of the hemorrhages but leaned toward the idea that they are the result of some change in the small vessels. Other investigators, following Leber's lead,1considered Coats's