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Child abuse: Anatomy and pathogenesis of retinal hemorrhages after abusive head trauma

Gil Binenbaum, MD, MSCE
Section Editors
Evelyn A Paysse, MD
Daniel M Lindberg, MD
Deputy Editor
James F Wiley, II, MD, MPH


Abusive head trauma (AHT) is also known as nonaccidental head injury, inflicted head injury, or inflicted childhood neurotrauma. One subset is referred to as shaken baby syndrome, with a constellation of inflicted injuries in young children characterized by repeated acceleration-deceleration injury with or without blunt head impact [1-4]. Characteristic clinical features include retinal hemorrhages (often but not always bilateral, multilayered, and extensive), subdural hematoma, and/or occult fractures (particularly of the ribs and long bone metaphyses). Multiple episodes of trauma may occur before the abuse is detected [5-8]. Early recognition can be lifesaving.

The pathogenesis of retinal hemorrhages in AHT will be reviewed here. Other aspects of AHT and the management of suspected child abuse are discussed separately. (See "Child abuse: Eye findings in children with abusive head trauma (AHT)" and "Child abuse: Epidemiology, mechanisms, and types of abusive head trauma in infants and children" and "Child abuse: Evaluation and diagnosis of abusive head trauma in infants and children" and "Physical child abuse: Diagnostic evaluation and management".)


The retina is comprised of several layers (figure 1). The retinal vessels are contained in the neural portion of the retina [9]. The large vessels course through the nerve fiber and ganglion cell layers. Smaller vessels are located between the nerve fiber and inner nuclear layers. There are three layers of retinal capillaries: those within the nerve fiber and ganglion cell layers, those in the inner nuclear layer, and the radial peripapillary capillaries.


Overview — Several mechanisms have been proposed to play a role in the development of retinal hemorrhages, but none is universally accepted. Different types of retinal hemorrhages may have different mechanisms, and more than one mechanism may operate in any given instance (figure 2 and figure 3 and figure 4 and figure 5).

Autopsy studies demonstrate an increased rate of orbital hemorrhage in abusive head trauma (AHT) victims compared with victims of unintentional (accidental) head injury [10]. Repetitive acceleration-deceleration (shaking) forces appear to play a primary role in the development of orbital and subdural hemorrhage in AHT [10-15]. The role of repetitive acceleration-deceleration forces in the pathogenesis of subdural hemorrhage in AHT is discussed separately. (See "Child abuse: Epidemiology, mechanisms, and types of abusive head trauma in infants and children", section on 'Mechanisms of injury'.)


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Literature review current through: Sep 2016. | This topic last updated: Apr 12, 2016.
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  1. Mills M. Funduscopic lesions associated with mortality in shaken baby syndrome. J AAPOS 1998; 2:67.
  2. Lancon JA, Haines DE, Parent AD. Anatomy of the shaken baby syndrome. Anat Rec 1998; 253:13.
  3. Caffey J. The whiplash shaken infant syndrome: manual shaking by the extremities with whiplash-induced intracranial and intraocular bleedings, linked with residual permanent brain damage and mental retardation. Pediatrics 1974; 54:396.
  4. Christian CW, Block R, Committee on Child Abuse and Neglect, American Academy of Pediatrics. Abusive head trauma in infants and children. Pediatrics 2009; 123:1409.
  5. King WJ, MacKay M, Sirnick A, Canadian Shaken Baby Study Group. Shaken baby syndrome in Canada: clinical characteristics and outcomes of hospital cases. CMAJ 2003; 168:155.
  6. Jenny C, Hymel KP, Ritzen A, et al. Analysis of missed cases of abusive head trauma. JAMA 1999; 281:621.
  7. Alexander R, Crabbe L, Sato Y, et al. Serial abuse in children who are shaken. Am J Dis Child 1990; 144:58.
  8. Lambert SR, Johnson TE, Hoyt CS. Optic nerve sheath and retinal hemorrhages associated with the shaken baby syndrome. Arch Ophthalmol 1986; 104:1509.
  9. Aryan HE, Ghosheh FR, Jandial R, Levy ML. Retinal hemorrhage and pediatric brain injury: etiology and review of the literature. J Clin Neurosci 2005; 12:624.
  10. Gilliland MG, Luckenbach MW, Chenier TC. Systemic and ocular findings in 169 prospectively studied child deaths: retinal hemorrhages usually mean child abuse. Forensic Sci Int 1994; 68:117.
  11. Gleckman AM, Evans RJ, Bell MD, Smith TW. Optic nerve damage in shaken baby syndrome: detection by beta-amyloid precursor protein immunohistochemistry. Arch Pathol Lab Med 2000; 124:251.
  12. Morad Y, Kim YM, Armstrong DC, et al. Correlation between retinal abnormalities and intracranial abnormalities in the shaken baby syndrome. Am J Ophthalmol 2002; 134:354.
  13. Levin AV. Ophthalmology of shaken baby syndrome. Neurosurg Clin N Am 2002; 13:201.
  14. Sturm V, Landau K, Menke MN. Optical coherence tomography findings in Shaken Baby syndrome. Am J Ophthalmol 2008; 146:363.
  15. Forbes BJ, Christian CW, Judkins AR, Kryston K. Inflicted childhood neurotrauma (shaken baby syndrome): ophthalmic findings. J Pediatr Ophthalmol Strabismus 2004; 41:80.
  16. Green MA, Lieberman G, Milroy CM, Parsons MA. Ocular and cerebral trauma in non-accidental injury in infancy: underlying mechanisms and implications for paediatric practice. Br J Ophthalmol 1996; 80:282.
  17. Geddes JF, Talbert DG. Paroxysmal coughing, subdural and retinal bleeding: a computer modelling approach. Neuropathol Appl Neurobiol 2006; 32:625.
  18. Shiau T, Levin AV. Retinal hemorrhages in children: the role of intracranial pressure. Arch Pediatr Adolesc Med 2012; 166:623.
  19. Binenbaum G, Rogers DL, Forbes BJ, et al. Patterns of retinal hemorrhage associated with increased intracranial pressure in children. Pediatrics 2013; 132:e430.
  20. Curcoy AI, Trenchs V, Morales M, et al. Is pertussis in infants a potential cause of retinal haemorrhages? Arch Dis Child 2012; 97:239.
  21. Goldman M, Dagan Z, Yair M, et al. Severe cough and retinal hemorrhage in infants and young children. J Pediatr 2006; 148:835.
  22. Mills MD. Terson syndrome. Ophthalmology 1998; 105:2161.
  23. Schloff S, Mullaney PB, Armstrong DC, et al. Retinal findings in children with intracranial hemorrhage. Ophthalmology 2002; 109:1472.
  24. Brinker T, Lüdemann W, von Rautenfeld DB, et al. Breakdown of the meningeal barrier surrounding the intraorbital optic nerve after experimental subarachnoid hemorrhage. Am J Ophthalmol 1997; 124:373.
  25. Budenz DL, Farber MG, Mirchandani HG, et al. Ocular and optic nerve hemorrhages in abused infants with intracranial injuries. Ophthalmology 1994; 101:559.
  26. Tomasi LG, Rosman NP. Purtscher retinopathy in the battered child syndrome. Am J Dis Child 1975; 129:1335.
  27. Kivlin JD, Simons KB, Lazoritz S, Ruttum MS. Shaken baby syndrome. Ophthalmology 2000; 107:1246.
  28. Lazoritz S, Baldwin S, Kini N. The Whiplash Shaken Infant Syndrome: has Caffey's syndrome changed or have we changed his syndrome? Child Abuse Negl 1997; 21:1009.