Official reprint from UpToDate®
www.uptodate.com ©2017 UpToDate, Inc. and/or its affiliates. All Rights Reserved.

Child abuse: Eye findings in children with abusive head trauma (AHT)

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


The ophthalmologic aspects of abusive head trauma will be reviewed here. The pathogenesis of retinal hemorrhages in AHT, other aspects of AHT, and the management of suspected child abuse are discussed separately:

(See "Child abuse: Anatomy and pathogenesis of retinal hemorrhages after abusive head trauma".)

(See "Child abuse: Epidemiology, mechanisms, and types of abusive head trauma in infants and children".)

(See "Child abuse: Evaluation and diagnosis of abusive head trauma in infants and children".)

(See "Physical child abuse: Diagnostic evaluation and management".)

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:

Subscribers log in here

Literature review current through: Nov 2017. | This topic last updated: Oct 13, 2017.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2017 UpToDate, Inc.
  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. AAP Publications Retired and Reaffirmed. Pediatrics 2017; 140.
  6. 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.
  7. Jenny C, Hymel KP, Ritzen A, et al. Analysis of missed cases of abusive head trauma. JAMA 1999; 281:621.
  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. Alexander R, Crabbe L, Sato Y, et al. Serial abuse in children who are shaken. Am J Dis Child 1990; 144:58.
  10. Bhardwaj G, Chowdhury V, Jacobs MB, et al. A systematic review of the diagnostic accuracy of ocular signs in pediatric abusive head trauma. Ophthalmology 2010; 117:983.
  11. Friendly DS. Ocular manifestations of physical child abuse. Trans Am Acad Ophthalmol Otolaryngol 1971; 75:318.
  12. Kivlin JD. A 12-year ophthalmologic experience with the shaken baby syndrome at a regional children's hospital. Trans Am Ophthalmol Soc 1999; 97:545.
  13. Levin AV. Ophthalmology of shaken baby syndrome. Neurosurg Clin N Am 2002; 13:201.
  14. Levin AV, Christian CW, Committee on Child Abuse and Neglect, Section on Ophthalmology. The eye examination in the evaluation of child abuse. Pediatrics 2010; 126:376.
  15. Wygnanski-Jaffe T, Levin AV, Shafiq A, et al. Postmortem orbital findings in shaken baby syndrome. Am J Ophthalmol 2006; 142:233.
  16. American Academy of Pediatrics: Committee on Child Abuse and Neglect. Shaken baby syndrome: rotational cranial injuries-technical report. Pediatrics 2001; 108:206.
  17. Kivlin JD, Simons KB, Lazoritz S, Ruttum MS. Shaken baby syndrome. Ophthalmology 2000; 107:1246.
  18. Morad Y, Kim YM, Mian M, et al. Nonophthalmologist accuracy in diagnosing retinal hemorrhages in the shaken baby syndrome. J Pediatr 2003; 142:431.
  19. Binenbaum G, Chen W, Huang J, et al. The natural history of retinal hemorrhage in pediatric head trauma. J AAPOS 2016; 20:131.
  20. Morad Y, Avni I, Benton SA, et al. Normal computerized tomography of brain in children with shaken baby syndrome. J AAPOS 2004; 8:445.
  21. Minns RA, Jones PA, Tandon A, et al. Prediction of inflicted brain injury in infants and children using retinal imaging. Pediatrics 2012; 130:e1227.
  22. D'Costa DF, Abbott RJ. Bilateral subdural haematomas and normal CT brain scans. Br J Clin Pract 1990; 44:666.
  23. Gudeman SK, Young HF, Miller JD, Becker DP. Bilateral acute subdural hematomas undiagnosed by computerized tomography: case report. Neurosurgery 1979; 5:273.
  24. Levin AV, Magnusson MR, Rafto SE, Zimmerman RA. Shaken baby syndrome diagnosed by magnetic resonance imaging. Pediatr Emerg Care 1989; 5:181.
  25. Feldman KW, Brewer DK, Shaw DW. Evolution of the cranial computed tomography scan in child abuse. Child Abuse Negl 1995; 19:307.
  26. Morad Y, Avni I, Capra L, et al. Shaken baby syndrome without intracranial hemorrhage on initial computed tomography. J AAPOS 2004; 8:521.
  27. Duhaime AC, Christian CW, Rorke LB, Zimmerman RA. Nonaccidental head injury in infants--the "shaken-baby syndrome". N Engl J Med 1998; 338:1822.
  28. 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.
  29. 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.
  30. Rao N, Smith RE, Choi JH, et al. Autopsy findings in the eyes of fourteen fatally abused children. Forensic Sci Int 1988; 39:293.
  31. Altman RL, Kutscher ML, Brand DA. The "shaken-baby syndrome". N Engl J Med 1998; 339:1329.
  32. Togioka BM, Arnold MA, Bathurst MA, et al. Retinal hemorrhages and shaken baby syndrome: an evidence-based review. J Emerg Med 2009; 37:98.
  33. Forbes BJ, Christian CW, Judkins AR, Kryston K. Inflicted childhood neurotrauma (shaken baby syndrome): ophthalmic findings. J Pediatr Ophthalmol Strabismus 2004; 41:80.
  34. 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.
  35. Binenbaum G, Mirza-George N, Christian CW, Forbes BJ. Odds of abuse associated with retinal hemorrhages in children suspected of child abuse. J AAPOS 2009; 13:268.
  36. Duhaime AC, Alario AJ, Lewander WJ, et al. Head injury in very young children: mechanisms, injury types, and ophthalmologic findings in 100 hospitalized patients younger than 2 years of age. Pediatrics 1992; 90:179.
  37. Child abuse and the eye. The Ophthalmology Child Abuse Working Party. Eye (Lond) 1999; 13 ( Pt 1):3.
  38. Bechtel K, Stoessel K, Leventhal JM, et al. Characteristics that distinguish accidental from abusive injury in hospitalized young children with head trauma. Pediatrics 2004; 114:165.
  39. Pierre-Kahn V, Roche O, Dureau P, et al. Ophthalmologic findings in suspected child abuse victims with subdural hematomas. Ophthalmology 2003; 110:1718.
  40. Riffenburgh RS, Sathyavagiswaran L. Ocular findings at autopsy of child abuse victims. Ophthalmology 1991; 98:1519.
  41. Gilles EE, McGregor ML, Levy-Clarke G. Retinal hemorrhage asymmetry in inflicted head injury: a clue to pathogenesis? J Pediatr 2003; 143:494.
  42. Kapoor S, Schiffman J, Tang R, et al. The significance of white-centered retinal hemorrhages in the shaken baby syndrome. Pediatr Emerg Care 1997; 13:183.
  43. Watts P, Maguire S, Kwok T, et al. Newborn retinal hemorrhages: a systematic review. J AAPOS 2013; 17:70.
  44. Massicotte SJ, Folberg R, Torczynski E, et al. Vitreoretinal traction and perimacular retinal folds in the eyes of deliberately traumatized children. Ophthalmology 1991; 98:1124.
  45. Lantz PE, Sinal SH, Stanton CA, Weaver RG Jr. Perimacular retinal folds from childhood head trauma. BMJ 2004; 328:754.
  46. Lueder GT, Turner JW, Paschall R. Perimacular retinal folds simulating nonaccidental injury in an infant. Arch Ophthalmol 2006; 124:1782.
  47. Gaynon MW, Koh K, Marmor MF, Frankel LR. Retinal folds in the shaken baby syndrome. Am J Ophthalmol 1988; 106:423.
  48. Kivlin JD, Currie ML, Greenbaum VJ, et al. Retinal hemorrhages in children following fatal motor vehicle crashes: a case series. Arch Ophthalmol 2008; 126:800.
  49. Greenwald MJ, Weiss A, Oesterle CS, Friendly DS. Traumatic retinoschisis in battered babies. Ophthalmology 1986; 93:618.
  50. Budenz DL, Farber MG, Mirchandani HG, et al. Ocular and optic nerve hemorrhages in abused infants with intracranial injuries. Ophthalmology 1994; 101:559.
  51. Marshall DH, Brownstein S, Dorey MW, et al. The spectrum of postmortem ocular findings in victims of shaken baby syndrome. Can J Ophthalmol 2001; 36:377.
  52. Gnanaraj L, Gilliland MG, Yahya RR, et al. Ocular manifestations of crush head injury in children. Eye (Lond) 2007; 21:5.
  53. 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.
  54. Hettler J, Greenes DS. Can the initial history predict whether a child with a head injury has been abused? Pediatrics 2003; 111:602.
  55. Agrawal S, Peters MJ, Adams GG, Pierce CM. Prevalence of retinal hemorrhages in critically ill children. Pediatrics 2012; 129:e1388.
  56. 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.
  57. Buys YM, Levin AV, Enzenauer RW, et al. Retinal findings after head trauma in infants and young children. Ophthalmology 1992; 99:1718.
  58. Goldman M, Dagan Z, Yair M, et al. Severe cough and retinal hemorrhage in infants and young children. J Pediatr 2006; 148:835.
  59. Sandramouli S, Robinson R, Tsaloumas M, Willshaw HE. Retinal haemorrhages and convulsions. Arch Dis Child 1997; 76:449.
  60. Tyagi AK, Scotcher S, Kozeis N, Willshaw HE. Can convulsions alone cause retinal haemorrhages in infants? Br J Ophthalmol 1998; 82:659.
  61. Binenbaum G, Christian CW, Guttmann K, et al. Evaluation of Temporal Association Between Vaccinations and Retinal Hemorrhage in Children. JAMA Ophthalmol 2015; 133:1261.
  62. Emerson MV, Pieramici DJ, Stoessel KM, et al. Incidence and rate of disappearance of retinal hemorrhage in newborns. Ophthalmology 2001; 108:36.
  63. Sezen F. Retinal haemorrhages in newborn infants. Br J Ophthalmol 1971; 55:248.
  64. Peyman GA, Bennett TO, Vlchek J. Effects of intravitreal prostaglandins on retinal vasculature. Ann Ophthalmol 1975; 7:279.
  65. Kaur B, Taylor D. Fundus hemorrhages in infancy. Surv Ophthalmol 1992; 37:1.
  66. Christian CW, Taylor AA, Hertle RW, Duhaime AC. Retinal hemorrhages caused by accidental household trauma. J Pediatr 1999; 135:125.
  67. Vinchon M, Defoort-Dhellemmes S, Desurmont M, Dhellemmes P. Accidental and nonaccidental head injuries in infants: a prospective study. J Neurosurg 2005; 102:380.
  68. Reece RM, Sege R. Childhood head injuries: accidental or inflicted? Arch Pediatr Adolesc Med 2000; 154:11.
  69. Johnson DL, Braun D, Friendly D. Accidental head trauma and retinal hemorrhage. Neurosurgery 1993; 33:231.
  70. Keenan HT, Runyan DK, Marshall SW, et al. A population-based comparison of clinical and outcome characteristics of young children with serious inflicted and noninflicted traumatic brain injury. Pediatrics 2004; 114:633.
  71. Tzioumi D, Oates RK. Subdural hematomas in children under 2 years. Accidental or inflicted? A 10-year experience. Child Abuse Negl 1998; 22:1105.
  72. Sturm V, Knecht PB, Landau K, Menke MN. Rare retinal haemorrhages in translational accidental head trauma in children. Eye (Lond) 2009; 23:1535.
  73. Plunkett J. Fatal pediatric head injuries caused by short-distance falls. Am J Forensic Med Pathol 2001; 22:1.
  74. Yoffe G, Buchanan GR. Intracranial hemorrhage in newborn and young infants with hemophilia. J Pediatr 1988; 113:333.
  75. Ryan CA, Gayle M. Vitamin K deficiency, intracranial hemorrhage, and a subgaleal hematoma: a fatal combination. Pediatr Emerg Care 1992; 8:143.
  76. Hymel KP, Abshire TC, Luckey DW, Jenny C. Coagulopathy in pediatric abusive head trauma. Pediatrics 1997; 99:371.
  77. Miner ME, Kaufman HH, Graham SH, et al. Disseminated intravascular coagulation fibrinolytic syndrome following head injury in children: frequency and prognostic implications. J Pediatr 1982; 100:687.
  78. Fahmy JA. Symptoms and signs of intracranial aneurysms with particular reference to retinal haemorrhage. Acta Ophthalmol (Copenh) 1972; 50:129.
  79. Gutierrez Diaz A, Jimenez Carmena J, Ruano Martin F, et al. Intraocular hemorrhage in sudden increased intracranial pressure (Terson syndrome). Ophthalmologica 1979; 179:173.
  80. Meyer FB, Sundt TM Jr, Fode NC, et al. Cerebral aneurysms in childhood and adolescence. J Neurosurg 1989; 70:420.
  81. McLellan NJ, Prasad R, Punt J. Spontaneous subhyaloid and retinal haemorrhages in an infant. Arch Dis Child 1986; 61:1130.
  82. Forbes BJ, Cox M, Christian CW. Retinal hemorrhages in patients with epidural hematomas. J AAPOS 2008; 12:177.
  83. Bhardwaj G, Jacobs MB, Moran KT, Tan K. Terson syndrome with ipsilateral severe hemorrhagic retinopathy in a 7-month-old child. J AAPOS 2010; 14:441.
  84. Schloff S, Mullaney PB, Armstrong DC, et al. Retinal findings in children with intracranial hemorrhage. Ophthalmology 2002; 109:1472.
  85. Fahmy JA. Fundal haemorrhages in ruptured intracranial aneurysms. I. Material, frequency and morphology. Acta Ophthalmol (Copenh) 1973; 51:289.
  86. Chen WS, Forbes B, Ying GS, et al. The natural history of retinal hemorrhage in pediatric head trauma. J AAPOS 2013; 17:e12.
  87. Levin AV. Retinal hemorrahges and child abuse. In: Recent Advances in Pediatrics, David TJ (Ed), Churchill Livingstone, London 2000. p.151.
  88. Weedn VW, Mansour AM, Nichols MM. Retinal hemorrhage in an infant after cardiopulmonary resuscitation. Am J Forensic Med Pathol 1990; 11:79.
  89. Gilliland MG, Luckenbach MW. Are retinal hemorrhages found after resuscitation attempts? A study of the eyes of 169 children. Am J Forensic Med Pathol 1993; 14:187.
  90. Odom A, Christ E, Kerr N, et al. Prevalence of retinal hemorrhages in pediatric patients after in-hospital cardiopulmonary resuscitation: a prospective study. Pediatrics 1997; 99:E3.
  91. Tomasi LG, Rosman NP. Purtscher retinopathy in the battered child syndrome. Am J Dis Child 1975; 129:1335.
  92. Geloneck MM, Forbes BJ, Shaffer J, et al. Ocular Complications in Children with Diabetes Mellitus. Ophthalmology 2015; 122:2457.
  93. Matthews GP, Das A. Dense vitreous hemorrhages predict poor visual and neurological prognosis in infants with shaken baby syndrome. J Pediatr Ophthalmol Strabismus 1996; 33:260.
  94. Levin, AV. Ocular manifestations of child abuse. Ophthalmol Clin North Am 1990; 3:249.
  95. Bonnier C, Nassogne MC, Evrard P. Outcome and prognosis of whiplash shaken infant syndrome; late consequences after a symptom-free interval. Dev Med Child Neurol 1995; 37:943.
  96. McCabe CF, Donahue SP. Prognostic indicators for vision and mortality in shaken baby syndrome. Arch Ophthalmol 2000; 118:373.
  97. Wilkinson WS, Han DP, Rappley MD, Owings CL. Retinal hemorrhage predicts neurologic injury in the shaken baby syndrome. Arch Ophthalmol 1989; 107:1472.
  98. Harcourt B, Hopkins D. Ophthalmic manifestations of the battered-baby syndrome. Br Med J 1971; 3:398.
  99. Fishman CD, Dasher WB 3rd, Lambert SR. Electroretinographic findings in infants with the shaken baby syndrome. J Pediatr Ophthalmol Strabismus 1998; 35:22.
  100. Harcourt B, Hopkins D. Permanent chorio-retinal lesions in childhood of suspected traumatic origin. Trans Ophthalmol Soc U K 1973; 93:199.