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1. Han DP, Wilkinson WS. Late
ophthalmic manifestations of the shaken baby syndrome.
Journal of Pediatric Ophthalmology Strabismus. 1990;27:299-303.
Han and Wilkinson examined six children after a shaking episode to determine
whether retinal abnormalities persisted. Shaken baby syndrome was defined
by the authors as the findings of retinal, vitreous or subhyaloid hemorrhage
along with intracranial injury without external signs of head trauma.
examination consisted of visual acuity testing, pupillary testing for afferent
defects, anterior segment examination and orthoptic evaluation for motility
disturbances. Indirect and direct ophthalmoscopy was also performed.
mean age at time of injury for the six patients was 9.1 months (range 3-20 months)
and the mean age at follow-up was 29.8 months (range 21-55 months). Three
children had profound visual loss due to occipital lobe atrophy. These three
children also had severe psychomotor retardation. Two children had moderate
visual loss in one eye. These two children had previous retinal
hemorrhages, macular folds and loss of retinal transparency. The last
child’s vision was described as central, steady and maintained; this patient
also had a left hemiparesis.
2. Matthews GP, Das A. Dense
vitreous hemorrhages predict poor visual and neurological prognosis in infants
with shaken baby syndrome. Journal of Pediatric Ophthalmology
Matthews and Das retrospectively examined the cases of five infants with
confirmed shaken baby syndrome who also underwent pars plana vitrectomy to
remove vitreous hemorrhages. All of the infants met the authors’ criteria
for shaken baby syndrome, which included evidence of intraocular hemorrhages
and subdural or subarachnoid hemorrhages with interhemispheric blood and a “history
of suspected child abuse.” The infants ranged in age from 3 months to 8
months (mean 5.5 months) at the time of injury.
of the infants had neurological examinations, but the interval to follow-up is
not recorded. Two of the infants were reported to be “neurologically
improved” at follow-up. The other three infants did not show neurological
improvement. Of these three infants, one was left in a chronic vegetative
state and died five months following injury. The other two infants had
seizures, spasticity and hemiparesis.
The postoperative visual acuity was also measured for each patient. Two
of the patients had fix and follow vision in both eyes. Of the remaining
three patients, two patients had light perception in both eyes and one patient
had light perception in one eye only.
3. McCabe CF, Donahue SP. Prognostic
indicators for vision and mortality in shaken baby syndrome. Arch Ophthalmology. 2000:118;373-377.
McCabe and Donahue reviewed the medical records of 30 children diagnosed with
shaken baby syndrome. A diagnosis of shaken baby syndrome was made when
bilateral retinal hemorrhages were seen and when the history was not consistent
with the injuries, when other obvious signs of abuse were present or when there
was a history of a previous suspicious episode of abuse. The mean age of
children at the time of injury was 9.3 months.
patients survived. Twenty patients returned to the outpatient clinic for
follow-up (range of time interval to follow-up: 1-36 months; mean 6.7
months). At each visit, the presence of retinal hemorrhages was noted. The
ophthalmologists also examined patients for ocular motility, fix and follow
vision and the presence of amblyopia.
retinal hemorrhages resolved, six patients (27 percent) had poor vision in at
least one eye. The poor vision was due to cortical visual impairment in
two patients, optic atrophy in two children, retinal fibrosis and retinal
scarring each in one patient. Twelve patients initially presented with fix
and follow vision (40 percent). Of those, 10 retained fix and follow vision.
Eighteen patients presented without fix and follow vision in at least one
eye. Of these 18 patients, eight died. Seven of the remaining 10
patients gained vision and three had no improvement.
There were 22 patients who had reactive pupils initially; all
survived. All eight patients who initially had nonreactive pupils died.
4. Kivlin JD, Simons KB, Lazoritz
S, Ruttum MS. Shaken
baby syndrome. Ophthalmology. 2000;107:1246-1254.
Kivlin and colleagues performed a retrospective case series of 123 children
younger than 3 years of age who had subdural hematomas and a diagnosis of child
abuse. The determination of child abuse (shaken baby syndrome) was made
by a child advocacy physician and was based on the presence of subdural
hematomas, characteristic bone injuries and the absence of a history of compatible
functioning was determined by review of the medical charts. Twenty-two of
87 survivors (25 percent) were documented as having a “good” neurologic
outcome, defined as normal for age, at the last follow-up visit. Eight
patients (9 percent) were mildly impaired at the last follow-up visit;
impairments included attention deficit disorders or mild speech delay. Twenty-six
patients (30 percent) were severely impaired, with deficits including
hemiparesis, ataxia or severe developmental delay. Thirty-six patients (29
percent) died. There was no information available in the chart for 31
children (36 percent).
authors also recorded the visual function and eye examinations of patients seen
in follow-up by ophthalmologists, other specialists or pediatricians; the
authors noted visual outcome for patients at their last outpatient visit (only
60 percent of the final evaluations were by an ophthalmologist). Mean time
interval to follow-up was 21 months (range one month-seven years). Forty-nine
patients (72 percent) were reported to have “good” vision at their last
follow-up visit. Seventeen patients (25 percent) had “poor” vision.
Two additional patients reportedly had poor vision in one eye. There was
no follow-up information for 19 patients.
Cerebral visual impairment from cortical brain injury was the most
common cause of bilateral visual impairment (15 / 19 patients). Poor
visual outcome and poor neurologic outcome were highly correlated. Eye findings
that were associated with death included initial lack of visual response,
initial poor pupillary response and the presence of retinal hemorrhages.
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