Visual Outcomes

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.

Follow-up 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.

The 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 Strabismus. 1996;33:260-265. 

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.

All 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.

Twenty-two 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.

After 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 accidental trauma.

Neurologic 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).

The 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.