Retinal and visual function in infants with non-accidental trauma and retinal hemorrhages



To investigate retinal function and visual outcomes in infants with retinal hemorrhages due to non-accidental trauma (NAT).


This is a retrospective review of full-field or multifocal electroretinogram (ERG) recordings, visual acuity in log minimum angle of resolution (logMAR), clinical status, and neuroimaging. Multifocal ERGs from the central 40° were compared to corresponding fundus imaging. Visual acuity was measured by Teller cards at follow-up. ERGs were compared to controls recorded under anesthesia.


Sixteen children met inclusion criteria (14 recorded during the acute phase and 2 during long-term follow-up). During the acute phase, ERGs (n = 4 full field; n = 10 multifocal ERG) showed abnormal amplitude, latency, or both in at least one eye. Ten subjects had significantly reduced responses in both eyes, 3 of which had an ERG dominated by a negative waveform (absent b-wave or P1). The remaining six subjects had responses in one eye that were near normal (≥ 50% of controls). ERGs were sometimes abnormal in local areas without hemorrhage. ERGs could be preserved in local areas adjacent to traumatic retinoschisis. Two subjects with reduced visual acuity had belated ERGs: One had an abnormal macular ERG and the other had a normal macular ERG implying cortical visual impairment. At follow-up, 10 of 14 subjects had significant visual acuity loss (≥ 0.7 age-corrected logMAR); four subjects had mild vision loss (≤ 0.5 age-corrected logMAR). Visual acuity outcome was not reliably associated with the fundus appearance in the acute phase. All subjects with a negative ERG waveform had severe vision loss on follow-up.


Retinal dysfunction was common during the acute phase of NAT. A near normal appearing fundus did not imply normal retinal function, and ERG abnormality did not always predict a poor visual acuity outcome. However, a negative ERG waveform was associated severe visual acuity loss. Potential artifacts of retinal hemorrhages and anesthesia could not fully account for multifocal ERG abnormalities. Retinal function can be preserved in areas adjacent to traumatic retinoschisis.

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This study was funded by an unrestricted Grant from the Peter LeHaye, Barbara Anderson, and William O. Rogers Endowment Funds.

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Correspondence to John P. Kelly.

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Conflict of interest

Drs. Feldman and Metz provide medical legal consultation in possible child abuse cases. No potentially conflicting relationship exists for the other authors. John Kelly is an unpaid consultant to the University of Washington to maintain the quality control of Teller Acuity Cards, which were used in this study.

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The study was approved by the Institutional Review Board of Seattle Children’s Hospital. Procedures conformed to the US Health Insurance Portability and Accountability Act requirements.

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This study did not involve animals.

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The study is a retrospective review of charts.

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Kelly, J.P., Feldman, K., Wright, J. et al. Retinal and visual function in infants with non-accidental trauma and retinal hemorrhages. Doc Ophthalmol 141, 111–126 (2020).

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  • Electroretinogram
  • Shaken baby syndrome
  • Non-accidental trauma
  • Pediatric ophthalmology