Journal of Family Violence

, Volume 31, Issue 7, pp 797–804 | Cite as

Ophthalmologic Concerns in Abusive Head Trauma

  • Alex V. Levin
  • Francois M. Luyet
  • Barbara L. Knox
Original Article


When Abusive Head Trauma (AHT) is suspected in a child, a dilated eye examination by an ophthalmologist is an essential part of the medical workup, as the presence and pattern of retinal hemorrhages can have a high positive predictive rate for abusive head injury. This article proposes to review the clinical presentation, pathophysiology, natural history, sequelae, and differential diagnosis of retinal hemorrhages and other ocular lesions associated with AHT.


Abusive head trauma Ocular lesions Retinal hemorrhages Retinoschisis Retinal folds Dilated eye exam 


  1. Adams, G. G., Agrawal, S., Sekhri, R., Peters, M. J., & Pierce, C. M. (2013). Appearance and location of retinal haemorrhages in critically ill children. The British Journal of Ophthalmology, 97(9), 1138–1142. doi: 10.1136/bjophthalmol-2012-302429.PubMedCrossRefGoogle Scholar
  2. Arlotti, S. A., Forbes, B. J., Dias, M. S., & Bonsall, D. J. (2007). Unilateral retinal hemorrhages in shaken baby syndrome. Journal of AAPOS, 11(2), 175–178. doi: 10.1016/j.jaapos.2006.09.023.PubMedCrossRefGoogle Scholar
  3. Bechtel, K., Stoessel, K., Leventhal, J. M., Ogle, E., Teague, B., Lavietes, S., & Duncan, C. (2004). Characteristics that distinguish accidental from abusive injury in hospitalized young children with head trauma. Pediatrics, 114(1), 165–168.PubMedCrossRefGoogle Scholar
  4. Betz, P., Puschel, K., Miltner, E., Lignitz, E., & Eisenmenger, W. (1996). Morphometrical analysis of retinal hemorrhages in the shaken baby syndrome. Forensic Science International, 78(1), 71–80.PubMedCrossRefGoogle Scholar
  5. Bhardwaj, G., Chowdhury, V., Jacobs, M. B., Moran, K. T., Martin, F. J., & Coroneo, M. T. (2010). A systematic review of the diagnostic accuracy of ocular signs in pediatric abusive head trauma. Ophthalmology, 117(5), 983–992 e917. doi: 10.1016/j.ophtha.2009.09.040.PubMedCrossRefGoogle Scholar
  6. Bielory, B. P., Dubovy, S. R., Olmos, L. C., Hess, D. J., & Berrocal, A. M. (2012). Fluorescein angiographic and histopathologic findings of bilateral peripheral retinal nonperfusion in nonaccidental injury: A case series. Archives of Ophthalmology, 130(3), 383–387. doi: 10.1001/archopthalmol.2011.1674.PubMedCrossRefGoogle Scholar
  7. Binenbaum, G., Mirza-George, N., Christian, C. W., & Forbes, B. J. (2009). Odds of abuse associated with retinal hemorrhages in children suspected of child abuse. Journal of AAPOS, 13(3), 268–272. doi: 10.1016/j.jaapos.2009.03.005.PubMedPubMedCentralCrossRefGoogle Scholar
  8. Binenbaum, G., Christian, C. W., Ichord, R. N., Ying, G. S., Simon, M. A., Romero, K., & Forbes, B. J. (2013). Retinal hemorrhage and brain injury patterns on diffusion-weighted magnetic resonance imaging in children with head trauma. Journal of AAPOS, 17(6), 603–608. doi: 10.1016/j.jaapos.2013.09.002.PubMedCrossRefGoogle Scholar
  9. Binenbaum, G., Chen, W., Huang, J., Ying, G. S., & Forbes, B. J. (2016). The natural history of retinal hemorrhage in pediatric head trauma. Journal of AAPOS, 20(2), 131–135. doi: 10.1016/j.jaapos.2015.12.008.PubMedCrossRefGoogle Scholar
  10. Breazzano, M. P., Unkrich, K. H., & Barker-Griffith, A. E. (2014). Clinicopathological findings in abusive head trauma: Analysis of 110 infant autopsy eyes. American Journal of Ophthalmology, 158(6), 1146–1154 e1142. doi: 10.1016/j.ajo.2014.08.011.PubMedCrossRefGoogle Scholar
  11. Burkhart, Z. N., Thurber, C. J., Chuang, A. Z., Kumar, K. S., Davis, G. H., & Kellaway, J. (2015). Risk factors associated with retinal hemorrhage in suspected abusive head trauma. Journal of AAPOS, 19(2), 119–123. doi: 10.1016/j.jaapos.2014.12.007.PubMedPubMedCentralCrossRefGoogle Scholar
  12. DeRidder, C. A., Berkowitz, C. D., Hicks, R. A., & Laskey, A. L. (2013). Subconjunctival hemorrhages in infants and children: A sign of nonaccidental trauma. Pediatric Emergency Care, 29(2), 222–226. doi: 10.1097/PEC.0b013e318280d663.PubMedCrossRefGoogle Scholar
  13. Friendly, D. S. (1971). Ocular manifestations of physical child abuse. Trans Am Acad Ophthalmol Otolaryngol, 75(2), 318–332.PubMedGoogle Scholar
  14. Gilles, E. E., McGregor, M. L., & Levy-Clarke, G. (2003). Retinal hemorrhage asymmetry in inflicted head injury: A clue to pathogenesis? The Journal of Pediatrics, 143(4), 494–499. doi: 10.1067/S0022-3476(03)00416-5.PubMedCrossRefGoogle Scholar
  15. Gilliland, M. G., Levin, A. V., Enzenauer, R. W., Smith, C., Parsons, M. A., Rorke-Adams, L. B., The Brody School of Medicine at East Carolina, U. (2007). Guidelines for postmortem protocol for ocular investigation of sudden unexplained infant death and suspected physical child abuse. The American Journal of Forensic Medicine and Pathology, 28(4), 323–329. doi: 10.1097/PAF.0b013e31815b4c00.
  16. Goldenberg, D. T., Wu, D., Capone Jr., A., Drenser, K. A., & Trese, M. T. (2010). Nonaccidental trauma and peripheral retinal nonperfusion. Ophthalmology, 117(3), 561–566. doi: 10.1016/j.ophtha.2009.08.013.PubMedCrossRefGoogle Scholar
  17. Kivlin, J. D., Simons, K. B., Lazoritz, S., & Ruttum, M. S. (2000). Shaken baby syndrome. Ophthalmology, 107(7), 1246–1254.PubMedCrossRefGoogle Scholar
  18. Levin, A. V. (1990). Ocular manifestations of child abuse. Ophthalmology Clin N AM, 3, 249–264.Google Scholar
  19. Levin, A. V. (2000). Retinal haemorrhages and child abuse. Recent Advances in Paediatrics, 18, 151–219.Google Scholar
  20. Levin, A. V. (2006). Retinal hemorrhages of crush head injury: Learning from outliers. Archives of Ophthalmology, 124(12), 1773–1774. doi: 10.1001/archopht.124.12.1773.PubMedCrossRefGoogle Scholar
  21. Levin, A. V. (2010). Retinal hemorrhage in abusive head trauma. Pediatrics, 126(5), 961–970. doi: 10.1542/peds.2010-1220.PubMedCrossRefGoogle Scholar
  22. Levin, A. V., Christian, C. W., Committee on Child, A.,, & Neglect, S. o. O. (2010). The eye examination in the evaluation of child abuse. Pediatrics, 126(2), 376–380. doi: 10.1542/peds.2010-1397.PubMedCrossRefGoogle Scholar
  23. Maguire, S., Pickerd, N., Farewell, D., Mann, M., Tempest, V., & Kemp, A. M. (2009). Which clinical features distinguish inflicted from non-inflicted brain injury? A systematic review. Archives of Disease in Childhood, 94(11), 860–867. doi: 10.1136/adc.2008.150110.PubMedCrossRefGoogle Scholar
  24. Maguire, S. A., Watts, P. O., Shaw, A. D., Holden, S., Taylor, R. H., Watkins, W. J., & Kemp, A. M. (2013). Retinal haemorrhages and related findings in abusive and non-abusive head trauma: A systematic review. Eye (London, England), 27(1), 28–36. doi: 10.1038/eye.2012.213.CrossRefGoogle Scholar
  25. McCabe, C. F., & Donahue, S. P. (2000). Prognostic indicators for vision and mortality in shaken baby syndrome. Archives of Ophthalmology, 118(3), 373–377.PubMedCrossRefGoogle Scholar
  26. Morad, Y., Kim, Y. M., Armstrong, D. C., Huyer, D., Mian, M., & Levin, A. V. (2002). Correlation between retinal abnormalities and intracranial abnormalities in the shaken baby syndrome. American Journal of Ophthalmology, 134(3), 354–359.PubMedCrossRefGoogle Scholar
  27. Morad, Y., Kim, Y. M., Mian, M., Huyer, D., Capra, L., & Levin, A. V. (2003). Nonophthalmologist accuracy in diagnosing retinal hemorrhages in the shaken baby syndrome. The Journal of Pediatrics, 142(4), 431–434. doi: 10.1067/mpd.2003.161.PubMedCrossRefGoogle Scholar
  28. Morad, Y., Avni, I., Benton, S. A., Berger, R. P., Byerley, J. S., Coffman, K., & Levin, A. V. (2004a). Normal computerized tomography of brain in children with shaken baby syndrome. Journal of AAPOS, 8(5), 445–450. doi: 10.1016/S1091853104001284.PubMedCrossRefGoogle Scholar
  29. Morad, Y., Avni, I., Capra, L., Case, M. E., Feldman, K., Kodsi, S. R., & Levin, A. V. (2004b). Shaken baby syndrome without intracranial hemorrhage on initial computed tomography. Journal of AAPOS, 8(6), 521–527. doi: 10.1016/j.jaapos.2004.07.009.PubMedCrossRefGoogle Scholar
  30. Muni, R. H., Kohly, R. P., Charonis, A. C., & Lee, T. C. (2010). Retinoschisis detected with handheld spectral-domain optical coherence tomography in neonates with advanced retinopathy of prematurity. Archives of Ophthalmology, 128(1), 57–62. doi: 10.1001/archophthalmol.2009.361.PubMedCrossRefGoogle Scholar
  31. Pierre-Kahn, V., Roche, O., Dureau, P., Uteza, Y., Renier, D., Pierre-Kahn, A., & Dufier, J. L. (2003). Ophthalmologic findings in suspected child abuse victims with subdural hematomas. Ophthalmology, 110(9), 1718–1723. doi: 10.1016/S0161-6420(03)00581-5.PubMedCrossRefGoogle Scholar
  32. Rangarajan, N., Kamalakkannan, S. B., Hasija, V., Shams, T., Jenny, C., Serbanescu, I., & Levin, A. V. (2009). Finite element model of ocular injury in abusive head trauma. Journal of AAPOS, 13(4), 364–369. doi: 10.1016/j.jaapos.2008.11.006.PubMedCrossRefGoogle Scholar
  33. Schoenfeld, A., Buckman, G., Nissenkorn, I., Cohen, S., Ben-Sira, I., & Ovadia, J. (1985). Retinal hemorrhages in the newborn following labor induced by oxytocin or dinoprostone. Archives of Ophthalmology, 103(7), 932–934.PubMedCrossRefGoogle Scholar
  34. Sturm, V., Landau, K., & Menke, M. N. (2008). Optical coherence tomography findings in shaken baby syndrome. American Journal of Ophthalmology, 146(3), 363–368. doi: 10.1016/j.ajo.2008.04.023.PubMedCrossRefGoogle Scholar
  35. Togioka, B. M., Arnold, M. A., Bathurst, M. A., Ziegfeld, S. M., Nabaweesi, R., Colombani, P. M., & Abdullah, F. (2009). Retinal hemorrhages and shaken baby syndrome: An evidence-based review. The Journal of Emergency Medicine, 37(1), 98–106. doi: 10.1016/j.jemermed.2008.06.022.PubMedCrossRefGoogle Scholar
  36. Vincent, A. L., & Kelly, P. (2010). Retinal haemorrhages in inflicted traumatic brain injury: The ophthalmologist in court. Clinical & Experimental Ophthalmology, 38(5), 521–532. doi: 10.1111/j.1442-9071.2010.02324.x.CrossRefGoogle Scholar
  37. Watts, P., Maguire, S., Kwok, T., Talabani, B., Mann, M., Wiener, J., & Kemp, A. (2013). Newborn retinal hemorrhages: A systematic review. Journal of AAPOS, 17(1), 70–78. doi: 10.1016/j.jaapos.2012.07.012.PubMedCrossRefGoogle Scholar
  38. Wygnanski-Jaffe, T., Levin, A. V., Shafiq, A., Smith, C., Enzenauer, R. W., Elder, J. E., & Atenafu, E. (2006). Postmortem orbital findings in shaken baby syndrome. American Journal of Ophthalmology, 142(2), 233–240. doi: 10.1016/j.ajo.2006.03.038.PubMedCrossRefGoogle Scholar
  39. Wygnanski-Jaffe, T., Murphy, C. J., Smith, C., Kubai, M., Christopherson, P., Ethier, C. R., & Levin, A. V. (2007). Protective ocular mechanisms in woodpeckers. Eye (London, England), 21(1), 83–89. doi: 10.1038/sj.eye.6702163.CrossRefGoogle Scholar
  40. Yamazaki, J., Yoshida, M., & Mizunuma, H. (2014). Experimental analyses of the retinal and subretinal haemorrhages accompanied by shaken baby syndrome/abusive head trauma using a dummy doll. Injury, 45(8), 1196–1206. doi: 10.1016/j.injury.2014.04.014.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2016

Authors and Affiliations

  • Alex V. Levin
    • 1
    • 2
  • Francois M. Luyet
    • 3
    • 4
  • Barbara L. Knox
    • 3
    • 4
  1. 1.Pediatric Ophthalmology and Ocular GeneticsWills Eye HospitalPhiladelphiaUSA
  2. 2.Departments of Ophthalmology and PediatricsSidney Kimmel Medical College at Thomas Jefferson UniversityPhiladelphiaUSA
  3. 3.Department of PediatricsUniversity of Wisconsin School of Medicine and Public HealthMadisonUSA
  4. 4.UW Child Protection ProgramUniversity of Wisconsin American Family Children’s HospitalMadisonUSA

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