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Inflicted childhood neurotrauma (shaken baby syndrome) ophthalmic findings


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Inflicted childhood neurotrauma (shaken baby syndrome) ophthalmic findings

  1. 1. Review Article Inflicted Childhood Neurotrauma (Shaken Baby Syndrome): Ophthalmic Findings Brian J. Forbes, MD, PhD; Cindy W. Christian, MD; Alexander R. Judkins, MD; and Kasia Kryston, BS ABSTRACT EDUCATIONAL OBJECTIVES Inflicted childhood neurotrauma (shaken baby syn- drome) is the term used for violent, nonaccidental, 1. To summarize the ophthalmic literature repetitive, unrestrained acceleration–deceleration related to inflicted childhood neurotrauma head and neck movements, with or without blunt to review not only the ocular findings, but head trauma, combined with a unique, age-related also the associated systemic and psychoso- biomechanical sensitivity in children typically cial findings in the syndrome. younger than 3 years. This syndrome is typically characterized by a combination of fractures, 2. To identify the limited differential diagno- intracranial hemorrhages, and intraocular hemor- sis of retinal hemorrhages in the case of a rhages. Retinal hemorrhage is the most common small child or infant. ophthalmic finding, and usually occurs at all levels 3. To recognize the important role of the oph- of the retina. In recent years, increasing pressure has thalmologist in the evaluation of victims of been placed on ophthalmologists to render diagnos- inflicted childhood neurotrauma. Dr. Forbes and Ms. Kryston are from the Department of Ophthalmology; See quiz on page 105; no payment required. Dr. Christian is from the Department of Pediatrics; and Dr. Judkins is from the Department of Pathology, The Children’s Hospital of Philadelphia, University of Pennsylvania, Philadelphia, Pennsylvania. Originally submitted October 26, 2003. Accepted for publication December 11, 2003. tic interpretations of the retinal findings in children Address reprint requests to Brian Forbes, MD, PhD, Department of suspected to be victims, which may have great Ophthalmology, Ninth Floor Main Building, The Children’s Hospital of forensic implications in criminal proceedings. New Philadelphia, 34th and Civic Center Blvd., Philadelphia, PA 19104. The authors have no industry relationships to disclose. research has increased our understanding of the In accordance with ACCME policies, the audience is advised that this pathophysiology of retinal hemorrhages, the impor- continuing medical education activity may contain references to unlabeled tance of specifically characterizing the types, pat- uses of FDA-approved products or to products not approved by the FDA for terns, and extent of these retinal hemorrhages, and use in the United States. The faculty members have been made aware of their obligation to disclose such usage. the differential diagnosis. J Pediatr Ophthalmol The material presented at or in any SLACK Incorporated continuing Strabismus 2004;41:80-88. medical education activities does not necessarily reflect the views and opinions of SLACK Incorporated. Neither SLACK Incorporated nor the faculty endorse or recommend any techniques, commercial products, or manufactur- INTRODUCTION ers. The faculty/authors may discuss the use of materials and/or products that have not yet been approved by the U.S. Food and Drug Administration. All Homicide is the leading cause of injury and readers and continuing education participants should verify all information before treating patients or utilizing any product. death in infancy, and half of all infant homicides 80 MARCH/APRIL 2004/VOL 41 • NO 2
  2. 2. occur during the first 4 months of life.1,2 Eighty TABLE percent of infant homicides are thought to represent COMMON PRESENTATIONS OF CHILDREN WITH child abuse, and each day in the United States, more INFLICTED CHILDHOOD NEUROTRAUMA than 3 children die as a result of child abuse. Most Upper respiratory infection symptoms of these deaths are caused by inflicted neurotrauma, Diarrhea which results from violent, nonaccidental shaking, Fever blunt impact to the head, or both. Historically, the Vomiting injuries resulting from repetitive unrestrained head Colic Irritability and neck movements from shaking were termed the Lethargy “whiplash shaken infant syndrome,” which is cur- Startling episodes rently commonly referred to as the “shaken baby Apnea syndrome.”3 Bulging fontanelle The most difficult and controversial aspect of History of minor trauma Poor feeding the diagnosis of shaken baby syndrome is the bio- Failure to thrive mechanical implication of this term. Although Seizures confessions are obtained in a few cases and the reliability of such confessions must be considered suspect, those perpetrators who have confessed support the prominence of repetitive violent evidence of direct blows to the eye. Skeletal frac- shaking as the key element in the generation of tures are found in 30% to 70% of injured chil- shaken baby syndrome. One landmark study sug- dren, and retinal hemorrhages are seen in approxi- gested that impact trauma in addition to shaking mately 80%.5-14 was required to generate the level of force needed Victims of inflicted childhood neurotrauma for an infant to sustain brain injury.4 Most are generally younger than 3 years, and most are infants with severe brain injury due to abuse have infants. The clinical presentation reflects the sever- clinical or autopsy evidence of blunt impact trau- ity of the injury, and this ranges from mild lethar- ma, and some biomechanical data suggest that gy or irritability to acute life-threatening events, impact is necessary for injury.4 Ultimately, the unexplained seizures, or coma. Falls in childhood contributions of shaking versus impact in the are the most common reason for emergency pathogenesis of this syndrome are debated, lead- department visits and hospital admissions; the ing clinicians and researchers to favor more table outlines the most common reasons that chil- generic terms for the injuries identified from dren who are eventually diagnosed as having inflicted head trauma. Some have suggested the inflicted childhood neurotrauma present to a syndrome be renamed “shaken impact syn- physician.15 In a review of missed cases of inflicted drome,” whereas others have suggested “inflicted childhood neurotrauma, viral gastroenteritis was traumatic brain injury” or “inflicted childhood the most common incorrect diagnosis made, fol- neurotrauma.” As inflicted childhood neurotrau- lowed by unintentional injury.15 When physicians ma was the favored term at a recent National misdiagnose inflicted injury as either unintention- Institutes of Health conference of leading investi- al trauma or a medical disease, approximately 25% gators in the field, it will be used throughout this of infants will sustain further injury before the cor- text. rect diagnosis is made. The consequences of Clinical findings in affected infants include missing abuse are more dangerous to a child than subdural hemorrhage, hypoxic–ischemic brain falsely accusing a family of abuse, although under- injury, retinal hemorrhages, skeletal injuries, and diagnosis and overdiagnosis have unacceptable cutaneous or other injuries. The frequency with consequences for both the children and their which noncranial injuries are identified varies by families. age and presentation, and skeletal or cutaneous Approximately one-third of injured infants are injuries are not necessary for diagnosis. Unlike misdiagnosed at the time of initial presentation, most other forms of ocular trauma, there are usu- especially those who are young, have mild injuries, ally minimal external ocular signs of injury and no or live in nonminority, 2-parent households.16 JOURNAL OF PEDIATRIC OPHTHALMOLOGY & STRABISMUS 81
  3. 3. Figure 2. Race of victims, 2001. Figure 1. Percentage of victims by age group, 2001. Figure 4. Perpetrators in criminal cases of abusive head trauma. Figure 3. Type of maltreatment of victims, 2001. criminal cases of abusive head trauma are outlined in Figure 4.22 Victims of inflicted childhood neurotrauma are ACUTE OPHTHALMIC FINDINGS IN younger (mean, 12.8 vs 27.5 months), more likely INFLICTED CHILDHOOD NEUROTRAUMA to have a history of medical problems (53% vs 14.1%), and 7 times more likely to have been born Autopsy and in vivo studies of the acute ocular prematurely (2.2% vs 0.07%) than are children findings in infants and toddlers younger than 3 with accidental neurotrauma.17 It has also been years with nonaccidental head injury from inflicted suggested that racial differences exist in the evalu- childhood neurotrauma have described a consistent ation and reporting of patients with fractures for clinical picture. These characteristic ophthalmic child abuse, particularly in toddlers with acciden- findings include intraocular hemorrhage with a tal injuries.18 In an effort to improve the early reported frequency of 50% to 100%, with most identification of abused infants, funduscopy to studies having reported approximately 80%.6-14 look for retinal hemorrhages has been advocated Retinal hemorrhage occurs at all levels of the retina, with some success in hospitals to evaluate infants including blot, flame-shaped, and preretinal hemor- who present with acute life-threatening events.19,20 rhage as well as vitreous hemorrhage. Retinal hem- No medical condition fully mimics the clinical fea- orrhages can be few in number, exclusively intrareti- tures of inflicted childhood neurotrauma, nal, and confined to the posterior pole, although although intracranial and retinal bleeding can they often are too numerous to count, are present at sometimes be seen in accidental injury, coagulopa- all layers, and extend to the ora serrata (Fig. 5). thy, and rare metabolic diseases. A detailed eye Dense preretinal or vitreous hemorrhages may examination is necessary to completely assess the obscure underlying retinal hemorrhage. presence and extent of intraocular injury in this The frequency of retinal hemorrhage is high- syndrome and to differentiate it from other med- est in autopsy cases and lowest in intact survivors, ical problems. and typically, hemorrhages are present in both In 2001, an estimated 903,000 children were eyes, although asymmetry and unilaterality are abused or neglected; Figures 1 to 3 outline the more well recognized (Fig. 6). Papilledema occurs in common characteristics of these children and the less than 10% of cases.23 Both optic nerve sheath type of abuse that occurred.21 The perpetrators in and intraocular hemorrhages are frequently 82 MARCH/APRIL 2004/VOL 41 • NO 2
  4. 4. A Figure 5. Wide-angle funduscopic photograph showing the ocu- lar fundus of an infant with acute inflicted childhood neurotrau- ma. Subretinal, intraretinal, and preretinal hemorrhages and optic disc hemorrhages are visible. reported findings in postmortem examinations of victims of inflicted childhood neurotrauma (Fig. 7A). Optic nerve sheath hemorrhages frequently involve multiple layers, but often show a prepon- derance of hemorrhage in the subdural space (Figs. 7B and 7C). Intraocular hemorrhages can involve vitreous, preretinal, intraretinal, and sub- retinal compartments. Retinal hemorrhages may B involve all layers (Fig. 7D) or may be more Figure 6. (A) Right and (B) left funduscopic photographs restricted in distribution depending on the sever- showing marked asymmetry in the degree of hemorrhaging ity of injury.24 present. Retinoschisis may occur, most often in the macular area but also peripherally. Ophthalmoscopically, there is a dense central hem- inflicted childhood neurotrauma are neither con- orrhage surrounded by a pale, elevated retinal fold sistent nor specific to inflicted childhood neuro- in a circular shape. These lesions, seen both trauma. Permanent visual impairment is frequent, histopathologically and clinically, have also been and central visual impairment related to the called “hemorrhagic macula cysts” and “perimacu- hypoxic ischemic brain injury from inflicted child- lar circular folds,”25-28 and have a unique and char- hood neurotrauma and optic atrophy is the most acteristic appearance seen only rarely in other common cause of long-term reduced vision. types of head trauma.26 Macular retinoschisis with Amblyopia caused by visual deprivation due to or without perimacular folds has been well docu- prolonged vitreous hemorrhage may occur.21 mented clinically, at postmortem examination, Optic disc pallor, optic atrophy, nonspecific retinal and by electroretinography as a distinctive finding pigmentary changes, macular hole, vitreous opaci- that has not been reported due to any other cause ties, retinal thinning, and high myopia may also be in children younger than 5 years.28 seen in survivors of inflicted childhood neurotrau- ma (Fig. 8).21,29,30 LATE OPHTHALMIC FINDINGS IN INFLICTED The age of an intraocular hemorrhage is diffi- CHILDHOOD NEUROTRAUMA cult to assess clinically. It is assumed that the hem- orrhages occur immediately at the time of injury. In contrast to the dramatic and relatively spe- Some evolution, including the darkening of the cific acute findings, late changes associated with retinal hemorrhages, organization of the vitreous JOURNAL OF PEDIATRIC OPHTHALMOLOGY & STRABISMUS 83
  5. 5. A B C D Figure 7. (A) The right and left eyes of a 7-week-old battered infant displaying striking optic nerve sheath hemorrhages, most promi- nent at the junction of the globe and optic nerve. (B) Low-magnification photomicrograph of a section of the optic nerve coming into the posterior globe. Note the acute hemorrhage in the subdural space on both sides of the optic nerve (arrowhead), projec- tion of the optic nerve head into the posterior chamber, and massive hemorrhage in all layers of the retina (arrow). (C) Higher mag- nification of the region indicated by the arrow in B, showing acute subdural hemorrhage with intradural extension along the course of the optic nerve. The nerve is in the upper half of the photomicrograph and is cut longitudinally. (D) Higher magnification of the region indicated by the arrow in B, showing massive retinal hemorrhage with bleeding into all layers of the retina with frank clot formation. Also note the accumulation of subretinal edema with scattered acute hemorrhages in the lower half of the figure. (Photographs contributed by Dr. Lucy B. Rorke.) hemorrhages, and disappearance of the retinal DIFFERENTIAL DIAGNOSIS OF RETINAL hemorrhages, occurs gradually during 2 to 4 weeks HEMORRHAGES IN INFANCY following the acute injury. There are many systemic and ocular conditions PROGNOSTIC VALUE OF OPHTHALMIC that may be associated with retinal hemorrhages, FINDINGS although the absence of supportive findings on ocu- lar examination, physical examination, history, or In addition to the diagnostic significance of acute laboratory evaluation make their consideration and late ophthalmic manifestations of inflicted child- equivocal. Retinal hemorrhages are known to be hood neurotrauma, several ocular findings have prog- rare in children with the conditions described nostic significance. The extent of intraocular hemor- below. When they do occur, they are few in number, rhage, presence of macular retinoschisis lesions, and are confined to the posterior pole, or have other rec- presence of pupillary abnormalities has been correlat- ognizable unique features. Again, many of these ed with a fatal outcome and permanent neurologic entities are readily excluded from the differential impairment.28,31-36 The correlation between the sever- diagnosis on the basis of history or physical exami- ity of the ocular injury and the neurologic outcome nation. suggests a relationship between the brain and ocular Idiopathic retinal hemorrhages of newborns, injuries in inflicted childhood neurotrauma. related to obstetric and perinatal hemodynamic 84 MARCH/APRIL 2004/VOL 41 • NO 2
  6. 6. changes, are frequent. Retinal hemorrhages sec- ondary to a normal birth have been extensively stud- ied both retrospectively and prospectively in tens of thousands of infants. From these data, it can be con- cluded that superficial retinal hemorrhages resolve by 1 week postpartum and deeper retinal hemor- rhages resolve by 6 weeks. However, these typically small hemorrhages with relatively few nerve fiber layers are present only during the first 2 to 3 weeks of life, and are distinguished by their exclusively pos- terior location and small size and number.37,38 Retinal hemorrhages have also been reported in association with severe accidental injury. Because many patients with nonaccidental injury present with a history of minor trauma, the threshold for retinal hemorrhage in accidental head trauma is important in consideration of the differential diag- Figure 8. Wide-angle funduscopic photograph showing an ocu- nosis. Multiple clinical and postmortem studies of lar fundus. Close inspection of the macula shows a macular hole eyes of patients with severe head injury suggest that in an infant with previous inflicted childhood neurotrauma. the rate of retinal hemorrhage is less than 3% of Myelinated optic nerve fibers are also present. instances.39-42 When retinal hemorrhages do occur, they are confined to the posterior pole, few in num- ber, and rarely subretinal. The types of accidental trauma that result in retinal hemorrhages are usual- Terson’s syndrome (ie, retinal hemorrhages ly severe, life-threatening injuries. Even with severe associated with subarachnoid hemorrhage) is well head and brain injuries sufficient for hospitaliza- recognized in adults, although it appears to be tion, retinal hemorrhage is quite uncommon.36,39-42 uncommon in children. The lack of correlation Many infants with severe abusive head injury between the side of involvement of the subarach- have cardiopulmonary resuscitation including chest noid hemorrhage and ocular hemorrhage suggests compressions and artificial ventilation. Retinal that this is not a sufficient explanation for the reti- hemorrhages have been seen after prolonged car- nal hemorrhages seen in inflicted childhood neu- diopulmonary resuscitation, but never as numer- rotrauma. Retinal hemorrhage has been found to ously or extensively as in inflicted childhood neuro- be uncommon in children with intracranial hem- trauma.43-46 It can be concluded from case reports orrhage from causes other than inflicted childhood and prospective studies that retinal hemorrhages neurotrauma, and the retinal hemorrhages are not occur only rarely from cardiopulmonary resuscita- in a pattern or quantity consistently found in tion, and when they do, they are few in number and inflicted childhood neurotrauma.48,49 confined to the posterior pole. There is no evidence to support a link between Purtscher’s retinopathy may occur following immunizations and retinal hemorrhages in chil- acute compression injuries to the thorax or head dren.50,51 with characteristic manifestations including cotton Coagulopathies and other bleeding disorders, wool spots, retinal hemorrhages, and retinal edema including thrombocytopenia, anemia, leukemia, most commonly surrounding the optic disc. factor deficiencies, and vitamin K deficiency, as well Purtscher’s retinopathy, which is probably caused as metabolic diseases such as glutaric acidemia must by complement-mediated leukoembolization, is be considered in the differential diagnosis of uncommon in inflicted childhood neurotrauma, intraocular hemorrhage in infants. In general, reti- and the retinal hemorrhages in inflicted childhood nal hemorrhages related to hematologic abnormali- neurotrauma do not appear to be correlated to the ties are less numerous and less extensive and do not presence or absence of rib fractures, a sign of severe extend peripherally in the retina. However, infants chest compression.47 with bleeding disorders such as a vitamin K defi- JOURNAL OF PEDIATRIC OPHTHALMOLOGY & STRABISMUS 85
  7. 7. ciency have been incorrectly diagnosed as victims of itself, with resultant shearing injury, that is the pri- abuse. Retinoschisis lesions have not been reported mary factor in the generation of retinal hemor- in these conditions. A basic hematologic evaluation rhages seen in inflicted childhood neurotrauma. including complete blood cell count and coagula- The optic atrophy often seen in survivors is best tion studies should be performed in all suspected explained by direct optic nerve injury within the cases of inflicted childhood neurotrauma.52 Other orbit. The role of vitreous traction and tissue shear- ocular syndromes associated with retinal hemor- ing must be further explored. Postmortem orbital rhage in childhood, including Norrie’s disease, findings suggest a role for autonomic dysregulation Coats’ disease, persistent hyperplastic primary vitre- and direct vessel damage that is yet to be explored. ous, hypotony retinopathy, cytomegalovirus retini- The compounding effects of anoxia or hypoxia, tis, toxoplasmosis, and retinopathy of prematurity, anemia, thrombocytopenia, mild coagulopathy, are usually easily distinguished from nonaccidental obstruction of retinal venous flow, or possible age- head injury by the distinctive clinical appearance as related anatomic variations in the retinal vascula- well as the clinical setting. ture are not well understood. The adjunctive role of increased intracranial pressure needs further explo- PATHOPHYSIOLOGY OF RETINAL ration. Although the role of vitamin C deficiency HEMORRHAGES IN INFLICTED CHILDHOOD has been suggested exclusively in lay and legal liter- NEUROTRAUMA ature, it has not been formally explored, and vita- min C deficiency is currently rare. The minimal Many theories regarding the cause of retinal forces required to generate retinal hemorrhages or, hemorrhages in inflicted childhood neurotrauma more specifically, the reason why shaking seems to continue to be debated in the literature. One theo- be unique in the generation of severe retinal hem- ry postulates that venous obstruction in the retina orrhages is not known. occurring from increased intracranial pressure due to cerebral edema and subdural hemorrhage is the CONTROVERSIES IN THE DIAGNOSIS AND source of retinal hemorrhages. Sudden increases in MANAGEMENT OF INFLICTED CHILDHOOD chest or head pressure may be contributing factors NEUROTRAUMA as well. Another theory postulates that traction of the vitreous on the retina during the acceleration The most difficult and controversial aspect of and deceleration of shaking and impact causes cir- the diagnosis of inflicted childhood neurotrauma is cular retinal folds and hemorrhagic retinoschisis the reliability of the designation. Physicians are cavities, as well as smaller hemorrhages. Subdural rarely in a position to make a diagnosis with such hemorrhages in inflicted childhood neurotrauma profound significance to patients and their families. are thought to be caused by the shearing of small Ascertainment of child abuse is critical to prevent a vessels from inertial injury, most likely due to rapid potentially fatal recurrence in victims. Extensive acceleration or deceleration movements. intraocular hemorrhage in young infants in the set- The correlation between the severity of ting of acute brain injury and in the absence of a intraocular and intracranial injury and histopatho- history of severe accidental trauma or underlying logic evidence suggests that similar inertial trauma medical cause must be considered to be nonacci- may lead to shearing within the retina and at areas dental injury until proven otherwise. of the retina–vitreous attachment, leading to the The management of acute intraocular hemor- funduscopic lesions seen. The role of vitreous shak- rhages is primarily supportive. Gradual resolution is ing in the generation of macular retinoschisis and generally seen in 2 to 6 weeks, although dense pre- perimacular folds has strong support in theory and retinal and vitreous hemorrhage may persist much in autopsy findings. The high frequency of hemor- longer. With prolonged vitreous clouding, young rhages at the vitreous base supports a theoretical children do have a risk of deprivational amblyopia. link to vitreous traction. Orbital shaking injury, In rare cases of prolonged vitreous opacity, surgical including disruption of the autonomic supply to vitrectomy may be necessary to allow normal visual the retinal vessels, may play a role. development. Survivors of inflicted childhood neu- The literature suggests that it is the shaking rotrauma must be reexamined for amblyopia, 86 MARCH/APRIL 2004/VOL 41 • NO 2
  8. 8. 5. Lazoritz S, Baldwin S, Kini N. The whiplash shaken infant syn- refractive errors, and other late complications that drome: has Caffey’s syndrome changed or have we changed his require treatment. syndrome? Child Abuse Negl 1997;21:1009-1014. 6. Merten DF, Osborne DRS, Radkowski MA, et al. Craniocerebral trauma in the child abuse syndrome: radiological observations. ROLE OF THE OPHTHALMOLOGIST IN THE Pediatr Radiol 1984;14:272-277. DIAGNOSIS AND MANAGEMENT OF 7. Levin A. Ocular manifestations of child abuse. Ophthalmol Clin North Am 1990;3:249-264. INFLICTED CHILDHOOD NEUROTRAUMA 8. Harcourt B, Hopkins D. Ophthalmic manifestations of the bat- tered-baby syndrome. Br Med J 1971;3:398-401. 9. Ober RR. Hemorrhagic retinopathy in infancy: a clinicopatho- Inflicted childhood neurotrauma is a clinical logic report. J Pediatr Ophthalmol Strabismus 1980;17:5-13. pattern of nonaccidental injuries including intracra- 10. Rao N, Smith RE, Choi JH, et al. Autopsy findings in the eyes of fourteen fatally abused children. Forensic Sci Int 1988;39:293-299. nial and intraocular hemorrhage occurring in 11. Green MA, Lieberman G, Milroy CM, Parsons MA. Ocular and infants and toddlers younger than 3 years. cerebral trauma in non-accidental injury in infancy: underlying mechanisms and implications for paediatric practice. Br J Examination of the eyes through undilated pupils Ophthalmol 1996;80:282-287. with a direct ophthalmoscope is inadequate for a 12. Altman RL, Kutscher MO, Brand DA. The “shaken-baby complete evaluation of the ocular findings in inflict- syndrome.” N Engl J Med 1998;339:1329-1330. 13. Duhaime AC, Christian CW, Rorke LB, Zimmerman RA. ed childhood neurotrauma. The primary role of the Nonaccidental head injury in infants: the “shaken baby syn- ophthalmologist in the care of these young children drome.” N Engl J Med 1998;338:1822-1829. 14. Kivlin JD, Simons KB, Laxoritz A, Ruttum MS. Shaken baby is to provide a complete evaluation of the intraocu- syndrome. Ophthalmology 2000;107:1246-1254. lar hemorrhages. Ophthalmic consultation allows 15. Rivera F. Population-based study of fall injuries in children and adolescents resulting in hospitalization or death. Pediatrics complete assessment and documentation of the 1993;92:61-63. ocular findings frequently with retinal photography, 16. Jenny C, Hymel KP, Ritzen A, et al. Analysis of missed cases of abusive head trauma. JAMA 1999;281:621-626. an essential component of the diagnosis of inflicted 17. DiScala C, Sege R, Li G, Reece RM. Child abuse and uninten- childhood neurotrauma. In addition to establishing tional injuries: a ten-year retrospective. Arch Pediatr Adolesc Med the diagnosis, examination provides prognostic 2000;154:16-22. 18. Lane WG, Rubin DM, Monteith R, Christian CW. Racial differ- information related to the ocular findings. ences in the evaluation of pediatric fractures for physical abuse. 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  9. 9. head injury. Arch Dis Child 1997;77:504-507. 42. Christian CW, Taylor AA, Hertle RW, Duhaime AC. Retinal 33. Matthews GP, Das A. Dense vitreous hemorrhages predict poor hemorrhages caused by accidental household trauma. J Pediatr visual and neurological prognosis in infants with shaken baby 1999;135:125-127. syndrome. J Pediatr Ophthalmol Strabismus 1996;33:260-265. 43. Goetting MG, Sowa B. Retinal hemorrhage after cardiopul- 34. McCabe CF, Donahue SP. Prognostic indicators for vision and monary resuscitation in children: an etiologic reevaluation. mortality in shaken baby syndrome. Arch Ophthalmol Pediatrics 1990;85:585-588. 2000;118:373-377. 44. Kramer K, Goldstein B. Retinal hemorrhages following car- 35. Wilkenson WS, Han DP, Rappley MD, Owings CL. Retinal diopulmonary resuscitation. Clin Pediatr 1993;32:366-368. hemorrhage predicts neurologic injury in the shaken baby syn- 45. Gilliland MGF, Luckenbach MW. Are retinal hemorrhages found drome. Arch Ophthalmol 1989;107:1472-1474. after resuscitation attempts? A study of the eyes of 169 children. 36. Duhaime AC, Alario AJ, Lewander WJ, Schut L, et al. Head Am J Forensic Med Pathol 1993;14:187-192. injury in very young children: mechanisms, injury types and oph- 46. Odom A, Christ E, Kerr N, et al. Prevalence of retinal hemor- thalmic findings in 100 hospitalized patients younger than 2 years rhages in pediatric patients after in-hospital cardiopulmonary of age. Pediatrics 1992;90:179-185. resuscitation: a prospective study. Pediatrics 1997;99:E3. 37. Kaur B, Taylor D. Fundus hemorrhages in infancy. Surv 47. Duane T, Osher R, Green W. White centered hemorrhages: their Ophthalmol 1992;37:1-17. significance. Ophthalmology 1980;87:66-69. 38. Emerson MV, Pieramici DJ, Stoessel KM, Berreen JP, Gariano 48. Mills M. Terson Syndrome. Ophthalmology 1998;105:2161- RF. Incidence and rate of disappearance of retinal hemorrhage in 2162. newborns. Ophthalmology 2001;108:36-39. 49. Schloff S, Mullaney MD, Armstrong DC, et al. Retinal find- 39. Ewing-Cobbs L, Kramer L, Prasad M, et al. Neuroimaging, ings in children with intracranial hemorrhage. Ophthalmology physical, and developmental findings after inflicted and nonin- 2002;109:1472-1475. flicted traumatic brain injury in young children. Pediatrics 50. Scheibner V. Shaken baby syndrome: the vaccination link. Nexus 1998;102:300-307. 1998;87:35-38. 40. Feldman KW, Bethel R, Shugerman RP, et al. The cause of infant 51. Friedlander E. Opposition to immunization: a pattern of decep- and toddler subdural hemorrhage: a prospective study. Pediatrics tion. Scientific Reviews of Alternative Medicine 2001;5:18-23. 2001;108:636-646. 52. Gayle MO, Kisson N, Gerd RW, et al. Retinal hemorrhage in the 41. Buys YM, Levin AV, Enzenauer RW, Elder JE, et al. Retinal find- young child: a review of etiology, predisposed conditions, and ings after head trauma in infants and young children. clinical implications. J Emerg Med 1995;13:233-239. Ophthalmology 1992;99:1718-1723. 88 MARCH/APRIL 2004/VOL 41 • NO 2
  10. 10. CME Quiz I N S T R U C T I O N S Inflicted Childhood Neurotrauma 1. Review the stated learning objectives on the first page of the CME article and determine if these objectives match your individ- (Shaken Baby Syndrome): ual learning needs. 2. Read the article carefully. Do not neglect the tables and other Ophthalmic Findings illustrative materials, as they have been selected to enhance your knowledge and understanding. 1. The leading cause of infant homicides is: 3. The following quiz questions have been designed to provide a A. Trauma. useful link between the CME article in the issue and your every- day practice. Read each question, choose the correct answer, and B. Motor vehicle accidents. record your answer on the CME REGISTRATION FORM at the end C. Child abuse. of the quiz. D. Accidental shootings. 4. Type or print your full name and address and your date of birth in the space provided on the CME REGISTRATION FORM. 2. Approximately how many victims of inflicted child- 5. Complete the Evaluation portion of the CME Registration Form. Forms and quizzes cannot be processed if the Evaluation hood neurotrauma are initially misdiagnosed: portion is incomplete. The Evaluation portion of the CME A. One-fourth. Registration Form will be separated from the quiz upon receipt at JOURNAL OF PEDIATRIC OPHTHALMOLOGY & STRABISMUS. B. One-third. Your evaluation of this activity will in no way affect the scoring of C. Half. your quiz. NO PAYMENT REQUIRED. You may be contacted at a future date with a follow-up survey to this activity. D. Three-fourths. 6. Send the completed form to: JOURNAL OF PEDIATRIC OPH- THALMOLOGY & STRABISMUS CME Quiz, PO Box 36, 3. Approximately how many children in the United Thorofare, NJ 08086. States were abused or neglected in 2001: 7. Your answers will be graded, and you will be advised whether you have passed or failed. Unanswered questions will be consid- A. 17,100. ered incorrect. A score of at least 80% is required to pass. B. 100,000. 8. Be sure to mail the CME Registration Form on or before the C. 502,000. deadline listed. After that date, the quiz will close. CME Registration Forms received after the date listed will not be D. 903,000. processed. 4. Approximately what percentage of victims of inflict- CME ACCREDITATION ed childhood neurotrauma have the characteristic oph- SLACK Incorporated is accredited by the Accreditation thalmic finding of intraocular hemorrhages: Council for Continuing Medical Education to provide continuing medical education for physicians. A. 0%. SLACK Incorporated designates this educational activity for a B. 20%. maximum of one (1) hour category 1 credit toward the AMA Physician’s Recognition Award. Each physician should claim only C. 40%. those credits that he/she actually spent in the activity. D. 80%. FULL DISCLOSURE POLICY 5. Vision loss as a result of inflicted childhood neuro- Current ACCME policies state that participants in CME activi- ties should be made aware of a faculty member’s significant finan- trauma is most commonly due to: cial or other relationships. Therefore, all faculty members partici- A. Retinal detachments. pating in any SLACK Incorporated-sponsored activity are expect- ed to disclose to the activity audience their relationships (1) with B. Macular holes. the manufacturer(s) of any commercial product(s) and/or C. Cortical visual impairment. provider(s) of commercial service(s) discussed in an educational D. Persistent vitreous opacities. presentation and (2) with any commercial supporters of the activ- ity. (Such relationships can include grants or research support, 6. Which of the following has not been directly corre- employee, consultant, major stockholder, member of speakers bureau, etc.) The intent of this disclosure is not to prevent a pre- lated with a fatal outcome and permanent neurologic senter with a significant financial interest or other relationship impairment in victims of inflicted childhood neurotrau- from making a presentation, but rather to provide participants ma: with information on which they can make their own judgments. It remains for the audience to determine whether the presenter’s A. The extent of intraocular hemorrhage. interests or relationships may influence the presentation with B. Presence of macular retinoschisis. regard to exposition or conclusion. In accordance with ACCME policies, the audience is advised C. Cataract formation. that this continuing medical education activity may contain refer- D. Pupillary abnormalities. ences to unlabeled uses of FDA-approved products or to products not approved by the FDA for use in the United States. The faculty 7. The differential diagnosis of retinal hemorrhages in members have been made aware of their obligation to disclose an infant reasonably includes all of the following such usage. This CME activity is primarily targeted to pediatric ophthal- EXCEPT: mologists and ophthalmic surgeons. There are no specific back- A. Inflicted childhood neurotrauma. ground requirements for participants taking this activity. JOURNAL OF PEDIATRIC OPHTHALMOLOGY & STRABISMUS 105
  11. 11. R E G I S T R A T I O N F O R M Questions about CME and the Journal? Call us at 856-848-1000 or write to: Inflicted Childhood Neurotrauma Journal of Pediatric Ophthalmology & Strabismus (Shaken Baby Syndrome): PO Box 36 Thorofare, NJ 08086 Ophthalmic Findings NO PAYMENT REQUIRED 1. The leading cause of infant homicides is: A. Trauma. MARCH/APRIL 2004 B. Motor vehicle accidents. C. Child abuse. Inflicted Childhood Neurotrauma (Shaken Baby D. Accidental shootings. Syndrome): Ophthalmic Findings 2. Approximately how many victims of inflicted child- Black out the correct answers hood neurotrauma are initially misdiagnosed: 1. A B C D 6. A B C D A. One-fourth. B. One-third. 2. A B C D 7. A B C D C. Half. 3. A B C D 8. A B C D D. Three-fourths. 4. A B C D 9. A B C D 5. A B C D 10. A B C D 3. Approximately how many children in the United States were abused or neglected in 2001: Number of hours you spent on this activity _________________________ A. 17,100. (reading article and completing quiz) Forms can be sent by fax B. 100,000. to 856-853-5991 C. 502,000. Deadline for mailing: For credit to be received, the envelope must be postmarked no later than April 15, 2005. D. 903,000. 4. Approximately what percentage of victims of inflict- PRINT OR TYPE ed childhood neurotrauma have the characteristic oph- thalmic finding of intraocular hemorrhages: Date of Birth: (used for tracking credits ONLY) A. 0%. B. 20%. Last Name First Name Degree C. 40%. D. 80%. Mailing Address 5. Vision loss as a result of inflicted childhood neuro- trauma is most commonly due to: City State Zip Code A. Retinal detachments. B. Macular holes. Phone Number C. Cortical visual impairment. D. Persistent vitreous opacities. Evaluation (must be completed in order for your CME Quiz to be scored) MARCH/APRIL 2004 6. Which of the following has not been directly corre- Check the appropriate box below. Yes No 1. The content of the article was accurately described by the lated with a fatal outcome and permanent neurologic learning objectives. _____ _____ impairment in victims of inflicted childhood neurotrau- a. To summarize the ophthalmic literature related to inflicted childhood neurotrauma to review not only the ocular ma: findings, but also the associated systemic and psychosocial A. The extent of intraocular hemorrhage. findings in the syndrome. b. To identify the limited differential diagnosis of retinal B. Presence of macular retinoschisis. hemorrhages in the case of a small child or infant. C. Cataract formation. c. To recognize the important role of the ophthalmologist in the evaluation of victims of inflicted childhood neurotrauma. D. Pupillary abnormalities. 2. This activity will influence how I practice ophthalmology. _____ _____ a. If you answered yes, list one new thing you learned as a 7. The differential diagnosis of retinal hemorrhages in result of this activity ______________________________________________ . an infant reasonably includes all of the following 3. The quiz questions were appropriate for assessing my learning. _____ _____ EXCEPT: 4. Please rate the degree to which the content presented in this A. Inflicted childhood neurotrauma. activity was free from commercial bias. No bias Significant bias B. Immunizations. 5 4 3 2 1 C. Idiopathic retinal hemorrhages of newborns. Comments regarding commercial bias _______________________________ ________________________________________________________________ D. Blood dyscrasia. 5. Please list topics you would like to see future CME activities address: _________________________________________________________. 8. In victims of inflicted childhood neurotrauma, reti- nal hemorrhage can occur: Journal: print CODE:JPOS-0204 106 MARCH/APRIL 2004/VOL 41 • NO 2