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Purpose Approximately 50% of patients receiving anti–vascular endothelial growth factor (VEGF) therapy show significant improvement in diabetic retinopathy severity score (DRSS), in particular at DRSS level 47 to 53 (moderately severe to severe nonproliferative diabetic retinopathy). Level 47 to 53 consists of 3 main features: deep hemorrhages (DH), venous beading (VB), and intraretinal microvascular abnormalities (IRMAs). It is unclear whether these features respond to anti-VEGF therapies differently. Design Post hoc analysis of Intravitreal Aflibercept versus Panretinal Photocoagulation in Patients with Proliferative Diabetic Retinopathy (CLARITY) study. Participants Treatment-naive participants randomized to intravitreal aflibercept. Methods We reanalyzed the fundus images at baseline, week 12, and week 52 to assess the changes of the 3 main features in DRSS level 47 to 53 in those patients who were treatment naive and had received aflibercept. Main Outcome Measures Changes in DH, VB, and IRMA after aflibercept therapy at weeks 12 and 52. Results Fifty-five treatment-naive eyes at baseline that received aflibercept were included in the study. Severe DH and severe IRMA improved in approximately 75% of eyes at week 12 and mostly remained improved at week 52; VB remained unchanged in all eyes at week 12. From 12 weeks, 32 eyes that had received injections showed improved or stable DH compared with 7 eyes that did not receive injections, and DH deteriorated in 6 eyes with no further injections compared with 4 eyes that had received more injections (P = 0.0072). Similarly, 15 eyes that continued to receive injections from week 12 showed improved or stable IRMA compared with 4 who did not receive injections (P = 0.006). Worsening of IRMA was seen in 5 eyes with no further injections compared with 4 eyes that continued to receive injections. The improvements in DH and IRMA are more likely to be maintained if less than 16 weeks have elapsed since the last anti-VEGF injection. Conclusions Aflibercept seems to improve DH and IRMA after just 3 injections. As soon as the frequency of injections were reduced, DH and IRMA can deteriorate again. It is unclear whether these results can be translated to patients without PDR.

Objective To determine the use of ophthalmology consultation as part of investigation of children with suspected abusive head trauma (AHT). Methods Retrospective chart review of children under age 3 years evaluated at McMaster Children's Hospital for suspected AHT from January 2011 to December 2017. Results Fifty-seven children were investigated, and 29 (50.9%) of these were determined to have likely AHT. Eleven (19.3%) had other nonaccidental injuries. A mean of 3.6 consulting services were involved. Neuroimaging was performed for 52 patients (91.2%), including all patients in the AHT group. Intracranial hemorrhage (ICH) was present in 21 of the 29 AHT children (72.4%). All 57 patients had a dilated fundus examination, and retinal hemorrhages (RH) were seen in 23 patients (40.4%), including 16 (55.2%) in the AHT group. All patients with RH in AHT also had ICH. In the AHT group, there were more cases of hemorrhages too numerous to count (68.8% vs 28.6%), multilayered hemorrhages (75.0% vs 57.1%), and hemorrhages in the posterior pole and periphery (87.5% vs 42.9%) when compared with patients with RH from other etiologies. Retinoschisis was seen in the AHT group only in 3 patients (18.8%). Conclusions A multidisciplinary approach is important when investigating suspected AHT. Not every child with RH had suffered AHT; however, children with AHT showed more widespread and more multilayered RH. The only finding specific to AHT was retinoschisis.

Purpose The aim of this study was to evaluate retinal hemorrhages (RHs) in newborns after therapeutic hypothermia performed for hypoxic–ischemic encephalopathy (HIE). Methods From 2014 January to October 2016, full-term newborns who were referred to us from the neonatal intensive care unit at our hospital for ophthalmological examination were evaluated retrospectively. Neonates diagnosed with HIE were examined with a RetCam Digital Retinal Camera (Massie Research Laboratories Inc., Pleasanton, CA) using a 130-degree or binocular indirect ophthalmoscope (Heine, Herrsching, Germany) imaging tool and were classified into three groups. Group 1 included patients without HIE, group 2 included patients with stage I HIE, and group 3 included patients with stage II or III HIE. The RH rates in cases of HIE were retrospectively reviewed. Results A total of 148 eyes of 74 patients were included in the study. RH was detected in 36 eyes (24.3%); there were two eyes (3.7%), 14 eyes (20.6%), and 20 eyes (76.9%), in groups 1, 2, and 3, respectively. In group 3, RH was mostly seen in a widespread form. RHs involving the macula were resorbed later than haemorrhages in other locations. Conclusion RHs are frequent in neonates with HIE. RHs were seen significantly more frequently in stage II–III HIE. These haemorrhages may require treatment, especially when the macula is involved.

Metastases are the most common adult intraocular tumors. However, those located in the optic nerve are very uncommon and are usually associated with spread to other locations such as the central nervous system, which darkens the prognosis. There is a case of a 67-year-old woman who reports progressive vision loss in the right eye of 15 days of evolution. The ophthalmological examination shows a relative afferent pupil defect in this eye and a pseudoedema of the papilla with retinal hemorrhages in the fundus. Personal history and characteristics of the optic nerve suggest the diagnosis of metastatic infiltration.

Purpose Retinal hemorrhages are observed frequently in patients with leukemia. However, little is known about the impact and natural history of these hemorrhages. The purpose of this study was to describe leukemic retinal hemorrhages using multimodal imaging and to monitor their evolution longitudinally. Design Retrospective case series. Participants A total of 11 eyes of 7 symptomatic leukemic patients with posterior segment hemorrhages. Methods Single-center study performed at the Johns Hopkins Hospital. Symptomatic leukemic patients with posterior segment hemorrhages underwent serial dilated fundus examinations. The hemorrhages were documented longitudinally with color fundus photographs and spectral-domain (SD) OCT. Main Outcomes Measures Microanatomic locations of leukemic retinal hemorrhages and their impact on vision and evolution over time. Results A total of 7 patients (71.4% men; 57.1% white, 28.6% black, and 14.3% Hispanic) were included, with 11 eyes showing posterior segment hemorrhages. The median age at presentation was 49.8 years. All patients had intraretinal hemorrhages; these involved the vitreous and sub–internal limiting membrane (ILM) space in 1 and 3 patients, respectively. The median total follow-up duration was 4.0 months. At the final follow-up visits, 4 of 6 patients showed complete resolution of hemorrhages on examination and color fundus photographs. The final SD-OCT images of all patients did not show any retinal thinning, disruption of the ellipsoid zone, disorganization of the retinal layers, intraretinal fluid, or subretinal fluid. Conclusions Symptomatic leukemic retinal hemorrhages are associated with anemia and thrombocytopenia. These hemorrhages, including visually significant central sub-ILM hemorrhages, tend to be self-limiting and resolve within a few months with treatment of the underlying disease.

Purpose To report family members with familial retinal arteriolar tortuosity (FRAT) identified after sudden visual loss. Observations A 15-year-old boy had sudden visual loss in his left eye while playing on a horizontal bar. He was referred to Nagoya City University Hospital from an eye clinic. The ophthalmologic examination showed retinal hemorrhage bilaterally. His best-corrected visual acuity (BCVA) was 20/17 in the right eye and 20/67 in the left eye. Bilateral retinal arteriolar tortuosity as well as retinal hemorrhage was seen. Since his mother with 54 years of age also had a history of retinal hemorrhage that improved spontaneously, fundus examination was performed, revealing tortuosity of the retinal arterioles. Consequently, the patient and his mother were diagnosed as FRAT. He was followed without intervention. Retinal hemorrhage gradually decreased and resolved after 3 months. The BCVA of his left eye gradually improved and reached 20/20 after 1 year. Conclusions and importance In this case, the family history was very useful for early diagnosis. Immediate and accurate diagnosis allowed the patient to be followed without intervention and achieve subsequent resolution of retinal hemorrhage and improved vision. FRAT should be considered in cases of sub-internal limiting membrane hemorrhages in young patients even in the presence of discrete retinal arteriolar tortuosity.

Diabetic retinopathy is a disease that can cause a loss of vision. An early and accurate diagnosis helps to improve treatment of the disease and prognosis. One of the earliest characteristics of diabetic retinopathy is the appearance of retinal hemorrhages. The purpose of this study is to design a fully automated system for the detection of hemorrhages in a retinal image. In the first stage of our proposed system, a retinal image is processed with variational mode decomposition (VMD) to obtain the first variational mode, which captures the high frequency components of the original image. In the second stage, four texture descriptors are extracted from the first variational mode. Finally, a classifier trained with all computed texture descriptors is used to distinguish between images of healthy and unhealthy retinas with hemorrhages. Experimental results showed evidence of the effectiveness of the proposed system for detection of hemorrhages in the retina, since a perfect detection rate was achieved. Our proposed system for detecting diabetic retinopathy is simple and easy to implement. It requires only short processing time, and it yields higher accuracy in comparison with previously proposed methods for detecting diabetic retinopathy.

The association between abusive head trauma and retinal hemorrhages is well documented. As such, ophthalmic review in suspected nonaccidental injury has become routine. However, there is a paucity of reports focusing on ocular trauma and retinal detachment presenting as unilateral findings in nonaccidental injury and in the absence of other signs of physical abuse. This report identifies 2 suspected cases of nonaccidental injury in infants presenting to a tertiary care center with retinal detachment presumed secondary to severe unilateral direct ocular trauma. The fellow eye was normal in both cases. Findings were inconsistent with the reported histories from parents.

There is currently no universally accepted grading system for describing retinal hemorrhages (RH) in abusive head trauma (AHT). The purpose of this study was to devise and evaluate a novel grading system and descriptive nomenclature for RH in AHT for clinical and research purposes.A traumatic hemorrhagic retinopathy (THR) grading system was developed for assessing and quantitatively analyzing retinal findings in abusive head trauma. The criteria for the THR grade included the extent, spread, and morphology of RH. Extent was classified as region 1 (posterior pole) or region 2 (peripheral). Spread, based on number of retinal hemorrhages, was classified as mild (10 or fewer RH), moderate (more than 10 RH) and severe (more than half of involved regions covered by RH). Morphology was classified by its intraretinal or extraretinal involvement. Two independent graders calculated the THR grade from RetCam images of 38 eyes of 19 patients3 years of age with retinal hemorrhages associated with head injury. Grading was performed on two separate occasions. Intra- and interobserver reliability was assessed with Spearman correlation coefficient (r) and intraclass correlation coefficient (ICC).There was a high level of intraobserver agreement across both assessments (97% agreement [Spearman r = 0.997; P0.0001] and 100% agreement [Spearman r = 1.0; P0.0000]). Intraclass correlation (ICC, 0.995; 95% CI, 0.991-0.997; P0.0001) confirmed a very high level of agreement overall.The traumatic hemorrhagic retinopathy grading system demonstrated excellent intraobserver and interobserver reliability. The nomenclature is easily understood and may be useful in medical records and medicolegal reports.

We aimed to elucidate the mechanism of the retinal hemorrhage (RH) accompanied by shaken baby syndrome or abusive head trauma (SBS/AHT) by analyses using a computational model. We focused on a hypothesis that the vitreoretinal traction due to acceleration and deceleration caused by abusive shaking leads to retinal hemorrhage. A finite element (FE) mechanical model with simple spherical geometry was constructed. When the FE mechanical model was virtually shaken, the intensity of the stress applied to the retinal plane agreed well with the results from an analysis using a physical model made of agar gel. Impacts due to falling events induced more intensive tensile stresses, but with shorter duration, than the shake did. By applying a mathematical theory on tackiness, we propose a hypothesis that the time integration of the stress, in the unit of Pa·s, would be a good predictor of the RH accompanied by SBS/AHT. A single cycle of abusive shake amounted to 101Pa·s of time integration of inflicted stress, while a single impact event amounted to 36Pa·s. This would explain the paradoxical observation that shaking induces RH while RH due to impact events is only seen in a major event such as a fatal motor vehicle accident.

The low level of awareness, treatment, and control of systemic hypertension is a global problem, but it is much more serious in Saudi Arabia. This study examines the contribution made by Saudi optometrists in detection and management of patients with systemic hypertension. We surveyed a sample of 250 optometrists practicing in Saudi Arabia to evaluate the level of knowledge and awareness of their role in combating systemic hypertension. A 48.4% response rate was obtained from practicing optometrists. Of those responding, optometrists were very positive towards the use of blood pressure (BP) monitors in optometric practice on a routine basis. Forty-six percent of the optometrists had access to a BP monitor, and about 93% of these respondents actually used the monitors during clinic consultations. Automated monitors were the most common (54%). Fifty-one percent and 49% of the optometrists reported that they did routinely question their patients about high BP and about their current BP medications, respectively. The less frequently asked question concerned the cholesterol level of the patient (21%). The tests most widely used by the optometrists while examining hypertensive patients was direct ophthalmoscopy with red free filter (56%) and the least was binocular indirect ophthalmoscopy (21%). Optometrists were more likely to refer patients suspected of systemic hypertension on the basis of elevated BP (74%) and presence of retinal hemorrhages (72%), but were less likely to refer patients with changes in arteriolar reflex (41%). The opinions were very positive towards the routine monitoring of BP within the Saudi optometry profession, as optometrists indicated that they had time within an eye examination to measure BP, it was financially rewarding (56% of respondents), and patients appreciated it (64% of respondents). Despite half of the optometrists having access to BP monitors (predominantly automated devices), many of the optometrists were unsure if they were trained enough to monitor BP in such patients. There is urgent need to train optometrists on the use of BP devices, interpretation of readings, and use of additional diagnostic tests during such eye examinations.

Purpose To systematically review the characteristics, prevalence, evolution, and obstetric associations of retinal hemorrhages (RH) in newborns. Methods A systematic review, searching 10 databases (1970-2011), identified 45 studies, which underwent two independent reviews via the use of standardized critical appraisal. Studies meeting the following criteria were included: examination by an ophthalmologist, use indirect ophthalmoscopy, and first examination conducted within 96 hours of birth and before hospital discharge. Results Thirteen studies were included, representing 1,777 infants. The studies revealed that 25.6% of newborns born via spontaneous vaginal deliveries had RH. In contrast, infants delivered by vacuum extraction had a 42.6% rate of RH (OR, 2.75; 95% CI, 1.32-5.70), and infants delivered by double-instrument deliveries (forceps and vacuum) had a 52% rate of RH (OR, 3.27; 95% CI, 1.68-6.36). The hemorrhages are commonly bilateral (59%), of varying severity, from "mild" (22%-56%) to "severe" (18%-37%), and predominantly intraretinal and in the posterior pole. The majority of RH (83%) resolved within 10 days; isolated cases persisted to 58 days. Conclusions Birth-related RH in infants occurs in one-quarter of normal deliveries and are far more common after instrumental deliveries. Commonly bilateral, they were predominantly intraretinal, posterior, resolved rapidly, and very rarely persisted beyond 6 weeks.

Abusive head trauma causes significant morbidity and mortality in infants and young children. The diagnosis of abusive head trauma can be difficult. Emergency medical providers frequently have initial contact with patients presenting with abusive head injuries. It is important for emergency medical providers to consider child abuse in the differential diagnosis of head trauma and to know how to perform a comprehensive evaluation when it is suspected. The pearls and pitfalls of diagnosing abusive head trauma are discussed in this article. Information on patient outcomes and the legal responsibilities of the medical provider are also described.

Purpose To present a series of infants found to have sparse retinal hemorrhages associated with isolated epidural hematomas. None of these infants had other intracranial or subdural hemorrhages present. Methods Children less than 3 years of age admitted to an urban children's hospital between January 1998 and December 2002 with radiographic evidence of an isolated epidural hematoma at the time of presentation were eligible for this study. Results During the time period of the study, 15 children were admitted with traumatic epidural hematomas. Nine patients had an ophthalmologic examination, of which five had evidence of sparse retinal hemorrhages. All five patients with retinal hemorrhages were less than 8 months of age and all required surgical evacuation of the epidural hematomas. Of the five patients with retinal hemorrhages, four were unilateral, one was bilateral, and in all cases, the retinal hemorrhages were superficial, few in number, and confined to the posterior pole. There were no deep retinal or subretinal hemorrhages present. The institutional child protection team evaluated all five patients with retinal hemorrhages and each case was felt to be consistent with the history provided and no history of shaking was elicited. Conclusions We found sparse retinal hemorrhages in five of nine patients who presented to our hospital with isolated epidural hematomas and who had had an ophthalmologic examination. All nine patients were evaluated by the institutional child protection team, who did not feel that there was sufficient evidence to be suspicious of nonaccidental trauma.

Child abuse is a significant cause of morbidity and mortality in children. Therefore, it is important that the pediatric emergency medicine physician is familiar with the literature pertinent to child abuse. This review contains articles that address different findings that can be seen with child physical abuse and child sexual abuse. It is not exhaustive, but covers the following areas: falls, physician bias, fractures, head injury, retinal hemorrhages, burns, bruises, abdominal injuries, examination findings in sexual abuse, sexual abuse forensic evidence collection, and sexually transmitted infections. Clin Ped Emerg Med 7:204-211

Inflicted traumatic brain injury (iTBI) is a common cause of morbidity and mortality in young children. Inflicted traumatic brain injury can present with a wide spectrum of symptoms and clinical findings. Children who have milder forms of iTBI and less ominous symptoms, such as vomiting and irritability, may not be recognized until they present later with more serious injury. Although retinal hemorrhages, rib fractures, and subdural hemorrhage are the triad typically associated with iTBI, a minority of patients will have all 3 findings. The importance of recognizing iTBI in a timely manner in the emergency department is vital to protect the child from future and possibly more severe brain injury.

Nearly 3 million children are victims of physical and sexual abuse each year, making nonaccidental injury one of the leading causes of morbidity and mortality in pediatrics. These children rely on medical and social intervention for identification, treatment, and protection. This review of the recent literature makes recommendations and suggestions for current medical management and social and legal interactions. Issues such as the team concept used for sexual assault victims; the expected, normal sexual assault exam; the window for obtaining high-yield DNA specimens; postexposure treatment for diseases and pregnancy; newer technology for the evaluation of retinal hemorrhages; the importance of skin findings in abusive injury; and current research in biomechanical and computer models to simulate abusive injury are addressed.

Purtscher retinopathy is a retinal vasculopathy most commonly caused by head or chest trauma. The most frequent signs include white ischemic infarcts (cotton-wool spots) and retinal hemorrhages (intraretinal, preretinal, or flame). The signs of ischemic vasculopathy predominate in the interpapillomacular zone. We report a case of a 31-year-old woman with sudden bilateral loss of vision caused by Purtscher retinopathy in acute alcoholic pancreatitis.

Resume L'hypertension arterielle est une affection frequente chez l'animal âge, en particulier le chat. Les consequences oculaires de cette affection sont importantes, voire irreversibles, allant jusqu'a une cecite d'installation parfois brutale. Les lesions se repartissent en retinopathie, choroidopathie et neuropathie optique, dont les consequences sont, entre autres, les hemorragies et decollements de retine. Le traitement fait appel a un inhibiteur des canaux calciques, le besylate d'amlodipine par voie generale, et apporte une stabilisation satisfaisante des lesions, l'amelioration de la fonction visuelle restant exceptionnelle.

A case of retinal hemorrhages with special features and degradation of the general condition is reported in a 27-year-old female patient, following the ingestion of ivermectin for the treatment of onchocerciasis. The patient was infested by both Onchocerca volvulus and Loa loa. A bilateral peripheral temporal location of the retinal lesions was observed. The role of L. loa microfilarial load in the occurrence of the retinal lesions as well as the transient character of the lesions are discussed, based on the clinical observation and with reference to the literature. The authors call for setting up a rapid therapeutic system to take care of serious adverse reactions following treatment with ivermectin in areas with a high prevalence of L. loa infestation.

This 2-month-old boy presented to the emergencydepartment with vomiting, lethargy, and episodes of apneaafterapparentlyfallingfromhisfather’slapwhilehisdiaperwas changed one day earlier. On examination, he waswell-nourished and inno acutedistress; hisvital signswerenormal. A hematoma was noted over the left foreheadand parietal region. A head computed tomographyrevealed a comminuted right parietal skull fracture withbilateral subdural hematomas. A brain magnetic resonanceimaging (MRI) confirmed bilateral subdural hematomas(right > left) and showed additional subdural blood alongthe tentorium (Fig. 1A). On trace of diffusion and apparentdiffusion coefficient maps, multiple scattered foci ofrestricted diffusion were seen at the corticomedullaryjunction within both hemispheres suggestive of diffuseaxonal injury (Fig 1B,C). Susceptibility weighted imaging(SWI) revealed multiple hypointense foci along the pe-riphery of both eye globes consistent with retinal hemor-rhages (Fig 2), which in combination with the diffusiontensor imaging findings and extra-axial hemorrhage, raised

For reasons inexplicable to many physicians, and unbeknownst to many others, the diagnosis of Abusive Head Trauma/Shaken Baby Syndrome (AHT/SBS) remains a lightning rod for controversy. Recent legal commentary has suggested that there is insufficient science girding this diagnosis. In Part I of the analysis on this topic, Dr. Narang presented a relatively comprehensive analysis of the current science surrounding AHT/SBS, and more specifically, surrounding two of the most common injuries found in AHT/SBS — subdural hemorrhages (SDHs) and retinal hemorrhages (RHs). Dr. Narang asserted that the diagnosis of AHT is supported by "at least 700 peer-reviewed, clinical medical articles comprising thousands of pages of medical literature, published by over one thousand different medical authors, from at least twenty-eight different countries." In response to this article, Findley et al reiterated an insufficient scientific basis for the diagnosis, citing, amongst other things, logical fallacies (such as "circularity" and "the prosecutor's fallacy") as premises for the fallacious literature. In Part II of this analysis, Narang et al swing the microscope in the opposite direction. Narang et al scrutinize the "differential diagnosis" of AHT, and the differential diagnosis methodology itself, to ascertain whether the scientific process of coming to the AHT diagnosis meets reliability and relevancy criteria under Daubert.

References Results Methods Conclusion Discussion The direct intraocular mechanisms and forces required to create retinal hemorrhages in non-accidental head injury remain a matter of controversy and conjecture. The predominant theory implicates vitreous traction on retinal vessels; however, retinal hemorrhages occur in other settings without history of rapid acceleration-deceleration injury, such as in healthy newborns. Circumferential macular folds are seen almost exclusively in severe non-accidental trauma. We sought to document the pattern of retinal hemorrhages relative to macular folds to determine if the altered vitreoretinal interface may influence the formation of retinal hemorrhages.

espanolObjetivo/Metodo: Presentamos el caso de un paciente de 31 anos con presunta coroiditis criptococica que ocurrio en el seno de una meningitis criptococica y SIDA. Multiples lesiones pequenas blanco-amarillentas aparecieron bilateralmente en coroides, asi como abundantes hemorragias y exudados algodonosos asociados a disminucion de agudeza visual. Tambien realizamos diagnostico diferencial con otras entidades frecuentes y revision de los tratamientos. Resultados/Conclusiones: Criptococos neoformans es un hongo oportunista con predileccion por afectacion meningea en SIDA (10%). Las manifestaciones oculares normalmente son por afectacion de los pares craneales o por papiledema secundario al aumento de presion intracraneal (hasta en un 50% de los casos). La coroiditis criptococica ocurre menos frecuentemente (5% de pacientes con meningitis). EnglishPurpose/Methods: We report the case of a 31 year old male with presumed cryptococcal choroiditis associated with cryptococcal meningitis and AIDS. Multiple yellowish-whitish small choroidal lesions, retinal hemorrhages and cotton-wool spots appeared in the posterior pole associated with vision loss. We also carried out differential diagnosis with other frequent diseases and a review of the treatments. Results/Conclusions: Cryptococcus neoformans is an opportunistic fungus with a predilection for infecting the meninges in patients with Acquired Immunodeficiency Syndrome AIDS (10%). Ocular manifestation usually includes cranial nerve palsies or papilledema secondary to increased intracranial pressure. Cryptococcal choroiditis is less frequent (5% of patients with meningitis).

Retinal hemorrhages in children occasionally accompany bacterial meningitis, usually due to hemophilus or meningococcal organisms. The hemorrhages may be intraretinal, usually in the posterior pole of the eye and few in number, or, more uncommonly, subhyaloid or vitreous. Pathogenesis may include vasculitis, disseminated intravascular coagulation, or intracranial hypertension. We report 2 cases of bilateral severe retinal hemorrhages in fatal Streptococcus pneumoniae meningitis.

m r i c p t S s c f o v d b r c y d i d w s m t UTHKELCH IN 1971 REPORTED ON 22 PATIENTS younger than 18 months of age with various combinations of subdural hemorrhage, fractures, arenchymal brain injury, and retinal hemorrhages. He as the first to recognize the important role of repeated cceleration-deceleration forces—that is, shaking—as a orm of abusive injury. In 1972 and 1974, Caffey exanded on this topic and coined the term Whiplash-Shaken nfant syndrome. Both authors recognized the frequent bsence of external signs of trauma and the role of torn ridging vessels in the brain as the cause of the intracranial emorrhage. Using autopsy evidence and a rudimentary ummy model, Duhaime and associates in 1987 suggested hat blunt impact trauma may be a prerequisite to generate ufficient deceleration forces for the characteristic injuries o occur. Whereas it has since been shown that shaking lone can be injurious, some authors still prefer the term haken Impact syndrome, particularly when there is clear vidence of blunt impact. The relative contributions of haking vs impact in the pathogenesis of this syndrome are till debated, leading some clinicians and researchers to avor more generic terms such as abusive head injury, nflicted head trauma, inflicted traumatic brain injury, and nflicted childhood neurotrauma, among others. In Shaken Baby syndrome (SBS), retinal hemorrhages re seen in 50% to 100% of patients, with most studies eporting approximately 85%. Typically, the hemorhages are present in both eyes, although asymmetry and nilaterality are well recognized. The mechanism by hich retinal hemorrhages occur in SBS has not yet been ully elucidated, which in part has led a minority of esearchers to question the validity of the diagnosis of SBS. In this issue of THE JOURNAL, Sturm and associates tudied the optical coherence tomography (OCT) features n three victims of SBS in an attempt to gain insight into he pathophysiology of the retinal hemorrhages as well as o attempt to aid in the diagnosis and to gain prognostic nformation. In two of the three patients reported, the erpetrators had confessed, although information was lackng on all patients regarding the relative amounts of

Resume Un equilibre alimentaire restreint a du riz, des fruits et legumes bouillis entraine une hypovitaminose C. Nous decrivons le troisieme cas d’hemorragies retiniennes liees au scorbut a notre connaissance. Une baisse d’acuite visuelle, bilaterale chez un patient âge de 50 ans fut associee a une anemie macrocytaire, une denutrition et a des ecchymoses cutanees. Un traitement oral par vitamine C permit une amelioration clinique subjective et une regression des hemorragies retiniennes a l’examen du fond d’œil sans effet secondaire. La vitamine C joue un role important dans la stabilite du collagene dans les parois vasculaires et osseuses.