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INTRODUCTION: We explored several modes of violent shaking using a dummy doll with an eyeball model to reproduce abusive events that lead to retinal haemorrhages (RH) seen in shaken baby syndrome or abusive head trauma (SBS/AHT). MATERIALS AND METHODS: A dummy doll equipped with an eyeball model was prepared. The eyeball model was filled with a model of vitreous body, i.e. agar gel or water, and was with a pressure sensor to measure normal stress. RESULTS: The modes of shaking were classified into three patterns, i.e. fast shaking with the fore arms, fast shaking with the whole arms and synchronized shaking with the whole arms. The frequency of the cyclic acceleration-deceleration history experienced by the head of the dummy doll was 5.0, 4.0 and 2.2Hz, respectively, with the maximum acceleration of 20, 20 and 60m/s(2), respectively. We considered the last of these three modes of shaking as possibly corresponding to the worst case of violent shaking. This mode of shaking could be instructed to volunteers who acted as imitate perpetrators, and resulted in both increased peak intensities of the acceleration experienced by the head of the dummy doll and increased stresses on the retina at the posterior pole of the eyeball model. DISCUSSION: The time integral of the stress through a single cycle of shaking was 107Pa·s, much larger than that of a single event of fall, which resulted in 60-73Pa·s. Taking into account that abusive shaking is likely to include multiple cycles, the time integral of the stress due to abusive shaking can be even larger. This clear difference may explain why RH in SBS/AHT is frequent, while RH in accidental falls is rare. Language: en

Purpose The aim of this study was to evaluate the efficacy and safety of photodynamic therapy (PDT) combined with intravitreal vascular endothelial growth factor (VEGF) inhibitors compared to those of PDT alone in the treatment of polypoidal choroidal vasculopathy (PCV). Methods A systematic search of Pubmed, Embase, and the Cochrane Library was performed to identify all comparative studies that compared the outcomes of the two approaches. Outcomes of interest included visual outcomes, anatomic variables, and adverse events. Results Two randomised controlled trials and nine retrospective studies including a total of 543 cases were identified. At three and six months post-injection, no significant difference in visual acuity was found in the combined therapy group compared with the PDT monotherapy group, with pooled weighted mean differences (WMDs) of 0.074 (-0.021, 0.17) at three months and 0.082 (-0.013, 0.18) at six months. However, the mean changes in visual acuity at month 12 in the combined therapy group were significantly better than those in the PDT monotherapy group, with pooled WMDs of 0.11 (0.012, 0.21). Similar efficacy was found at 24 months (WMD: 0.21; 95%CI: 0.054, 0.36; P = 0.008). Patients in the combined therapy group also might benefit from reduced retinal haemorrhage (OR: 0.32; 95% CI: 0.14, 0.74; P = 0.008). Polyp regression, recurrence of PCV, central retinal thickness reduction, and pigment epithelial detachment resolution did not differ significantly between the two treatments. Conclusions Combined treatment appeared to result in better visual acuity and lower retinal haemorrhage. However, combined treatment did not affect the resolution and recurrence of lesions. Given the inherent limitations of the included studies, future well-designed RCTs are awaited to confirm and update the findings of this analysis.

Pathological changes of the ocular fundus in acute severe head or extracranial injury are difficult to document. In vivo examination usually has to be carried out under intensive care conditions. Postmortem ophthalmoscopy is usually impeded by rapid blurring of the cornea. Therefore, endoscopic fundal photography has been applied by using a pars plana approach during forensic postmortem procedures. This technique provides fundoscopic pictures of high quality as a valuable supplement for subsequent macro- and histopathological preparations and sections. Different patterns of fundoscopic findings seem to correspond to different types of injuries such as craniocerebral trauma, traumatic asphyxia and decompression sickness, and may allow some insight into the respective pathogenetic mechanism.

Purpose: To review the Swedish experience using transpupillary thermotherapy (TTT) as an adjunct to ruthenium plaque radiotherapy for choroidal melanoma. Methods: A retrospective chart review of 27 patients receiving TTT for juxtapapillary or juxtafoveal growth present at the time of diagnosis, or recurrent growth at the tumour margin, or significant exudation following ruthenium brachytherapy for choroidal melanoma. Results: Follow-up ranged from 6 to 29 months (median=20 months). Tumour growth regressed completely (n=8), regressed partially (n=11), remain unchanged (n=6) or progressed (n=2). Complications included focal lens opacity with or without associated posterior synechiae (n=3), retinal haemorrhage (n=2) and retinal vein occlusion (n=1). Seventeen patients (63%) maintained or improved visual acuity and 2 eyes were enucleated following combined treatment. Conclusion: Many of the treated eyes would have been enucleated in the past, suggesting that TTT used in combination with ruthenium brachytherapy improves the short term globe salvage rate. Ocular side effects do occur but are usually not significant.

In contrast to the recommendations of the International Liga against Epilepsy, many hospitals perform routinely complete ophthalmological examinations in children admitted after a first seizure. As there is no study available to date to prove the benefit of complete eye examinations in first seizure diagnosis, we conducted a study to analyse the value of a complete ophthalmological examination. All children aged 1 month to 18 years who were admitted to the children's university hospital of Leipzig with the clinical diagnosis of a first convulsive or non-convulsive afebrile seizure between 1999 and August 2005 were investigated. All children who had obtained a complete ophthalmological examination within 72 h after the seizure were included in the observational study. A total of 310 children were analysed in the study. Two hundred thirty patients had a tonic-clonic afebrile seizure, the others focal, complex-partial seizures or absences. Two hundred seven out of 310 children showed no ophthalmological pathologies. Eighty-three children had refraction anomalies or strabism, 18 children had optic atrophy, three had congenital eye muscle paresis, and three had malformations. A 16-year-old girl had a homonymous quadrantanopia due to an occipital glioglioma that caused the seizure. An 11-year-old girl had a retinal haemorrhage without any brain lesions after a fall caused by a first tonic-clonic seizure. None of the ophthalmological findings influenced directly the immediate clinical course of diagnosis and treatment of the seizure. Our data suggest that routine ophthalmological examination in all children does not have additional benefit in the first seizure diagnosis management.

Background: Non-accidental head injury (NAHI) is a form of child abuse where a perpetrator may violently subject an infant to repeated acceleration-deceleration forces with or without head impact, producing injuries including retinal haemorrhages in most cases. Animal models have included laboratory shaking of mice and rats, but only a small fraction develop retinal haemorrhages presumably due to the small eyes, which would require unattainable force levels to mimic that sustained by the infant eye. Animal models are also problematic due to ethical issues raised by subjecting even anaesthetized animals to abusive injury. Methods: We investigated a naturally occurring event, where three animal victims were shaken by a canine. The eyes were harvested and examined histologically. Results: The victims' eyes showed no haemorrhage or retinoschisis. Conclusions: Our model may not be a complete NAHI mimic. The discrepancies may ensue from anatomical and mechanical differences in the injury mechanism. Other models must be sought to further study this form of abusive eye injury. Language: en

benefits of thrombolysis in people with diabetes and an acute myocardial infarction are well grounded. Life saving treatment may be inappropriately withheld due to concerns regarding retinal haemorrhage and subsequent visual impairment. We believe that all patients with an acute anterior myocardial infarction and diabetes should be considered for thrombolysis, irrespective of their retinal appearance. We therefore audited our junior doctors to assess their views on thrombolytic treatment in patients with differing degrees of diabetic eye disease. The participating doctors were provided with the case of a man with long-standing type 2 diabetes and an acute anterior myocardial infarction, along with five unlabelled retinal photographs including a normal eye, background diabetic retinopathy, pre-proliferative retinopathy, proliferative retinopathy, and maculopathy. The doctors were then asked if the patient should or should not receive thrombolysis. One quarter of the doctors surveyed would not give thrombolysis in the presence of a normal retina or background disease. A quarter would not give thrombolysis with maculopathy and two thirds would not treat in the presence of pre-proliferative retinopathy. Over two thirds would not treat those with proliferative disease. Although more senior doctors were more likely to give thrombolysis in the presence of increasing diabetic eye disease than their juniors colleagues, these results suggest that some patients may not receive appropriate potentially life saving therapy. Better education of junior doctors to avoid this oversight is therefore necessary. Copyright © 2007 John Wiley & Sons. Practical Diabetes Int 2007; 24(5): xxx-xxx

Non-accidental head injury, be it shaking, impact(s) or a combination of the two, is characterised by subdural and/or subarachnoid haemorrhages with retinal haemorrhages, but minimal or absent external cranio-facial trauma. The classical assault scenario depicts the infant being gripped around the head, face, chest and abdomen and shaken or being gripped by a limb and swung. This gripping might be expected to leave physical evidence in the form of bruising. A study was undertaken to establish the prevalence, distribution and pathological association of external bruising in 24 cases of fatal non-accidental head injury in children. At autopsy, 17 cases had new external bruises, 15 old external bruises and 13, a combination of both. However, seven (29%) cases showed no fresh external bruising and five (21%) showed no external bruising at all. Thus, external bruising may be absent in children with fatal intracranial injury. The face was shown to be the commonest site of bruising followed by the forehead and buttocks. Limb, chest and abdominal bruising were found to be uncommon. Retinal haemorrhages were confirmed in 23 (96%) cases. It is hypothesised that bruising, when present, may be a result of abuse in the form of punches and slaps rather than due to gripping during the assault. We discuss why gripping does not necessarily result in external bruising.

Ehrlichia canis infection was diagnosed in a Labrador retriever presented with a primary complaint of acute blindness. Ocular signs on admission included bilateral hyphema, retinal haemorrhage and retinal detachment. Serum protein electrophoresis results revealed monoclonal gammopathy. This report discusses and suggests the pathogenesis of ocular bleeding in canine monocytic ehrlichiosis. Blood hyperviscosity, elevation in oncotic pressure, vasculitis, thrombocytopenia and platelet dysfunction are all proposed to be important factors in the pathogenesis of acute blindness in canine monocytic ehrlichiosis.

Retinal changes are common in adult acute leukaemia patients at presentation, but whether they correlate with the risk of subsequent intracranial haemorrhage is unknown. A 4-year study has been carried out in 82 newly-diagnosed acute leukaemia patients, aged 12–77 years, who were studied prospectively for the presence of intra-retinal haemorrhages (IRH), white-centred haemorrhages (WCH), cotton-wool spots (CWS) and macular haemorrhages (MH). Groups with and without these features were compared for their risk of intra-cranial haemorrhage (ICH) within the first 30 d following diagnosis. There was no association between the incidence of ICH and the presence of IRH, WCH or CWS. However, 6/13 of those with MH developed ICH, compared to 6/69 of those without MH (relative risk 5.0, CI 95% [2.03–12.33], P=0.003). The only other identifiable risk factor for ICH was the M3 subtype of AML, but if the four cases of M3-AML were discounted from analysis, MH remained a highly significant risk factor for ICH. Patients with MH should be monitored intensively for the development of ICH, and receive priority in the allocation of platelets where these are in short supply.

Fatal non-accidental head injury (NAHI) in infancy is characterised by severe bilateral retinal haemorrhage (sbRH), thin film diffuse bilateral subdural haemorrhage (dbSDH) and severe fatal hypoxic ischaemic encephalopathy (sfHIE). The Geddes hypothesis is that sfHIE is the direct cause of sbRH and dbSDH. The conventional hypothesis (post-Geddes) is that trauma precipitates hypoxia to cause sfHIE and independently tears veins to cause sbRH and dbSDH. These hypotheses are assessed using Bradford Hill criteria of causation. The triad (sbRH, dbSDH and sfHIE) is a strong, specific and consistent association which suggests a causative link. Furthermore sbRH and dbSDH are positively correlated with severity of HIE but negatively correlated with objective evidence of trauma. The conventional hypothesis (post-Geddes) fails the test of biological plausibility because trauma causes asymmetrical and focal bleeding not diffuse bilateral capillary and venular oozing. The conventional hypothesis lacks coherence since it was shown that the encephalopathy of the triad is not traumatic. Arguments by analogy also support the Geddes hypothesis. There is a paucity of experimental evidence for either hypothesis but this is likely to be rectified as molecular methods (genomics and proteomics) are used in the infant autopsy.

A seven-month-old baby was admitted to a hospital emergency department after collapsing suddenly while staying with his nanny. The baby displayed classic symptoms of shaken baby syndrome, including subdural haemorrhage, cytotoxic cerebral oedema, and bilateral retinal hemorrhages. Child protection services were informed, but both the parents and the nanny denied any involvement. In the subsequent weeks, the baby developed three other episodes of new subdural bleeding and a medico-legal investigation was started into the origin of the repeated subdural bleeding. Eventually, platelet aggregation tests and electron microscopy diagnosed a delta-storage pool disease; that is, a haemostatic disorder involving dense granules of the platelets. Initial minor blunt trauma may have resulted in subdural bleeding, while subsequent retinal haemorrhage could have been facilitated by the underlying haemostatic disorder. Delta-storage pool disease should be considered as a possible mimic of abusive head trauma similar to other rare conditions such as Menkes disease and type 1 glutaric aciduria.

Haemodialysis (HD) patients are at an increased risk of bleeding because of uraemic bleeding tendency and systemic anticoagulation caused by intermittent heparinization. Additional risk factors may be aspirin or coumarin use for the prevention of fistula thrombosis, diffuse intravascular coagulation, recent trauma, postsurgical state, inadequate control of hypertension, gastrointestinal lesions, diabetic retinopathy, renal cystic disease, and uraemic pericarditis. In HD patients with an active bleeding focus blood transfusion, desmopressin acetate (DDAVP), conjugated oestrogens, and dialysis treatment can limit the bleeding risk. Strategies to reduce the bleeding risk conveyed by systemic anticoagulation during HD are regional heparin anticoagulation and minimal heparinization. In our opinion, dialytic modalities that completely preclude systemic anticoagulation, i.e. peritoneal dialysis (PD), heparin-free HD, and HD with regional anticoagulation with prostacyclin, mesilates, or citrate, are indicated for patients who are actively bleeding, or who are within 3 days from a bleeding episode, or a surgical or accidental wound, or who are less than 2 weeks from cerebral or retinal haemorrhage, and for patients with incompletely treated proliferative diabetic retinopathy or uraemic pericarditis.

Purpose: To present a patient with the novel finding of vascular telangiectasis as a cause of intra-schitic haemorrhage, occurring in optic disc pit-associated maculopathy. Methods: A clinical history was detailed. Clinical examination included visual acuity assessment and slit-lamp microscopy. Fluorescein angiography was performed. Results: A temporal optic disc pit, macular retinoschisis and a circumscribed detachment of the outer retinal layer and inner leaf holes were noted. A retinal haemorrhage extending into the schitic cavity was present, along with an associated vitreous haemorrhage. Fluorescein angiography showed telangiectatic vessels in association with the haemorrhage. Conclusion: This is the first reported case of vascular telangiectasis as a cause of intra-schitic haemorrhage occurring in optic disc pit-associated maculopathy.

The indications of point-of-care ultrasound (POCUS) in the management of multiple trauma patients have been expanding. Although computed tomography (CT) scan of the orbit remains the gold standard for imaging orbital trauma, ultrasound is a quick, safe, and portable tool that can be performed bedside. Here we report two patients who had severe eye injuries with major visual impairment where surgeon-performed POCUS was very useful. One had a foreign body injury while the other had blunt trauma. POCUS was done using a linear probe under sterile conditions with minimum pressure on the eyes. Ultrasound showed a foreign body at the back of the left eye globe touching the eye globe in the first patient, and was normal in the second patient. Workup using CT scan, fundsocopy, optical coherence tomography, and magnetic resonance imaging of the orbits confirmed these findings. The first patient had vitreous and sub retinal haemorrhage and a full thickness macular hole of the left eye, while the second had traumatic optic neuropathy. POCUS gave accurate information concerning severe eye injuries. Trauma surgeons and emergency physicians should be trained in performing ocular ultrasound for eye injuries.

Snakebite is a serious community health problem in India. On an average, there are 200,000 people bitten by snakes annually and 30,000–40,000 of them die because of the ensuing complications [1]. In India 20,000 people die every year due to the same reason. Snake venoms are complex heterogeneous poisons with multiple effects. Venomous snakebites may result in haemostatic or neurological dysfunction. Ocular complications are very rare, but common ocular involvements are generally connected with neurological ones. The varied ophthalmic effects of envenomation are blepharoptosis, muscle palsies, haemorrhages into the conjunctiva, anterior chamber, vitreous or retina, lid oedema, conjunctival chemosis, retinal and optic nerve oedema, pupillary changes, optic neuritis and optic atrophy [2]. Bilateral retinal haemorrhage is an infrequent ocular effect caused by snakebite. In the current study, we describe a case that developed bilateral retinal haemorrhage following Indian Russell viper (Daboia russelii) snakebite.

Few paediatric diagnoses generate as much controversy as abusive head trauma (AHT), also known as shaken baby/shaken impact syndrome (or SBS). Major signs such as multifocal subdural haematomas, cerebral injury, retinal haemorrhage and skeletal fractures are exhaustively described in myriad radiological reports, and are the result of extremely violent trauma. While bruises have significant diagnostic value, they may be missed when located in hidden areas like behind the ears and in the axilla. In some cases, subdural haematomas appear to be isolated, with no other apparent signs, making diagnosis difficult. We would like to stress the need for careful vertex screening to look for bridging vein thrombosis, which—as some pathologists have pointed out—has high diagnostic value [1]. The bridging veins are draining veins that arise from the coalescence of the superficial cortical venous network at the midline, within the subarachnoid space. They extend, bridge-like, at intervals along the midline, from their attachment to the arachnoid at the medial border of the cerebral hemispheres to the superior sagittal sinus of the dura mater, into which they flow after having traversed the arachnoid space and the deep layers of the dura mater [2]. These veins constitute a short, non-tortuous, perpendicular pipeline between the

AIMS To analyse the clinical features, social circumstances, investigations and outcome of 49 children with significant non-accidental head injury admitted to The Prince of Wales Children's Hospital between 1979 and 1993. CLINICAL FEATURES Age ranged from one month to eight years, with 30 children less than one year old. There were 28 boys and 21 girls. Thirty-three were in the care of a parent. Eleven of these were known to the Department of Community Services and 22 were from families with stressed socioeconomic circumstances characterised by deprivation. In 44 cases the history was incompatible with the clinical findings. On admission, 21 had marked depression of awareness, with a Glasgow Coma Scale score (GCS) of 9 or less. Eleven of this group were fitting. Seizures were present in a further 13 children who were semi-purposeful (GCS > 9). Twenty-eight had retinal haemorrhages and 35 had soft tissue scalp contusions, 23 in association with skull fracture. Twenty-six had associated injuries. Seven children died. Of the 42 survivors at the time of discharge, 19 had severe motor disability associated with other deficits. Twenty-four were returned to the care of their families. CONCLUSIONS Retinal haemorrhage and unconsciousness on admission (GCS < or = 9) were positively associated with a poor outcome (P < 0.001 and 0.002, respectively). Cerebral oedema found on computerised tomography was positively associated with severe motor disability on discharge (P < 0.001). Lowest socioeconomic circumstances appeared to be a risk factor for occurrence of injury: 22 of 49 children came from circumstances of deprivation.

Spontaneous subarachnoid haemorrhage (SAH) in children is uncommon, but is sometimes seen after rupture of aneurysms, and in different disorders. Traumatic SAH is common after serious accidental head injury, but is also reported after child abuse with vigorous shaking. To avoid unnecessary accusations of innocent care givers, it is important not to misinterpret the findings as abusive head trauma in small children with SAH. In the presented case, a nearly two-year-old girl was brought to the hospital after a fall witnessed by her father. The girl was unconscious, with elevated intracranial pressure, SAH and bilateral retinal haemorrhage (RH). She was pronounced dead after 9 h. Premortem angiography revealed a dissection of the right vertebral artery, and postmortem examination revealed a traumatic lesion deep in the neck, at the base of the skull. Cerebral edema, in combination with SAH and RH, is highly suggestive of abusive head trauma. However, no external lesions, no skeletal lesions, especially no long bone metaphyseal lesions, or subdural haematomas occurring at the same time as SAH, were found. There was no report of previous child abuse in the family. Based on the radiological and postmortem findings, we believe that an accidental fall caused a blunt force trauma with a subsequent dissection of the right vertebral artery. To our knowledge, accidental tear of one of the vertebral arteries, leading to SAH in a toddler, has previously not been described. Child abuse is an important exclusion diagnosis with serious legal implications.

Dengue fever is the most common arthropod borne disease of human in the tropical and subtropical regions.1 It is caused by the dengue virus, a Flavivirus, and is transmitted by the Aedes aegypti mosquito. It is an endemic disease in India and the latest outbreak occurred in 2012 during which a total of 47,029 cases of dengue fever was reported.2 According to a multinational study, the number of infections stood at 390 million a year and India had the highest burden, accounting for about a third of the world’s cases.3 Dengue has seen a global resurgence recently despite extensive control efforts. Ocular involvement in dengue fever has been reported in many studies. Subconjunctival petechial haemorrhage, secondary to marked thrombocytopenia, is the most common ocular involvement as reported in an East Indian population.4 However patients may present during recovery phase i.e. one week after the onset of fever with a sudden loss of vision or a central scotoma. These manifestations are due to involvement of the retinal and/or choroidal circulation, with a predilection for the macular area. The main findings of dengue maculopathy are retinal haemorrhage, venular sheathing, yellow subretinal dots, retinal pigment epithelium mottling, foveolitis, disc hyperaemia and disc oedema. Neurosensory retinal detachment is seen in 15% of eyes with retinal vascular leakage.1 Optic neuritis is another important ocular involvement in patients of dengue fever, which may be unilateral or bilateral.5 Japanese encephalitis (JE), a leading cause of viral encephalitis in Asia, is an endemo-epidemic disease in some regions in India. It is a vector-borne viral disease caused by Flavivirus. JE is the only virus so far confirmed to cause epidemics of encephalitis in India.6 It has a high mortality rates and usually affects children below 10 years of age. Ocular manifestations are not common. But cases have been reported with ocular palsy, papilloedema and ischaemic maculopathy during recovery stage. A case of optic neuritis has been reported three weeks after an attack of serologically positive JE.7

International audience; Background: There is currently no universally accepted classification of childhood retinal haemorrhages. Aim: To measure the inter- and intra-observer agreement of clinical classifications of retinal haemorrhages in children. Methods: Four examiners (2 consultant ophthalmologists and 2 other clinicians) were shown 142 retinal haemorrhages on 31 RetCam photographs. The retinal haemorrhages were from children with accidental or abusive head injury, or other encephalopathies, and included retinal haemorrhages of different ages. Specified haemorrhages were initially classified by each examiner according to their clinical understanding. Twenty-six haemorrhages were re-presented to test intra-observer consistency. Examiners then agreed a common description for each haemorrhage type and five categories were described (vitreous, pre-retinal, nerve fibre layer, intra-retinal/sub-retinal, or indeterminate), and the study repeated. Results: There was ‘fair agreement' initially (Fleiss' unweighted kappa = 0.219), and with the agreed classification, slight improvement (0.356). Intra-observer agreement marginally improved on re-test. The 2 consultant ophthalmologists showed ‘fair' agreement on both occasions (paired kappa statistic). The other rater pair improved from ‘fair' to ‘substantial' agreement with the new classification. Conclusions: The classification of retinal haemorrhage in children by appearance alone shows only fair agreement between examiners. Clinicians who are not consultant ophthalmologists appear to benefit from the new succinct classification. (200 words)

Purpose To describe the clinical presentations and treatment modalities of a series of BB gun-related perforating ocular injuries. Methods Clinical records of all consecutive cases of perforating BB gun injuries to the globe seen between September 2004 and September 2008 were reviewed retrospectively. At the time of the trauma and after final treatment, all patients underwent a complete ocular examination, including visual acuity, applanation tonometry for intraocular pressure, slit lamp biomicroscopy, indirect ophthalmoscopy and fundus photography, if possible. In all cases, primary globe repair was performed in the first session, and then appropriate surgery took place based on the individual situation. Results In this study, 13 patients (11 males and 2 females) with a mean age of 20.8 years (range 9–50 years) were enrolled. The mean follow-up period was 7.2 ± 4.3 months (range 1–25 months). Initial visual acuity (VA) ranged from no-light perception (NLP) to finger counting (CF). Vitreous haemorrhage and retinal detachment were present in all involved eyes. Hyphema (30.76%), uveal and retinal prolapse (30.8%), retinal incarceration (30.8%) and retinal haemorrhage (53.8%) were other ocular findings. VA remained stable in 46.2% of the patients (6 cases). The best achieved final VA was CF at 2 m in one case after 6 months follow-up. After several surgical procedures, enucleation was necessary in only 2/13 (15.4%) cases. Conclusion Despite several surgical procedures which decreased the number of enucleations, BB gun-perforating ocular injuries still lead to a grim visual outcome. This implies the importance of political strategies targeting on education of parents and restriction for children to access to these guns.

Purpose: To evaluate the prognosis of mortality in patients with spontaneous subarachnoid haemorrhage associated with Terson’s syndrome. Methods: A prospective, consecutive case series study was conducted in patients admitted to the emergency room with a diagnosis of acute subarachnoid haemorrhage. After a complete neurological examination, funduscopic examination using binocular indirect ophthalmoscopy under mydriasis was performed upon admission and at days 3, 7, 30 and 60 after the onset. In all cases, the diagnosis of intracranial bleeding was made by computerized tomography, and the clinical condition was graded according to the Hunt & Hess and Glasgow coma scales. Results: Forty-seven patients with the diagnosis of subarachnoid haemorrhage were enrolled. Forty-four cases were associated with a ruptured aneurysm and three cases with arterio-venous malformation. Fourteen patients (29%) were diagnosed with Terson’s syndrome. Seven patients (50%) with Terson’s syndrome died, whereas death occurred in three patients (9%) without Terson’s syndrome (p = 0.002). Ocular findings in Terson’s syndrome were preretinal, intraretinal, sub-retinal and vitreous haemorrhage. Associated ocular findings included third-nerve palsy, papilloedema and subconjunctival haemorrhage. Conclusion: The presence of Terson’s syndrome was associated with an increased mortality rate (50% versus 9%; p

The shaken baby syndrome is highly contentious. The term is characteristically applied to infants showing a triad of subdural haemorrhage, retinal haemorrhage and encephalopathy. These three features form part of a cascade of events due to a variety of natural diseases and impact, whether inflicted or accidental. Subdural bleeding and retinal bleeding are very common after birth and reflect immaturity of the brain and its coverings. The demographics of babies with the triad overlap with SIDS (sudden infant death syndrome), suggesting that they may be a subgroup of SIDS. Over 40 years after the shaking hypothesis was proposed, a systematic review has concluded that it is unjustifiable to infer that shaking has taken place on the basis of this triad. Unless doctors and the courts are aware of this and of the alternative causes of the triad, we risk wrongful convictions and wrongful removal of babies from innocent parents and carers. Key Concepts Shaken baby syndrome is a hypothesis and has not to date been supported by science. There is insufficient evidence to infer that shaking has occurred on the basis of patterns of intracranial bleeding. Bleeding into the dural membrane around the brain is common in infants and a function of immaturity. Bleeding into the eyes (retinal haemorrhage) results from raised pressure within the head from any cause. Retinal haemorrhage is commonly associated with subdural bleeding of any cause and may serve as a marker for it. Encephalopathy is a nonspecific response of the brain. An understanding of the specific pathophysiology of the infant brain is essential to determining causes of retinodural bleeding. Until it is widely recognised that shaking cannot be diagnosed on the basis of patterns of intracranial bleeding, we risk miscarriage of justice and wrongful allegations of abuse. Keywords: shaken baby syndrome; subdural haemorrhage; retinal haemorrhage; nonaccidental injury; abusive head trauma

In 1974 Caffey reported the features of the shaken baby syndrome, describing the relative lack of external signs of injury to the head and neck in infants who have intracranial and retinal haemorrhages. 1 Subsequent studies have confirmed the importance of the presence of retinal haemorrhages in helping to establish a diagnosis of the shaken baby syndrome? -6 Ophthalmologists may be asked to examine possible victims of the shaken baby syndrome to determine the presence, type and extent of retinal haemorrhages as well as any associated ocular findings. In addition, they may be asked to comment on possible mechanisms that gave rise to the haemorrhages. The shaken baby syndrome tends to occur in infants and younger children, typically under the age of 3 years. 7 The higher rate of shaken baby syndrome in infants, as compared to older children, has been explained by the greater head to body size, and less developed neck musculature in infants, which allows for a greater whiplash effect during shaking. Older children will more likely show a pattern of recurrent and habitual abuse, which may result in various injuries in different stages of healing. 80lver & Hague have found that 4/133 children with traumatic injuries who presented to an ophthalmologic emergency room in the UK were mistreated, 9 and so the ophthalmologist may be responsible for being the first to recognize abuse. 7 Studies on humans and primates concluded that severe head injuries commonly diagnosed as shaking injuries require some impact to occur and that shaking alone in an otherwise normal baby is unlikely to cause the shaken baby syndrome. I° Postulated mechanisms of retinal haemorrhage production are via acceleration/deceleration forces alone owing to

Subdural haemorrhage (SDH) in the infant has a different pattern from that seen in the older child and adult. It is usually a widespread, bilateral, thin film, unlike the thick, space-occupying and often unilateral clot seen in older children and adults after trauma. Whether both arise by the same mechanism is unknown, but it seems unlikely. Most SDH is said to be due to trauma but in infants there are other, atraumatic causes. Birth is also important; recent MRI studies show an incidence of almost 50% in asymptomatic neonates. Traumatic SDH is said to result from rupture of bridging veins but new insights into the anatomy of infant dura suggest a dural origin for thin film subdural bleeding in young babies. Acute SDH usually rapidly resolves, but sometimes develops into a chronic fluid collection. Healing of SDH is by formation of a granulating membrane which may confer vulnerability to rebleeding, either spontaneously or after an otherwise innocuous event. SDH has a particular significance as one of the features of the triad (together with retinal haemorrhage and encephalopathy) associated with non-accidental injury. As the possibility of non-accidental injury is often first raised by a radiologic report of subdural bleeding, it becomes critically important in the interpretation of the scan appearances to understand the unique physiology and anatomy of the infant dura.

Shaken baby syndrome (SBS), characterized by the triad of subdural haemorrhage, retinal haemorrhage, and encephalopathy, was initially based on the hypothesis that shaking causes tearing of bridging veins and bilateral subdural bleeding. It remains controversial. New evidence since SBS was first defined three decades ago needs to be reviewed. Neuropathology shows that most cases do not have traumatic axonal injury, but hypoxic-ischaemic injury and brain swelling. This may allow a lucid interval, which traumatic axonal injury will not. Further, the thin subdural haemorrhages in SBS are unlike the thick unilateral space-occupying clots of trauma. They may not originate from traumatic rupture of bridging veins but from vessels injured by hypoxia and haemodynamic disturbances, as originally proposed by Cushing in 1905. Biomechanical studies have repeatedly failed to show that shaking alone can generate the triad in the absence of significant neck injury. Impact is needed and, indeed, seems to be the cause of the majority of cases of so-called SBS. Birth-related subdural bleeds are much more frequent than previously thought and their potential to cause chronic subdural collections and mimic SBS remains to be established.

Seventeen patients with central retinal vein occlusion aged 40 or under were reviewed. Ocular involvement was characteristically unilateral, with moderate degrees of retinal haemorrhage, little retinal ischaemia, and a tendency to optic disc swelling. Visual prognosis was good. Follow-up showed that most patients have good general health and no involvement of the fellow eye. There was little evidence to support an inflammatory aetiology or underlying vascular disease in most of the patients. An alternative explanation for the development of CRVO in young patients might be a congenital anomaly of the central retinal vein.

The benefits of thrombolytic therapy in a patient with diabetes having a myocardial infarction are now well accepted but this treatment may be withheld inappropriately because of concerns about retinal haemorrhage. We therefore examined whether junior doctors alter their use of thrombolysis for the treatment of acute myocardial infarctions according to the type of diabetic retinopathy present. A questionnaire asking whether thrombolysis would be given to a 50-year-old male smoker with insulin-treated diabetes and an acute anterior MI was shown, with four unlabelled retinal photographs, to all doctors prescribing thrombolytic therapy in a south London teaching hospital and an affiliated district general hospital. In all, 24 medical SHOs, 16 medical registrars/specialist registrars, 3 medical senior registrars, and 23 casualty SHOs were interviewed. Of these 89 % would thrombolyse such a patient with normal fundi, 55 % with background diabetic retinopathy, 54 % if this also involved the macula, and 26 % if they saw proliferative retinopathy. The more senior grades were more aggressive in their approach. As we believe that all patients with an acute anterior myocardial infarction and diabetes should be considered for thrombolysis irrespective of their retinal appearance these results suggest thrombolytic therapy is being withheld inappropriately. Copyright © 1998 John Wiley & Sons, Ltd.

Background: West Nile virus (WNV) was first identified in the United States in 1999. In addition to a spectrum of systemic manifestations, several ocular conditions secondary to the virus have been reported, including chorioretinitis, uveitis and optic neuritis. Age and diabetes mellitus (DM) have been reported to be associated risk factors for the more severe forms of the systemic disease. Only seven cases of occlusive retinal vasculitis have been reported in patients with WNV infection. Case history: A 60-year-old Asian male presented with complaints of decreased vision in his left eye. He had been hospitalised approximately seven weeks earlier with meningo-encephalitis secondary to presumed WNV infection, at which time he was also diagnosed with DM. The visual loss coincided with the manifestation of systemic WNV infection. Old peripheral chorioretinal lesions without active inflammation in both eyes were consistent with WNV infection. In addition, retinal haemorrhage and cotton wool spots were noted in the posterior pole of both eyes with severe macular ischaemia in the left eye. Conclusion: Occlusive retinal vasculitis is an uncommon ocular manifestation of WNV, which should be suspected in patients with meningitis or encephalitis who reside in endemic areas with ocular findings of the disease.

Aims: To study the incidence, systemic associations, presenting features and natural history of Purtscher’s retinopathy in the UK and Ireland. Methods: Cases were collected prospectively by active surveillance through the British Ophthalmological Surveillance Unit. Clinical details were obtained using an incident questionnaire, with follow-up at 1 and 6 months. Results: Clinical details were obtained for 15 cases over 12 months. These were associated with road traffic accidents in 6 cases, chest compression in 6 cases and acute pancreatitis in 3 cases. All cases were symptomatic and presented with loss of visual acuity, visual field or a combination. Bilateral involvement was noted in 9 cases. The acute retinal signs of cotton wool spots, retinal haemorrhage and Purtscher flecken cleared within 1 month in 26% of eyes and within 6 months in all eyes. The most common chronic signs were optic disc pallor and atrophy of the retinal pigment epithelium. Without treatment, 50% of eyes improved by at least 2 Snellen lines at final follow-up and 23% improved by at least 4 Snellen lines. Only 1 of the 24 eyes had a final acuity worse than that recorded at presentation. Conclusion: Purtscher’s retinopathy is a rare but sight-threatening eye condition, most commonly seen in young or middle-aged men and after trauma. Spontaneous visual recovery of at least 2 Snellen lines is seen in half of the cases.

Autonomic dysreflexia is a potentially life-threatening hypertensive medical emergency that occurs most often in spinal cord-injured individuals with spinal lesions at or above the mid-thoracic spinal cord level. It is a condition that remains poorly recognised outside of spinal cord injury centres, which may result in adverse outcomes including mortality from potentially delayed diagnosis and treatment. Acute autonomic dysreflexia is characterised by severe paroxysmal hypertension associated with throbbing headaches, profuse sweating, nasal stuffiness, flushing of the skin above the level of the lesion, bradycardia, apprehension and anxiety, which is sometimes accompanied by cognitive impairment. The key to effective management is prevention of the condition, by recognition and avoidance of factors that initiate the condition. When it occurs, immediate recognition and reversal of trigger factors along with prompt administration of pharmacological treatment is of paramount importance in order to prevent complications, which include intracranial and retinal haemorrhage, convulsions, cardiac irregularities and death. Promising data from recent animal studies may hold the key to future treatment options.

The transcaruncular approach to the medial orbit is growing in popularity and although reported complications are minimal, ophthalmic and orthoptic sequelae can occur after any conjunctival surgery and nonophthalmic surgeons should be aware of these. This study aims to document these sequelae in a cohort of patients having transcaruncular surgery. A retrospective case series of all consecutive patients undergoing orbital fracture repair through a transcaruncular approach for medial wall and floor fractures in two centers over a 2-year period was examined. Computed tomography findings, pre- and postoperative ophthalmic and orthoptic findings, including ocular motility (with Hess chart evaluation), Hertel exophthalmometry, slit lamp biomicroscopy examination, follow-up time, and occurrence of complications were recorded. Thirteen patients, mean age 34 years (range, 18-82 years), underwent repair for medial wall (n=5) or combined medial wall and orbital floor (n=8) fractures with median a follow up of 7 months (range, 2-18 months). Preoperative ocular injuries included conjunctival chemosis, eyelid swelling, subconjunctival hemorrhage, retinal haemorrhage, traumatic uveitis and traumatic mydriasis, eye movement restriction, and enophthalmos (range, 3-4 mm). Postoperatively, corneal epitheliopathy with reduced vision (6/60), orbital inflammation, inferior oblique underaction, and superomedial fornix symblepharon at the caruncular incision sight each occurred in one patient along with extensive subconjunctival hemorrhage and a suture-related conjunctival granuloma in others. All patients experienced an improvement in diplopia and globe restriction. Ophthalmic complications can occur with this approach, and so it may be advisable to seek an ophthalmic opinion with the aim of comanagement in planning this approach.

The concept proposed is that transient bacteraemia occurring in otherwise healthy individuals can cause acute life threatening events due to bacterial toxaemia even though the bacteraemia is rapidly cleared (

A 44-year-old woman from Guyana was referred to the neurology services with headache and blurred vision. The ophthalmology services had made the referral following discovery of apparent bilateral papilloedema and a right retinal haemorrhage. A CT venogram reported enlarged optic nerve sheaths, empty sella and asymmetrical lateral sinuses. The initial lumbar puncture revealed a normal opening pressure of 14 cm H2O and clinical headache assessment suggested migraine. Further ophthalmology advice was sourobight. Having excluded drusen by B-scan ultrasound, a second lumbar puncture was performed and revealed opening pressure 23 cm H2O. Despite extensive investigation, diagnostic uncertainty persisted until the patient presented to Eye Casualty with acute deterioration in right eye visual acuity. A large retinal haemorrhage was noted and fluorescein angiography revealed multiple choroidal vascular polyps. A diagnosis of peripapillary polypoidal choroidal vasculopathy (PCV) was made. Treatment with intraocular anti-VEGF injections and photodynamic therapy successfully avoided permanent visual loss. Caution is advised when interpreting CT findings consistent with idiopathic intracranial hypertension, as PCV is an important differential diagnosis in unexplained papilloedema, which if left untreated can lead to irreversible blindness.

We report a case of a 32-year-old woman who developed an antenatal Valsalva-induced retinal haemorrhage causing unilateral blindness 38 weeks into her pregnancy. Delivery was achieved by elective Caesarean section under epidural anaesthesia. The influence of anaesthetic technique on a recent retinal haemorrhage is discussed.

Examination induced retinal haemorrhage in preterm infants is uncommon. It may occur independently of retinopathy of prematurity (ROP) associated neovascularisation. Retinal haemorrhages due to ROP tend to occur on the surface of the neovascular ridge, which represents an arteriovenous shunt formed by the anastomosis of primitive retinal vessels.1 However, ROP related retinal haemorrhages occurring posteriorly,2 as well as vitreous haemorrhage,3 have also been described in advanced disease. Other common causes of retinal haemorrhage in infancy such as birth4 and shaken baby syndrome should be excluded. Retinal haemorrhage in a premature infant after RetCam photography has been reported.5 We report retinal haemorrhages in a premature infant immediately following examination for ROP. A 1416 g, 33 week gestation infant was transferred to our centre after developing necrotising enterocolitis at 6 days old. Ventilatory support was required briefly following …

BACKGROUND Since the CRYO-ROP study showed the benefit of treating babies with ROP, a number of different treatment modalities have become available. Solid-state lasers have been extensively used in the treatment of ROP since their introduction some 10 years ago. Diode, argon and frequency-doubled YAG (FD-YAG) lasers have all been used to perform photocoagulation in ROP. We aimed to assess current treatment practices of ROP treatment in the UK. METHODS A questionnaire survey was performed in June 2004 and sent to all consultants known to be involved in the treatment or screening of ROP patients. We asked about the number of patients treated in the last year, the treatment method, and whether there had been any serious complications. RESULTS In all, 53 questionnaires were sent out, of which 42 were returned. Also, 30 respondents treated ROP. Of these 19 used transpupillary diode, 11 argon, and three FD-YAG. Cryotherapy and transscleral diode laser were used by two centres in particular cases. In all, 20 patients were treated with FD-YAG, 21 with argon laser, and 188 with diode laser. The number of burns per eye varied from 800 to 2500. Reported complications included hyphaema, retinal haemorrhage, and acute cataract formation; however, there was no significant difference in complications between different types of laser used. DISCUSSION This survey of laser use in the treatment of ROP has shown that diode laser is now the most common mode of treatment in the UK. The incidence of complications was similar for centres using argon, diode, or FD-YAG laser.

To review the ocular manifestations of crush head injuries in children. Retrospective clinical and pathological reviews. Group 1: A total of 16 children admitted with crush head injuries from television tip over. Group 2: Nine autopsy findings in crush head injury. Group 1: A total of 11 children had fundus examination: three by neurosurgeons, eight by ophthalmologists. Scattered posterior pole preretinal and blot haemorrhages extending to mid equator region observed in one child. No evidence of traumatic retinoschisis or retinal folds in any patient. Group 2: All with multiple skull fractures and six with subdural haemorrhage. Posterior pole retinal haemorrhages in four children, extending to the ora serrata in one after motor vehicle accident. No child had retinal folds. Subinternal limiting membrane haemorrhages in three children. Optic nerve sheath haemorrhage in three children. Intraretinal and preretinal haemorrhages, predominantly in the posterior pole, can occur in crush injury to the paediatric head. Haemorrhage under the internal limiting membrane or extending to the ora serrata were only seen in situations where crush injury was part of a fatal trauma scenario related to motor vehicles. Retinal folds and the typical macular retinoschisis associated with abusive head injury were not observed.

In this article we reply to the recent critique by Punt et al. in Pediatric Rehabilitation. Our hypothesis about the pathogenesis of intracranial bleeding in infants has three important implications. First, in the case of an infant with a swollen brain, subdural and retinal haemorrhage but no objective evidence of trauma, the findings by themselves are not certain evidence of abuse; second, violence is not necessary to produce subdural and retinal haemorrhage; and lastly, non-traumatic events producing apnoea with a catastrophic rise in intracranial pressure could produce a clinical picture identical to that seen in trauma.

The trials over the deaths of Matthew Eappen and Victoria Climbie have highlighted the importance of forensic evidence in cases of suspected child abuse. The debate as to whether bruises, fractures or head injuries have been sustained as a result of previous trauma or non-accidental injury is central to these, and other, cases. A variety of subjects are encountered in forensic paediatric pathology, including Shaken Baby Syndrome, non-accidental injury, retinal haemorrhage, skeletal injury, Sudden Infant Death, sexual abuse and Munchausen Syndrome by Proxy. The coverage of these areas on the internet was assessed using two search engines (Google and the meta-search engine Mamma) and revealed patchy coverage. The majority of sites uncovered were, unsurprisingly, aimed at the layperson concerned by such issues; however, several sites containing useful information for the professional are available.

A 41-year-old man noticed decreased central vision in his left eye several hours after arriving at the advance base camp on the north east face of Everest, in April, 2001. He had had symptoms of headache and nausea consistent with acute mountain sickness (AMS) 6 days earlier at 5000 m, which resolved completely over a 24 h period. He had ascended by road from 1300 m over 6 days to 5000 m and rested for 10 days before ascending to 6450 m over 2 days. He had no history of cardiovascular or neurological disease, and he had previously climbed safely to 6000 m. A medical assessment done 3 months before the climb included a normal full blood count, and documented a brisk ventilatory response to hypoxia and no risk factors for high-altitude illness. However he developed diplopia the morning after arrival at advance base camp. We examined his visual fields and found that he had bilateral scotomas and visual acuity of 6/6 in each eye. The remainder of his physical examination was normal. Direct ophthalmoscopy showed engorged retinal veins and wide large flame-shaped haemorrhages extending into both maculae (figure). The climber descended to base camp and eventually flew home to Australia. The scotomas resolved in 3 months, but the flame-shaped haemorrhages took 6 months to resolve. When last seen in May, 2002, he had no complaints and no discernible ophthalmological abnormalities. The risks of ocular problems at high altitudes include high altitude retinal haemorrhage (HARH), cortical blindness, amaurosis fugax, lateral rectus palsy, and refractive changes at altitude after refractive surgery. 1 HARH is the commonest of

Retinal haemorrhage is often observed in patients with Plasmodium falciparum, especially when combined with cerebral malaria. However, few cases of retinopathy have been reported in P. vivax malaria. Benign tertian malaria has re-emerged among soldiers in the South Korean demilitarized zone since 1993. We report an indigenous case of retinal haemorrhage caused by P. vivax and review the relevant literature.

Adrenocortical carcinoma is a rare tumour with a poor prognosis. Mitotane (o,p'-DDD), a chemotherapy drug that suppresses the adrenal cortex and modifies peripheral steroid metabolism has been reported to cause ocular side effects including visual blurring, diplopia, cataract, toxic retinopathy with retinal haemorrhage, oedema, and papilloedema. We present a 32 year old woman with reduced visual acuity, retinal pigmentation, macular oedema, and abnormal ERG after taking mitotane. While primary hypoadrenalism in Addison's disease has never been reported to cause any retinal problem, secondary hypoadrenalism in adrenoleucodystrophy is associated with pigmentary retinopathy and other ocular findings. We postulate that the retinal problems secondary to mitotane treatment may act via a similar mechanism. A 30 year old woman had a left nephrectomy, adrenalectomy, and chemotherapy in September 1997 following diagnosis of an adrenal carcinoma. In 1999, she was found to have secondary tumours in her lungs and liver. She was commenced on intra-arterial cisplatin and oral mitotane of up to 4.5 g daily for 6–8 months, ceasing in December 1999 because of …