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Objective Ocular hemorrhages (OHs) may cause visual disturbances and incidence vary from 18 to 39% in newborns. Precipitated/instrumental delivery and perinatal asphyxia were predefined risk factors. Acidosis can interfere with coagulation and disrupt the pressure of ocular capillaries and put infants with moderate acidosis with or without hypoxic–ischemic encephalopathy at risk for OH. We aimed to evaluate the OH in neonates with fetal acidosis. Study Design Neonates >34 weeks are included if pH < 7.10 and BE < −12 mmol/L within the first hour. Ophthalmologic examinations for retinal (RH), vitreous, and anterior chamber (hyphema) hemorrhage were done within the third day. RH was staged according to Egge's classification. Follow-up of the patients was continued until the age of 2. Clinical characteristics of newborns were analyzed. Results Sixty-two neonates (38 ± 2.3 weeks, 2,971 ± 612 g) were included. pH = 6.91 ± 0.16, BE = − 17.2 ± 5.3 mmol/L. OH was found in 22 (36.7%) neonates (hyphema n = 2, vitreous n = 2, RH n = 21). Thirty-eight eyes with RH were staged (Stage 3: n = 15 [39.5%]; Stage 2: n =11 [28.9%]; Stage 1: n = 12 [31.6%]). Vaginal delivery (OR: 4.9, 95% CI [1.4–17.8]) and advanced resuscitation at the delivery room (OR: 8.8; 95% CI [1.9–41.7]) were found to increase the risk of RH. Conclusion Approximately one-third of neonates with moderate to severe acidosis exhibited RH when examined on the third day. Contrary to previous studies that reported mild RH in otherwise healthy neonates, our findings revealed that neonates with moderate to severe acidosis predominantly presented with Stage 3 RH. While the higher incidence of RH in vaginally delivered infants is consistent with previous studies, the identification of advanced resuscitation as a risk factor is a new addition to the literature. The findings in our study highlight the importance of retinal examination in neonates with acidosis in the presence of intubation during resuscitation. Key Points One-third of neonates with moderate to severe acidosis exhibited RH. Stage 3 RH was identified as the most prevalent. Advanced resuscitation was identified as an independent risk factor for RH. [ABSTRACT FROM AUTHOR]

Objectives: Shaken baby syndrome (SBS), a subset of abusive head trauma, results from non-accidental, violent head shaking. Most survivors suffer permanent neurological sequelae. Accurate diagnosis is imperative and remains challenging. The purpose of this study is to describe ocular injuries and associated neurotrauma in suspected SBS. Methods: We retrospectively surveyed the National Trauma Data Bank 2008–2014 for patients ≤ 3 years old admitted for suspected SBS. Statistical analysis was performed with SPSS software. Significance was set at p < 0.05. Results: Three hundred forty-seven (13.9%) of 2495 patients who were ≤ 3 years old were admitted with abusive head trauma and ocular injuries which resulted from suspected SBS. Most were < 1 year old (87.9%) and male (54.2%). Common eye injuries were retinal hemorrhages (30.5%), eye/adnexa contusion (14.7%), and retinal edema (10.7%). Common neurotrauma were subdural (75.5%), subarachnoid (23.9%), and intracerebral hemorrhage (ICH) (10.4%). Mean (SD) Injury Severity Score was severe, 20.2 (8.2), and Glasgow Coma Score was moderate, 9.2 (12.8). The mortality rate was 16.7%. Retinal hemorrhages were not significantly associated with one type of neurotrauma over others. Ocular/adnexa contusion (OR 4.06; p < 0.001) and commotio retinae/Berlin's edema (OR 5.27; p < 0.001) had the greatest association with ICH than other neurotrauma. Optic neuropathy (OR 21.33; p < 0.001) and ICH (OR 3.34; p < 0.001) had the highest associated with mortality. Conclusions: Our study supports previous studies showing that retinal and subdural hemorrhages were the most common ocular injury and neurotrauma in SBS, respectively. However, we did not find a significant propensity for their concurrence. Commotio retinae/Berlin's edema was significantly associated with both intracerebral and subdural hemorrhages. [ABSTRACT FROM AUTHOR]

(1) Underlying Diabetic Retinopathy (DR) is the primary cause of poor vision in young adults. There are automatic image reading systems that can aid screening for DR. (2) Methods: Using our automatic reading system we have counted the number of microaneurysms and hemorrhages in the four quadrants of the ETDRS grid and evaluated the differences between them according to the type of DR. The study was carried out using data from two different databases, MESSIDOR and MIRADATASET. (3) Results: The majority of microaneurysms and hemorrhages are found in the temporal and inferior quadrants of the ETDRS grid. Differences are significant with respect to the other two quadrants at p < 0.001. Differences between the type of DR show that severe-DR has a greater number of microaneurysms and hemorrhages in the temporal and inferior quadrant, being significant at p < 0.001. (4) Conclusions: The count of microaneurysms and hemorrhages is higher in the temporal and inferior quadrants in all types of DR, and those differences are more important in the case of severe-DR. [ABSTRACT FROM AUTHOR]

Key Clinical Message: Severe, too many to count retinal hemorrhages (RH) in infants have been associated with abusive head trauma, but can occur in short falls. An 8‐month‐old male fell backward from a height of 26 cm, landing on his buttocks then hitting the back of his head on a vinyl floor. The fall was videotaped. Acute subdural hemorrhages were found along with extensive, too many to count intra‐RH in both eyes. Falls from small heights on to the occiput can lead to extensive RH of the type often associated with abusive head trauma. [ABSTRACT FROM AUTHOR]

Purpose: Compare follow-up optical coherence tomography with visual function in children with abusive head trauma (shaken baby syndrome). Methods: Retrospective follow-up studies of three children who were victims of abusive head trauma within the first year of life. Results: Optical coherence tomography showed disrupted retinal layering, thick detached internal limiting membrane, focal posterior vitreous separation, and multilayered tractional retinoschisis. Significant vision loss occurred in three of four eyes with a history of traumatic retinoschisis. Normal visual acuity and low-normal visual-evoked potentials were measured in a child with foveal distortion, reduced global nerve fiber layer thickness, detached internal limiting membrane, and history of vitreous hemorrhage. Conclusion: Significant abnormalities of retinal anatomy can be detected on optical coherence tomography years after abusive head trauma. Optical coherence tomographies and assessment of visual pathways help to elucidate causes of visual dysfunction in children with abusive head trauma. [ABSTRACT FROM AUTHOR]

Key Clinical Message Severe, too many to count retinal hemorrhages (RH) in infants have been associated with abusive head trauma, but can occur in short falls. An 8‐month‐old male fell backward from a height of 26 cm, landing on his buttocks then hitting the back of his head on a vinyl floor. The fall was videotaped. Acute subdural hemorrhages were found along with extensive, too many to count intra‐RH in both eyes. Falls from small heights on to the occiput can lead to extensive RH of the type often associated with abusive head trauma.

A term male newborn small for gestational age and with microcephaly was born from uncomplicated vaginal delivery. Pregnancy was not followed up until 32 weeks. Maternal serologies and vaginal/rectal swabs were negative. Routine ophthalmoscopy revealed hemovitreous in the right eye and massive retinal hemorrhages (RH) in the left eye; subsequent RetCam II examination with fluorescein angiography revealed bilateral RH, involving the fovea in the left eye. Retinal vascularization was normal in both eyes, without signs of ischemic injury or pathological angiogenesis. Complete blood count, coagulation, and thrombophilic studies were normal; a toxicology screen, performed on a hair sample from both mother and infant, was positive for cocaine. With its significant vasoconstrictive effects, cocaine may induce ischemic‑hypoxic damage in the developing retinal vascular system of the fetus, leading to extensive RH. Although cocaine‑related RH is indistinguishable from other birth‑related RH, the formers persist for longer periods, warranting prolonged follow‑up and long‑term evaluation of visual function [ABSTRACT FROM AUTHOR]

(1) Underlying Diabetic Retinopathy (DR) is the primary cause of poor vision in young adults. There are automatic image reading systems that can aid screening for DR. (2) Methods: Using our automatic reading system we have counted the number of microaneurysms and hemorrhages in the four quadrants of the ETDRS grid and evaluated the differences between them according to the type of DR. The study was carried out using data from two different databases, MESSIDOR and MIRADATASET. (3) Results: The majority of microaneurysms and hemorrhages are found in the temporal and inferior quadrants of the ETDRS grid. Differences are significant with respect to the other two quadrants at p < 0.001. Differences between the type of DR show that severe-DR has a greater number of microaneurysms and hemorrhages in the temporal and inferior quadrant, being significant at p < 0.001. (4) Conclusions: The count of microaneurysms and hemorrhages is higher in the temporal and inferior quadrants in all types of DR, and those differences are more important in the case of severe-DR.

Purpose: Function and anatomy of the visual system were evaluated in children with abusive head trauma (AHT). The relationships between retinal hemorrhages at presentation were examined with outcome measures. Methods: Retrospective review of data in children with AHT for 1) visual acuity at last follow-up, 2) visual evoked potentials (VEP) after recovery, 3) diffusion metrics of white matter tracts and grey matter within the occipital lobe on diffusion tensor imaging (DTI), and 4) patterns of retinal hemorrhages at presentation. Visual acuity was converted into logarithm of minimum angle of resolution (logMAR) after correction for age. VEPs were also scored by objective signal-to-noise ratio (SNR). Results: Of 202 AHT victims reviewed, 45 met inclusion criteria. Median logMAR was reduced to 0.8 (approximately 20/125 Snellen equivalent), with 27% having no measurable vision. Thirty-two percent of subjects had no detectable VEP signal. VEPs were significantly reduced in subjects initially presenting with traumatic retinoschisis or hemorrhages involving the macula (p < 0.01). DTI tract volumes were decreased in AHT subjects compared to controls (p < 0.001). DTI metrics were most affected in AHT victims showing macular abnormalities on follow-up ocular examination. However, DTI metrics were not correlated with visual acuity or VEPS. There was large inter-subject variability within each grouping. Discussion: Mechanisms causing traumatic retinoschisis, or traumatic abnormalities of the macula, are associated with significant long-term visual pathway dysfunction. AHT associated abnormalities of the macula, and visual cortical pathways were more fully captured by VEPs than visual acuity or DTI metrics. [ABSTRACT FROM AUTHOR]

Purpose:To report a unique case of Valsalva retinopathy associated with ear popping behavior. Observations:A 57-year-old woman with a history of well-controlled hypertension presented with episodes of seeing "spots" in her left eye for many years. Her most recent episode failed to resolve spontaneously. Fundus examination revealed scattered retinal hemorrhages in the left eye, and optical coherence tomography demonstrated sub-internal limiting membrane location of these hemorrhages. Fluorescein angiography did not reveal any vascular abnormalities. Based on these findings and an in-depth review of systems, a diagnosis of Valsalva retinopathy was made associated with patient's ear popping habit. Conclusions and importance:Habitual ear popping can be a potential etiology of symptomatic Valsalva retinopathy. This under-appreciated association may be clinically relevant for patients with a history of suspected Eustachian tube narrowing or dysfunction.

Introduction: In the case of sudden unexpected death in infancy (SUDI), eye examination is systematic to detect retinal hemorrhages (RH) that are a crucial hallmark for abusive head trauma (AHT). The aim of this study is to assess the ability of non-invasive post-mortem fundus photographs (PMFP) to detect RH in case of SUDI. Methods: Bicentric retrospective analysis of consecutive cases of SUDI under 2 years of age were managed by two French SUDI referral centers with PMFP by RetCam (Clarity Medical Systems USA). PMFP were reviewed randomly, twice, by three independent ophthalmologists blinded for clinical data. Results: Thirty cases (60 eyes) were included. Median age was 3.5 months (interquartile [1.6; 6.0]). No child died of AHT. Image quality was sufficient to assert presence or absence of RH in 50 eyes (83%). Sufficient quality rate was significantly higher when the post-mortem interval was inferior to 18 h (91%, 42/46) as opposed to over 18 h (57%, 8/14, p=0.0096). RH were found in six eyes (10%), four children (13%), with excellent inter and intra-raters' concordance (Cohen's Kappa from 0.81 [0.56–1.00] to 1.00 [1.00–1.00]). Conclusion: PMFP can detect RH in case of SUDI and is a relevant systematic screening test to be carried out as soon as the deceased child arrives in the hospital. It can decrease the need of eye removal for pathological examination, but further studies are needed to define the best decision algorithm. [ABSTRACT FROM AUTHOR]

Purpose: The aim of this experimental study was to investigate the pathogenesis of Terson syndrome (TS), which currently is controversial.Methods: The central retinal artery (in 39 orbits), posterior ciliary arteries (in 8 orbits), and central retinal vein (CRV in 21 orbits) were occluded in rhesus monkeys by exposing them to lateral orbitotomy. Fundus examination and fluorescein fundus angiography were performed before and immediately after cutting the vessels and serially thereafter during the follow-up period. The rationale of the experimental study design is discussed.Results: In eyes with central retinal artery occlusion, retinal hemorrhages were seen soon after the procedure in 7 eyes, and on follow-up in a total of 15 eyes. In posterior ciliary artery occlusion, retinal hemorrhages were seen soon after the procedure in one eye, and on follow-up in a total of three eyes. In eyes with CRV, all eyes had extensive scattered retinal hemorrhages.Conclusion: The findings of this experimental study, and my basic, experimental, and comprehensive clinical studies on CRVO, suggest the following concept of the pathogenesis of TS: Compression of the CRV plays a crucial role in the development of TS. The CRV is compressed, as it lies in the subarachnoid space of the optic nerve sheath, by raised cerebrospinal fluid pressure and/or accumulated blood.. This results in retinal: venous stasis and raised venous pressure in the retinal veins, leading to venous engorgement, rupture of the retinal capillaries.and: retinal hemorrhages. The clinical importance of compression of the CRV and not occlusion of CRV in TS is that optic nerve sheath decompression by opening it and releasing the blood and raised cerebrospinal fluid (CSF) pressure, would result in immediate decompressing of the CRV in the subarachnoid space and restoration of normal circulation and prevent visual loss. [ABSTRACT FROM AUTHOR]

Purpose: The aim of this experimental study was to investigate the pathogenesis of Terson syndrome (TS), which currently is controversial. Methods: The central retinal artery (in 39 orbits), posterior ciliary arteries (in 8 orbits), and central retinal vein (CRV in 21 orbits) were occluded in rhesus monkeys by exposing them to lateral orbitotomy. Fundus examination and fluorescein fundus angiography were performed before and immediately after cutting the vessels and serially thereafter during the follow-up period. The rationale of the experimental study design is discussed. Results: In eyes with central retinal artery occlusion, retinal hemorrhages were seen soon after the procedure in 7 eyes, and on follow-up in a total of 15 eyes. In posterior ciliary artery occlusion, retinal hemorrhages were seen soon after the procedure in one eye, and on follow-up in a total of three eyes. In eyes with CRV, all eyes had extensive scattered retinal hemorrhages. Conclusion: The findings of this experimental study, and my basic, experimental, and comprehensive clinical studies on CRVO, suggest the following concept of the pathogenesis of TS: Compression of the CRV plays a crucial role in the development of TS. The CRV is compressed, as it lies in the subarachnoid space of the optic nerve sheath, by raised cerebrospinal fluid pressure and/or accumulated blood. This results in retinal venous stasis and raised venous pressure in the retinal veins, leading to venous engorgement, rupture of the retinal capillaries and retinal hemorrhages. The clinical importance of compression of the CRV and not occlusion of CRV in TS is that optic nerve sheath decompression by opening it and releasing the blood and raised cerebrospinal fluid (CSF) pressure, would result in immediate decompressing of the CRV in the subarachnoid space and restoration of normal circulation and prevent visual loss.

Ella H Leung,1 Jason Fan,2 Harry W Flynn Jr,2 Thomas A Albini2 1Georgia Retina, Atlanta, GA, USA; 2Bascom Palmer Eye Institute/University of Miami, Miami, FL, USACorrespondence: Ella H LeungGeorgia Retina, 833 Campbell Hill St NW, Suite 300, Marietta, GA, 30328, USATel +1 770-218-1888Email eleung@garetina.comAbstract: There is increasing information available about the effects of the SARS-CoV-2 virus on the systemic and ocular health of patients, as well as the effects of delayed health care. This mini-review summarizes the potential complications and treatments of COVID-19. Systemic findings include respiratory illness, risk of thromboembolic events, and neurologic findings. Some patients may develop persistent symptoms even after the infection resolves. Effective treatment options include glucocorticoids, antivirals, interleukin-6 antagonists, monoclonal antibodies, Janus kinase inhibitors and vaccines. Potential ocular findings of COVID-19 include conjunctivitis, cranial nerve palsies, and microvascular changes in the retina; most symptoms resolved over time. During the lockdown periods, teleophthalmology was utilized to triage non-urgent issues; patients who did present to emergency departments tended to have more severe disease with worse visual prognoses. While transient delays in outpatient ophthalmic care may be tolerated in some patients, others experienced significant vision loss with interruptions in treatments. Resumption of ophthalmic care as soon as possible may help mitigate the effects of delayed care due to the pandemic.Keywords: COVID-19, SARS-CoV-2, quarantine, steroids, interleukin 6, tocilizumab, monoclonal antibodies, casirivimab, imdevimab, antiviral, remdesivir; teleophthalmology; vaccine; trauma

Predominantly visual loss, is very rare in Wernicke's encephalopathy. A 22 year old lady, in her 28th week of gestation, presented with a confused mental state, bilateral papilloedema with retinal hemorrhages, ophthalmoparesis, and cerebellar signs. Her MRI brain was suggestive of Wernicke's encephalopathy and she recovered with intravenous thiamine [ABSTRACT FROM AUTHOR]

Abstract Predominantly visual loss, is very rare in Wernicke's encephalopathy. A 22 year old lady, in her 28th week of gestation, presented with a confused mental state, bilateral papilloedema with retinal hemorrhages, ophthalmoparesis, and cerebellar signs. Her MRI brain was suggestive of Wernicke's encephalopathy and she recovered with intravenous thiamine

To describe retinal findings and spectral-domain optical coherence tomographic (SD-OCT) features of a patient with Crimean-Congo hemorrhagic fever (CCHF) presenting as Purtscher-like retinopathy. A 70-year-old woman presented with the emerging bilateral blurring of vision. She had been diagnosed with CCHF one week ago and hospitalized in another hospital for treatment of disease. Fundoscopy of the patient revealed cotton-wool spots, retinal whitening areas, and few retinal hemorrhages in a Purtscher-like configuration in both eyes. Spectral-domain optical coherence tomography revealed inner retinal hyperreflectivity corresponding to the cotton-wool spots in both eyes, and also showed subretinal fluid in the left eye. Without any treatment retinal lesions and inner retinal hyperreflectivity on SD-OCT regressed within one month. Crimean-Congo hemorrhagic fever is known to cause mild ocular disease, and may also cause Purtscher-like retinopathy. It is important to aware of the ocular findings of CCHF. [ABSTRACT FROM AUTHOR]

Abstract Introduction Nonaccidental trauma (NAT) is considered when pediatric patients present with intracranial injuries and a negative history of an accidental injury or concomitant medical diagnosis. The evaluation of NAT should include the consideration of possible medical causes including coagulation, hematologic, metabolic and other genetic disorders, as well as witnessed and unwitnessed accidental injuries. Case Presentation We present a 7‐month‐old male with spells and incidental findings of bilateral subdural hematomas, retinal hemorrhages, and secondary macrocephaly, leading to investigation for NAT. Biochemical analysis showed excretion of a large amount of D‐2‐hydroxyglutaric in urine consistent with a biochemical diagnosis of D‐2‐hydroxyglutaric aciduria, a rare neurometabolic disorder characterized by developmental delay, epilepsy, hypotonia, and psychomotor retardation. None of these symptoms were present in our patient at the time of diagnosis. Molecular genetic testing revealed a pathogenic splice site variant (c.685‐2A>G) and a variant of uncertain significance (c.1256G>T) with evidence of pathogenicity in the D2HGDH gene, consistent with a molecular diagnosis of D‐2‐hydroxyglutaric aciduria type I (OMIM #600721). Conclusion Since several metabolic disorders, including D‐2‐hydroxyglutaric aciduria type I, can present solely with symptoms suggestive of NAT (subdural and retinal hemorrhages), an early metabolic evaluation by urine organic acid analysis should be included in clinical protocols evaluating NAT. A methodical and nonjudgmental approach coordinated between pediatricians and metabolic specialists is also necessary to ensure that rare genetic conditions are not overlooked to prevent devastating social, legal, and financial consequences of suspected child abuse.

Abstract Background To report four cases with interesting anatomical presentations of multilayer macular hemorrhages with preretinal hemorrhage possibly preventing subretinal involvement of the macular area. Cases presentation Observational study of four patients presenting with macular hemorrhages. Results Four patients with multilayer macular hemorrhage due to different causes, presented with a halo-shaped submacular hemorrhage coincident with the preretinal hemorrhage borders. After resolution, in all cases, the macular area underneath the preretinal hemorrhage was found to be spared. Conclusion We hypothesized that an extensive preretinal hemorrhage can exert a mechanical force pushing the subretinal hemorrhage towards the periphery, consequently protecting the macular area.

A leading cause of death and disability in infancy is abusive head trauma (AHT) and there are common clinical signs that help to establish this diagnosis. Children diagnosed with AHT can have many ophthalmologic findings, including retinal hemorrhages, retinoschisis, subconjunctival hemorrhages, corneal injury, and globe rupture. If any such injuries are suspected, an ophthalmologic consultation, with indirect ophthalmoscopy, should be completed. In addition to a complete physical exam, a thorough history imaging, and lab work, should be obtained to investigate the etiology of ophthalmic pathology including accidental and systemic causes. In general, studies show that retinal hemorrhages that are multilayered, too numerous to count, and located from the posterior pole to the ora serrata are highly suspicious for abusive head trauma. [ABSTRACT FROM AUTHOR]

The recent outbreak of the Coronavirus SARS-CoV-2 has been declared a worldwide pandemic. Within various multi-organ involvement, several ocular manifestations have been described, such as conjunctivitis and retinopathy. The prevalence and severity of retinal lesions and their relation to the severity of the systemic disease are unknown. We performed a prospective, observational study on 172 consecutively hospitalized patients with acute confirmed COVID-19 infection. All patients underwent screening widefield fundus photography at the time of hospital admission. Despite no ocular or vision-related symptoms, we found cotton wool spots (CWS) and/or hemorrhages in 19/172 patients (11%). Diabetes history, overweight, and elevated C-reactive protein were more frequently observed among patients with retinal abnormalities, while a history of systemic hypertension was more frequently observed among patients without retinal findings. At a 3-month follow-up visit, CWS had subsided in all patients. [ABSTRACT FROM AUTHOR]

Purpose: To evaluate the clinical characteristics of intraocular hemorrhages among babies screened for retinopathy of prematurity (ROP) and thereby their additional risk to the progression of ROP. Methods: A descriptive study was conducted at a tertiary referral hospital, which included 108 eyes of 60 neonates who were discovered to have retinal hemorrhages on retinal screening of 540 babies at risk for ROP. Maternal, obstetric, and neonatal risk factors were assessed in neonates with retinal hemorrhages. Retinal hemorrhages were assessed in terms of type, area, and relation to different retinal zones. Results: Among 540 neonates who were screened, retinal hemorrhages were found in 11.2% (n = 60 babies). Elderly primigravida mothers and spontaneous vaginal deliveries with prolonged second stage of labor were a common maternal risk factors for retinal hemorrhages. Low birth weight and preterm were fetal risk factors with neonatal retinal hemorrhages. These hemorrhages were more often bilateral (no. of babies = 48, 80%). Flame-shaped hemorrhages were more common than dot and blot ones. The majority of cases (no. of eyes = 74, 65%) resolved within 4 weeks, whereas four babies (8 eyes, 7.4%) progressed to ROP were treated with laser. Conclusion: Retinal hemorrhages in neonates are commonly associated with prolonged duration of second stage of labor, advanced maternal age, and anemia. Although not all progress to ROP, recognizing preterm and low birth weight babies with junctional hemorrhages is crucial not to delay the treatment. Regular follow-up until the clearance of hemorrhages and monitoring systemic conditions in these babies of amblyogenic age-group are required.

Background: Pediatric abusive head trauma (AHT) refers to head injury from intentional blunt force or violent shaking in children aged five years or less. We sought to evaluate the epidemiology of ocular injuries in AHT.Methods: This retrospective analysis of the National Trauma Data Bank (2008 to 2014) identified children aged five years or less with AHT and ocular injuries using ICD-9-CM codes. Demographic data, types of ocular and nonocular/head injuries, geographic location, length of hospital admission, injury severity, and Glasgow Coma scores were tabulated and analyzed.Results: A total of 10,545 children were admitted with AHT, and 2550 (24.2%) had associated ocular injuries; 58.7% were female. The mean age was 0.5 (±1.0) years. Most (85.7%) were aged one year or less. Common ocular injuries included contusion of eye/adnexa (73.7%) and retinal edema (59.3%), and common head injuries were subdural hemorrhage (SDH) (72.8%) and subarachnoid hemorrhage (22.9%). Retinal hemorrhages occurred in 5.3%. About 42.8% of children had injury severity scores greater than 24 (very severe), and the mortality rate was 19.2%. Children aged one year or less had the greatest odds of retinal hemorrhages (odds ratio [OR] = 2.44; P = 0.008) and SDH (OR = 1.55; P < 0.001), and the two- to three-year-old group had the greatest odds of contusions (OR = 1.68; P = 0.001), intracerebral hemorrhages (OR = 1.55; P = 0.002), and mortality (OR = 1.78; P < 0.001). For all ages, SDH occurred most frequently with retinal edema compared with other ocular injuries (OR = 2.25; P < 0.001).Conclusions and Relevance: Ocular injuries varied with age and were variably associated with nonocular injury. The youngest group was most frequently affected; however, the two- to three-year-old group was most likely to succumb to injuries. [ABSTRACT FROM AUTHOR]

Abstract Background Our purpose was to document the swept source optical coherence tomography (SSOCT) findings in a patient with Shaken baby syndrome (SBS). Case presentation SSOCT was obtained without sedation in a six-month-old girl with bilateral multilayered retinal hemorrhages due to SBS. It documented vitreoretinal interface abnormalities, including internal limiting membrane (ILM) detachment with retinal traction, in association with other specific changes in the inner and outer retinal layers. Six weeks later, retinal hemorrhages had substantially resolved, and there was optic disc pallor. OCT showed ILM reattachment with release of retinal traction and the development of severe diffuse retinal atrophy involving the fovea. Conclusions SS OCT can provide useful information in SBS, revealing a wide variety of vitreoretinal interface, inner, and outer retinal changes not detected by clinical examination. It also may have a prognostic value over follow-up.

Lalit Agarwal,1 Deepti Pradhan,1 Nisha Agrawal,2 Ichhya Joshi,1 Archana Kumari,1 Anamika Kushwaha1 1Biratnagar Eye Hospital, Biratnagar, Nepal; 2Taparia Eye Care, Biratnagar, NepalCorrespondence: Deepti PradhanBiratnagar Eye Hospital, Rani, Biratnagar, NepalTel +977 9808119112Email deeptiprdhn@gmail.comPurpose: To report an uncommon case of intraoperative ocular decompression retinopathy (ODR).Case report: A 48-year-old man presented with decreased vision and pain in the left eye (LE) for 10 days following trauma with a bamboo stick. He had visual acuity of counting finger close to face in the same eye, along with corneal edema, dilated pupil and posteriorly dislocated lens. Intraocular pressure (IOP) was 42 mm of mercury (Hg). He underwent 23-gauge pars plana vitrectomy with removal of the dislocated lens. Towards the end of otherwise uneventful surgery, blot hemorrhages appeared over the posterior pole and equator. The following day, his vision was counting finger close to face and IOP was 16 mm of Hg. Fundus examination revealed large blotches of hemorrhages at different levels of the retina, later confirmed by optical coherence tomography. Disc hyperfluorescence and blocked fluorescence corresponding to blot hemorrhages were seen on fundus fluorescein angiography. Blood investigations to rule out blood dyscrasias were within normal limits.Conclusion: Ocular decompression retinopathy, though not common, has been reported to occur following various types of surgeries, especially if associated with preoperatively raised IOP. The event can also occur intraoperatively and the preoperative control of IOP is of paramount importance in the prevention of ODR.Keywords: pars plana vitrectomy, intraoperative complication, preoperative raised intraocular pressure, retinal hemorrhages, decompression retinopathy

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.

Competing Interests: Conflict of Interest None.

Purpose: To evaluate the clinical characteristics of intraocular hemorrhages among babies screened for retinopathy of prematurity (ROP) and thereby their additional risk to the progression of ROP.Methods: A descriptive study was conducted at a tertiary referral hospital, which included 108 eyes of 60 neonates who were discovered to have retinal hemorrhages on retinal screening of 540 babies at risk for ROP. Maternal, obstetric, and neonatal risk factors were assessed in neonates with retinal hemorrhages. Retinal hemorrhages were assessed in terms of type, area, and relation to different retinal zones.Results: Among 540 neonates who were screened, retinal hemorrhages were found in 11.2% (n = 60 babies). Elderly primigravida mothers and spontaneous vaginal deliveries with prolonged second stage of labor were a common maternal risk factors for retinal hemorrhages. Low birth weight and preterm were fetal risk factors with neonatal retinal hemorrhages. These hemorrhages were more often bilateral (no. of babies = 48, 80%). Flame-shaped hemorrhages were more common than dot and blot ones. The majority of cases (no. of eyes = 74, 65%) resolved within 4 weeks, whereas four babies (8 eyes, 7.4%) progressed to ROP were treated with laser.Conclusion: Retinal hemorrhages in neonates are commonly associated with prolonged duration of second stage of labor, advanced maternal age, and anemia. Although not all progress to ROP, recognizing preterm and low birth weight babies with junctional hemorrhages is crucial not to delay the treatment. Regular follow-up until the clearance of hemorrhages and monitoring systemic conditions in these babies of amblyogenic age-group are required. [ABSTRACT FROM AUTHOR]

Purpose: Until now, the diagnosis of optic nerves hemorrhages in abusive head trauma (AHT) has been obtained only in the postmortem setting. The aim of the IRB-approved study was to assess the presence of optic nerves hemorrhages in AHT patients using 3D-SWI. Methods: Thirteen children with a final confirmed multidisciplinary diagnosis of AHT underwent coronal and axial 3D-SWI imaging of the orbits. The presence of optic nerve sheath (ONS) hemorrhages was defined by thickening and marked 3D-SWI hypointensity of the ONS, resulting in mass effect upon the CSF space. Optic nerve (ON) hemorrhages were defined by areas of susceptibility artifacts in the ON parenchyma. Superficial siderosis was defined by susceptibility artifact coating the ON. Furthermore, data about post-traumatic deformity of the ONS at the head of the optic nerve were collected. Results: The average age of the population was 7.9 ± 5.9 months old. The average GCS was 11.8 ± 4.5. The male to female ratio was 7:6. ONS hemorrhages were identified in 69.2% of cases. Superficial siderosis and ON hemorrhages were identified in 38.5 and 76.9% of cases, respectively. 3D-SWI also depicted traumatic deformity of the ONS at the level of the optic nerve head in 10 cases (76.9%). No statistical correlations were identified between RetCam findings and 3D-SWI findings or GCS and ON hemorrhages. Conclusion: This research shows that dedicated MRI with volumetric SWI of the orbits can depict hemorrhages in the ON, ONS, and ONS injury, in AHT victims. [ABSTRACT FROM AUTHOR]

Abusive head trauma (AHT) is frequently accompanied by dense/extensive retinal hemorrhages to the periphery with or without retinoschisis (complex retinal hemorrhages, cRH). cRH are uncommon without AHT or major trauma. The study objectives were to determine whether cRH are associated with inertial vs. contact mechanisms and are primary vs. secondary injuries. This retrospective study utilized a de-identified PediBIRN database of 701 children <3-years-old presenting to intensive care for head trauma. Children with motor vehicle related trauma and preexisting brain abnormalities were excluded. All had imaging showing head injury and a dedicated ophthalmology examination. Contact injuries included craniofacial soft tissue injuries, skull fractures and epidural hematoma. Inertial injuries included acute impairment or loss of consciousness and/or bilateral and/or interhemispheric subdural hemorrhage. Abuse was defined in two ways, by 1) predetermined criteria and 2) caretaking physicians/multidisciplinary team's diagnostic consensus. PediBIRN subjects with cRH frequently experienced inertial injury (99.4 % (308/310, OR = 53.74 (16.91–170.77)) but infrequently isolated contact trauma (0.6 % (2/310), OR = 0.02 (0.0004–0.06)). Inertial injuries predominated over contact trauma among children with cRH sorted AHT by predetermined criteria (99.1 % (237/239), OR = 20.20 (6.09—67.01) vs 0.5 % (2/339), OR = 0.04 (0.01–0.17)). Fifty-nine percent of patients with cRH, <24 h altered consciousness, and inertial injuries lacked imaging evidence of brain hypoxia, ischemia, or swelling. cRH are significantly associated with inertial angular acceleration forces. They can occur without brain hypoxia, ischemia or swelling suggesting they are not secondary injuries. [ABSTRACT FROM AUTHOR]

Introduction: High altitude has various effects on human beings. Altitude-related illnesses are a frequent cause of morbidity and occasional mortality in travelers to high altitudes throughout the world. Altitude has potential undesired ophthalmological effects too. Most of these problems are primarily preventable with an adequate level of information before and during travel. In this article, ophthalmological effects like altitude retinopathy and other ocular presentations of high altitude, likely to be encountered by mountaineers, are reviewed. Materials and methods: This is a hospital-based cross-sectional study from March 2016 to March 2017 done in Swacon International Hospital and Sleep Care Center, Kathmandu, Nepal. All the patients diagnosed as acute mountain sickness in the hospital during the study period were included. All the patients were evaluated by a physician and an ophthalmologist. All the findings were recorded in the proforma. Results: A total of 167 patients were admitted. Among them, 98 patients were diagnosed with acute mountain sickness; 20 patients had High altitude cerebral edema and 40 had High altitude pulmonary edema. Ocular findings, among patients who presented to our centre, were a high altitude retinopathy (28.48%) corneal abrasions (5.6%), snow blindness (8.86%), acetazolamide induced myopia (2.53%), conjunctivitis(8.22%), corneal ulcer (1.26%) and retinal detachment(0.63%). Conclusions: Mountaineers are at risk of developing high-altitude-related illnesses. Many other tissues in the eyes are also affected by high-altitude hypoxia, and effects can be observed on the conjunctiva, cornea, intraocular pressure, lens, uvea apart from the retina and the optic nerve.

Purpose The aim of this study was to compare the incidence of ophthalmological complications in chronic hepatitis C virus patients treated with dual versus triple antiviral protocols. Study design A Prospective, observational, comparative study. Setting Ahmed Maher Teaching Hospital and revised in the Outpatient Clinic of Ophthalmology Department of Beni Suef University. Patients and methods One hundred and fifty chronic hepatitis C virus patients were treated by dual therapy of sofosbuvir and ribavirin for 6 months (group A), and 150 patients were treated by triple therapy of sofosbuvir, ribavirin, and interferon pegylated interferon (pegINF-α) for 3 months (group B). Full general and ophthalmological examinations were done at the baseline visit before receiving treatment and at 3 and 6 months after treatment. Any ophthalmological complications including deterioration in best corrected visual acuity, anterior segment inflammation, or retinal complications in the form of hemorrhages, soft exudates, or changes in cup/disk ratio were recorded. Results In 11% of the patients under triple therapy, retinal hemorrhages and soft exudates were detected by the second visit; however, they resolved by the third visit. Patients under dual therapy showed no ophthalmological complications throughout the 6-month follow-up period. No uveitis or changes in best corrected visual acuity and cup/disk ratio were detected. Conclusion Interferon-free protocols showed no retinal complications. However, the retinal complications related to the interferon-containing protocols resolved shortly within weeks. Thus, interferon-free protocols showed higher safety on the eye.

Background: To report four cases with interesting anatomical presentations of multilayer macular hemorrhages with preretinal hemorrhage possibly preventing subretinal involvement of the macular area. Cases presentation: Observational study of four patients presenting with macular hemorrhages. Results: Four patients with multilayer macular hemorrhage due to different causes, presented with a halo-shaped submacular hemorrhage coincident with the preretinal hemorrhage borders. After resolution, in all cases, the macular area underneath the preretinal hemorrhage was found to be spared. Conclusion: We hypothesized that an extensive preretinal hemorrhage can exert a mechanical force pushing the subretinal hemorrhage towards the periphery, consequently protecting the macular area. [ABSTRACT FROM AUTHOR]

We report a case of bilateral retinal hemorrhages with macular edema in a patient with dengue fever (DF). This patient also had cerebral hemorrhage. A 17-year-old female presented with sudden painless loss of vision in her both eyes for 2 days associated with redness of eyes. She was diagnosed having DF based on detected dengue immunoglobulin M in her blood sample. Fundus examination of both eyes showed preretinal and intraretinal hemorrhages. Optical coherence tomography showed neurosensory detachment and macular edema. This case report warrants the importance of ocular screening in a patient having systemic complications of DF. [ABSTRACT FROM AUTHOR]

A 53-year-old man presented with acute loss of vision, negative scotoma and dyschromatopsia in his left eye. He reported contact with people with severe respiratory syndrome - coronavirus-2 (SARS-CoV-2) 8 days prior symptoms. Funduscopic examination revealed several retinal hemorrhages. Spectral-domain optical coherence tomography showed lesions consistent with acute macular neuroretinopathy and paracentral acute middle maculopathy. Quickly after his presentation, SARSCov-2 was confirmed by chest computed tomography-scan and RT-PCR in this patient. Thrombotic complications associated with Covid-19 infection have high incidence and may involve the retina. We described a case of retinal involvement associated with Covid-19 infection. Funduscopic examination revealed retinal hemorrhages in a man with loss of vision. Optical coherence tomography showed an acute macular neuroretinopathy and paracentral acute middle maculopathy. Coronavirus disease was confirmed by chest computed tomography-scan and RT-PCR. [ABSTRACT FROM AUTHOR]

Purpose: To report a unique case of Valsalva retinopathy associated with ear popping behavior. Observations: A 57-year-old woman with a history of well-controlled hypertension presented with episodes of seeing “spots” in her left eye for many years. Her most recent episode failed to resolve spontaneously. Fundus examination revealed scattered retinal hemorrhages in the left eye, and optical coherence tomography demonstrated sub-internal limiting membrane location of these hemorrhages. Fluorescein angiography did not reveal any vascular abnormalities. Based on these findings and an in-depth review of systems, a diagnosis of Valsalva retinopathy was made associated with patient's ear popping habit. Conclusions and importance: Habitual ear popping can be a potential etiology of symptomatic Valsalva retinopathy. This under-appreciated association may be clinically relevant for patients with a history of suspected Eustachian tube narrowing or dysfunction.

Background. Retinal hemorrhages in infants are frequent pathologies, but their causes, clinical forms and functional outcomes are poorly studied. The study of hemorrhage localization in the eye structure, time frames of their resolution, and the long-term effects that may affect the development of vision is of particular interest.Objective. Our aim was to analyze clinical forms, time frames of resolution and long-term clinical and functional outcomes of retinal hemorrhages in infants.Methods. All children with retinal hemorrhages, who applied to a premature baby room in the MRI of ED n. a. Helmholtz at the age from 3 weeks to 3 months for 5 years (2011–2015), were examined using indirect ophthalmoscopy. In case of extensive lesions, the process dynamics was controlled by a pediatric digital retinal imaging system. Long-term clinical and functional outcomes of retinal hemorrhages were studied using ultrasound examination and spectral optical coherence tomography.Results. Fundus hemorrhages were revealed in 108 (5.9%) of 1,825 infants on 142 eyes (34 children had bilateral hemorrhages). Hemorrhages were more frequent in children delivered vaginally (79 children, 73.2%), were unilateral (74 children, 63.5%), pre-retinal (108 eyes, 76.1%), of central localization (119 eyes, 83.8%). The time frames of hemorrhage resolution in 53 children (49.1%) were more than one month. Long-term outcomes of retinal hemorrhages were studied in 22 children (33 eyes) at the age of 2–5 years. Residual changes in the structure of the neuroepithelium and vitreoretinal interface with a decrement in visual acuity were noted in 7 children (9 eyes).Conclusion. Retinal hemorrhages of newborns are characterized by clinical polymorphism, different time frames of resolution and outcomes, which requires a case follow-up.

Background: There are very few previous studies regarding ocular screening done in term neonates. Retinal hemorrhages can occur in babies during delivery. Aims: To evaluate the correlation of retinal findings with the duration of second stage of labor in term neonates and mode of delivery. Settings and Design: This was a cross-sectional, observational study done on term newborns in a tertiary care centre. Convenience sampling was done. Subjects and Methods: Neonates were examined in the postnatal ward using handheld slit lamp and indirect ophthalmoscope. Fundus examination was done after dilating the pupils with 0.5% tropicamide and 2.5% phenylephrine eyedrops. Second stage of labor and mode of delivery were noted. Chi-square test and independent sample t-test were used to analyze the data. Results: One hundred and fifty infants were screened, of which 75 (50%) had retinal hemorrhages. Chi-square test showed statistical significance with duration of second stage of labor and occurrence of retinal hemorrhages (P < 0.001). Patients with second stage of labor shorter than 30 minutes of duration were found to have more chances of having retinal hemorrhages. Independent sample t-test used for association between mode of delivery and retinal hemorrhages showed patients born of normal vaginal delivery to have more chances of having hemorrhages (P = 0.006). Chi-square test showed statistical significant association with the presence of hemorrhages and day of evaluation (P < 0.001). Conclusion: Retinal hemorrhages were found to be common in full-term babies whose second stage of delivery was shorter than 30 minutes of duration.

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