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W4245301753 abstract "We thank Drs Levin et al for their interest in our article. Using their numbered queries: 1, 2Blood accumulation in the subhyaloid space gives a round, dome-shaped, well-margined hemorrhage appearance, which was found in 46% of our cases (106/231). Traumatic retinoschisis has indeed been reported in shaken babies. We were nevertheless unable to distinguish clearly retrohyaloidal hemorrhages (RHHs) from blood trapped underneath the internal limiting membrane. Therefore, traumatic retinoschisis, if any in our series, would be included among the RHH cases. None of our patients had clinically documented macular retinoschisis. Unfortunately, eye autopsies were not performed on the 19 children with fatal outcomes.3When we used the term child neglect, we meant physical neglect of a child. Neglect is defined as a failure to look after someone.1Sinclair J, ed. Collins Cobuild Dictionary. 3rd ed. London: Harper Collins; 1990:963.Google Scholar The term child neglect refers to child abuse in the U.S. National Library of Medicine's Medical Subject Headings database.4Assessing a correlation between intraocular hemorrhages (IOHs) and subdural hematoma (SDH) was not the main purpose of this article. However, a score was assigned for each eye regarding IOHs as follows: 0, no IOHs; 1, ≤10 retinal hemorrhages (RHs) and/or RHHs; 2, >10 RHs and/or RHHs; 3, diffuse RHs and/or RHHs too numerous to count; and 4, intravitreous hemorrhage. A score was also assigned regarding the width of the SDH on each hemisphere: 0, no SDH; 1, SDH's maximum width of <1 cm; 2, SDH's maximum width of 1 to 2 cm; and 3, SDH's maximum width of >2 cm. Each infant had a final ocular and subdural score determined by adding the scores for both sides. Statistical analysis (Spearman rank correlation test) showed no correlation between the severity of the intraocular and subdural hemorrhages. Acute subdural bleeding related to shaking may occur in preexisting benign pericerebral cerebrospinal fluid collections (external hydrocephalus). Therefore, the width of the acute subdural bleeding is not reflected in the measurement of the total SDH width. This could explain the lack of correlation between the severity of IOHs and SDH, unlike other reports.2Morad Y. Kim Y.M. Armstrong D.C et al.Correlation between retinal abnormalities and intracranial abnormalities in the shaken baby syndrome.Am J Ophthalmol. 2002; 134: 354-359Abstract Full Text Full Text PDF PubMed Scopus (192) Google Scholar, 3Wilkinson W.S. Han D.P. Rappley M.D. Owings C.L. Retinal hemorrhage predicts neurologic injury in the shaken baby Syndrome.Arch Ophthalmol. 1989; 107: 1472-1474Crossref PubMed Scopus (111) Google Scholar No correlation was also seen between the IOH score, the SDH score, and the early fatal outcome. The cause of death for the 19 children in this study was mainly severe cerebral edema, SDH being most of the time minor.5Retinal hemorrhages were believed to be of different ages when the initial funduscopy revealed areas of fresh red hemorrhages combined with fading ones. Several reasons led us to consider white-centered hemorrhages to be older than fresh reddish ones. Firstly, they are thought to result from post-traumatic capillary ruptures, with subsequent extravasation and formation of a fibrin platelet plug.4Duane T.D. Osher R.H. Green W.R. White centered hemorrhages their significance.Ophthalmology. 1980; 87: 66-69Abstract Full Text PDF PubMed Scopus (69) Google Scholar Another proposed mechanism includes central clearing of a previously homogenous hemorrhage.5Phelps C.D. The association of pale-centered retinal hemorrhages with intracranial bleeding in infancy. A report of two cases.Am J Ophthalmol. 1971; 72: 348-350PubMed Scopus (15) Google Scholar These mechanisms are probably not immediate. Secondly, the funduscopy follow-up in our study showed that the presumed oldest RHs were the first to disappear, followed by the disappearance of the fresh ones.Increased intrathoracic pressure could to explain RHs in shaken babies who are known to have been grasped by the thorax. Thirteen percent of the children in our series had rib fractures. The mechanism responsible for these RHs may be the same advocated by Goetting and Sowa6Goetting M.G. Sowa B. Retinal hemorrhage after cardiopulmonary resuscitation in children an etiologic reevaluation.Pediatrics. 1990; 85: 585-588PubMed Google Scholar when they described RHs after cardiopulmonary resuscitation in children.Because RHs were significantly less frequent in the presence of head impact or in cases of proven accidental head trauma, one could advocate that mechanisms encountered only in pure shaken abuse (chest compression and/or concussion waves to the eye) may explain RHs in shaken babies. We thank Drs Levin et al for their interest in our article. Using their numbered queries: 1, 2Blood accumulation in the subhyaloid space gives a round, dome-shaped, well-margined hemorrhage appearance, which was found in 46% of our cases (106/231). Traumatic retinoschisis has indeed been reported in shaken babies. We were nevertheless unable to distinguish clearly retrohyaloidal hemorrhages (RHHs) from blood trapped underneath the internal limiting membrane. Therefore, traumatic retinoschisis, if any in our series, would be included among the RHH cases. None of our patients had clinically documented macular retinoschisis. Unfortunately, eye autopsies were not performed on the 19 children with fatal outcomes.3When we used the term child neglect, we meant physical neglect of a child. Neglect is defined as a failure to look after someone.1Sinclair J, ed. Collins Cobuild Dictionary. 3rd ed. London: Harper Collins; 1990:963.Google Scholar The term child neglect refers to child abuse in the U.S. National Library of Medicine's Medical Subject Headings database.4Assessing a correlation between intraocular hemorrhages (IOHs) and subdural hematoma (SDH) was not the main purpose of this article. However, a score was assigned for each eye regarding IOHs as follows: 0, no IOHs; 1, ≤10 retinal hemorrhages (RHs) and/or RHHs; 2, >10 RHs and/or RHHs; 3, diffuse RHs and/or RHHs too numerous to count; and 4, intravitreous hemorrhage. A score was also assigned regarding the width of the SDH on each hemisphere: 0, no SDH; 1, SDH's maximum width of <1 cm; 2, SDH's maximum width of 1 to 2 cm; and 3, SDH's maximum width of >2 cm. Each infant had a final ocular and subdural score determined by adding the scores for both sides. Statistical analysis (Spearman rank correlation test) showed no correlation between the severity of the intraocular and subdural hemorrhages. Acute subdural bleeding related to shaking may occur in preexisting benign pericerebral cerebrospinal fluid collections (external hydrocephalus). Therefore, the width of the acute subdural bleeding is not reflected in the measurement of the total SDH width. This could explain the lack of correlation between the severity of IOHs and SDH, unlike other reports.2Morad Y. Kim Y.M. Armstrong D.C et al.Correlation between retinal abnormalities and intracranial abnormalities in the shaken baby syndrome.Am J Ophthalmol. 2002; 134: 354-359Abstract Full Text Full Text PDF PubMed Scopus (192) Google Scholar, 3Wilkinson W.S. Han D.P. Rappley M.D. Owings C.L. Retinal hemorrhage predicts neurologic injury in the shaken baby Syndrome.Arch Ophthalmol. 1989; 107: 1472-1474Crossref PubMed Scopus (111) Google Scholar No correlation was also seen between the IOH score, the SDH score, and the early fatal outcome. The cause of death for the 19 children in this study was mainly severe cerebral edema, SDH being most of the time minor.5Retinal hemorrhages were believed to be of different ages when the initial funduscopy revealed areas of fresh red hemorrhages combined with fading ones. Several reasons led us to consider white-centered hemorrhages to be older than fresh reddish ones. Firstly, they are thought to result from post-traumatic capillary ruptures, with subsequent extravasation and formation of a fibrin platelet plug.4Duane T.D. Osher R.H. Green W.R. White centered hemorrhages their significance.Ophthalmology. 1980; 87: 66-69Abstract Full Text PDF PubMed Scopus (69) Google Scholar Another proposed mechanism includes central clearing of a previously homogenous hemorrhage.5Phelps C.D. The association of pale-centered retinal hemorrhages with intracranial bleeding in infancy. A report of two cases.Am J Ophthalmol. 1971; 72: 348-350PubMed Scopus (15) Google Scholar These mechanisms are probably not immediate. Secondly, the funduscopy follow-up in our study showed that the presumed oldest RHs were the first to disappear, followed by the disappearance of the fresh ones. Increased intrathoracic pressure could to explain RHs in shaken babies who are known to have been grasped by the thorax. Thirteen percent of the children in our series had rib fractures. The mechanism responsible for these RHs may be the same advocated by Goetting and Sowa6Goetting M.G. Sowa B. Retinal hemorrhage after cardiopulmonary resuscitation in children an etiologic reevaluation.Pediatrics. 1990; 85: 585-588PubMed Google Scholar when they described RHs after cardiopulmonary resuscitation in children. Because RHs were significantly less frequent in the presence of head impact or in cases of proven accidental head trauma, one could advocate that mechanisms encountered only in pure shaken abuse (chest compression and/or concussion waves to the eye) may explain RHs in shaken babies." @default.
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