Forensic S&lace Znternutionul, 39 (1988) 293 - 299 Elsevier Scientific Publishers Ireland Ltd.

293

AUTOPSSY FINDINGS IN THE EYES OF FOURTEEN FATALLY ABUSED CHILDREN

NARSING lRAO*, RONALD E. SMITHb, JOSEPH H. CHOP, XU XIAOHV and RONALD N. KORNBLUM”

“Estelle Doh.eny Eye Foundation, 4Cions Doheny Eye Bank, 1355 San Pablo Street, Los Angeles, CA 90093, ‘Department of Chief Medical Examiner, 1104 N. Mission Road, Los Angeles CA 90055 Kl.S.A.l and dDepartment of Forensic Pathology, Sun Yat-Sen University of Medical Sciences, Guang Zhou, Guung Dong (Peoples Republic of Chinal

(Received February 19th, 1988) (Revision received May lst, 1988) (Accepted June 6th, 1988)

Summary

The eyes of fourteen fatally abused children and sixteen control cases were examined histo- pathologically. Ten of the abused children showed intraocular change. The most common ocular changes were subdural hemorrhage of the optic nerve and retinal hemorrhage which involved all the layers of the retina, but most commonly the nerve fiber layer, ganglion cell layer and inner nuclear layer. The presence of blood cavities within the retina partially supported the hypothe- sis of traumatic retinoschisis. The control cases of non-abused children rarely showed intraocular hemorrhage.

Key words: Autopsy eye; Fatally abused child; Retinal hemorrhage; Subdural hemorrhage; Traumatic retinoschisis.

Introduction

Since Caffey first described the ocular changes in “battered child syndrome”, numerous reports have been published [l-3], which gave the basic picture of ocular change in child abuse. A review of the literature reveals that most of those reports are clinical observations [2- 91. Histopathological evidence is still needed to support some hypotheses. In order to better understand the relationship between the general injuries and the ocular changes in child abuse, we have conducted this study in the Los Angeles’ Chief Medical Examiner-Coroner Office and Lion’s Doheny Eye Bank.

Materials and Methods

The specimens of eye were taken from the autopsy cases of the Chief Medical Examiner-Coroner’s Office in the period from February, 1985 to

0379-07331881503.50 0 1988 Elsevier Scientific Publishers Ireland Ltd. Printed and Published in Ireland

294

February, 1987. Fourteen cases of fatally abused children have been col- lected, including nine case of traumatic injury and five cases of shaken chil- dren. Ten were males and four were females. The age range was from 2 months to 4 years old. Ten were Caucasian, three were Black, and one was Hispanic. In addition, 16 cases of non-abused children were obtained as con- trol (Table 11, including three cases of traumatic injury, one case of traffic accident, four cases of sudden infant death syndrome and eight cases of other diseases.

Both eyes were taken from each case and were fixed with 10% neutral buffered formalin solution for at least 3 days. After gross and macroscopic examination, horizontal sections of the eyeballs (including the optic nerve) were made and stained with H & E, PAS and iron stain methods. Color photographs were taken of the intraocular changes. The history and autopsy findings were reviewed in each case, special attention being paid to the injuries on the body and their relationship to the ocular changes.

Results

(1) Child abuse cases Ten of the 14 child abuse cases showed ocular changes. Cases nos. 6,9,10,

11 and 14 were shaken children (Table 21. Figures l-2 show the intraocular hemorrhage.

Nine of the 14 cases showed subdural hemorrhage of the optic nerve (Fig. 31. Retinal hemorrhage was seen in eight cases, bilaterally in five cases and unilaterally in three cases (Table 31.

121 Control cases One of three cases of traumatic injury showed bilateral retinal hemor-

rhage and subdural hemorrhage of the optic nerve. This was an 11-month-old black male who hit his head on the leg of the table, when he was playing

TABLE 1

THE AGE RANGE AND SEXUAL DISTINCTION OF THE CASES

4s Child abwe caeee Control case

Male Female Ma& Female

*l year 6 3 5 6 -2 years 2 1 1 1 -3 years - - 2 1 m4 years 2 - -

Total 10 4 8 8

295

TABLE 2

THE GENERAL INJURIES AND THE OCULAR CHANGES

Case no.

1 2S 4 56 7 89 10 11 12 19 14 Total

Scaip contution + Skull fracture + Subdural hemorrhage Subarachnoid hemorrhage + Cerebral edema + Periorbitaha Face and neck + Chest + Abdomen + Buttock + Extremities +

Cornea Cataract VitreaI hemorrhage + Retinal hemorrhage Retinal detachment Choroid hemorrhage PapiIIedema Subdural hemorrhage

of the optic nerve + Hemosiderin

++ + ++ + + + + + ++ + + + + ++ + + ++ ++

+ + ++

+ +

+

+ +

+ +

+ + +

+ + + +

+ + + + + ++

++

+ ++ +

+ + +

+ ++

+

+ +

+

+

+

+ + 11 + + 6

+ 6 + + 6 + 8

8 8 4 7 3 4

1 1

+ 2 + + 8

2 1

+ + 4

+ + 9 + 1

with his father. The general injuries were subdural hemorrhage of the head and cerebral edema.

Two cases showed the intraocular change of cataract (non-traumatic), one died of the sudden infant death syndrome and another died of aspiration pneumonia. No other injury was seen in either case.

No ocular changes were seen in the other control cases, except for the postmortem changes such as partial absence of the cornea1 epithelium or choroidal congestion.

Discussion

Greenwald et al. [S] presented a clinical observation of three cases of child abuse with the ocular fundus change of “a large cystic or dome-like lesion in the macular region, completely or partially filled with blood”. They described the lesions as appearing to be intra-retinal cysts or retinoschisis. Two cases of child abuse in our material did show the “dome-like lesion” histopafhologically. ’ These were cavities between the internal limiting membrane and the nerve fiber layer, which were filled with blood and fluid

296

Fig. 1. Hemorrhage in the papilla of the optic nerve.

Fig. 2. Hemorrhage in pre-retina and vitrous.

Fig. 3. Subdural hemorrhage in the optic nerve.

TABLE 3

RETINAL HEMORRHAGE AND SUBDURAL HEMORRHAGE OF THE OPTIC NERVE

Layer Case no.

1 2.84 56 7 8 9 10 11 12 13 14

Retinal hemorrhage Internal limiting ++ ++ ++ + + ++ ++ Nerve fiber ++ ++ ++ + + ++ ++ Ganglion cell ++ ++ ++ + + ++ ++ Inner pl.exiform + + + ++ Inner nuclear ++ ++ ++ + + ++ Outer plexiform ++ + + ++ Outer nuclear + ++ + ++ External limiting + + + ++ Rods and cons + ++ ++ + ++ Pigmentary epithelium + + + ++

Subdura of the optic nerve ++ ++ ++ + ++ ++++ ++ ++

298

Fig. 4. The trauniatic bloody cavity in the retina.

(Fig. 41. Our finding supports the presence of the “dome-like lesion” and shows their common location within the retina.

Reviewing the literature and our results, we propose that concussion is one of the most important causes of retinal hemorrhage in child abuse. Con- cussion implies a severe blow or an impact to an organ, which may be from a blunt object hurling through space and striking a second object. If the concussion is of sufficient intensity to disrupt the blood vessels, it results in hemorrhage [lo]. When a child is physically abused, he may suffer from head trauma or whiplash injuries, either of which can cause concussion to the brain and eyes. Because of the weakness of the neck muscles in children, the energy can not be absorbed by the neck muscle [ll]. The head is subjected to repetitive acceleration and deceleration, as it whiplashes back and forth. The retina is particularly vulnerable as it impacts against the sclera. Additional force may impinge on this area by virtue of the globe being thrust against the orbital contents and the wave of force may be transmitted through the facial bones and through the orbital contents to produce an impact upon the globe [12]. All of these may cause the rupture of the blood vessels in the ret- ina. Most commonly, hemorrhage occurred between the interal limiting membrane and the ganglion cell layer, especially in the nerve fiber layer of the retina.

There were four cases of child abuse without ocular change, all of them with complicated scalp contusion, and three of them with complicated cere- bral edema. This suggests that the mechanism of ocular change in child

299

abuse is multiple rather than single. All five cases of shaken children show intraocular hemorrhage, which gives the impression that shaking is an important factor causing ocular change.

About 10% of infant death is presented to the pathologist as sudden or unexpected death. Both child abuse and sudden infant death syndrome have been shown to occur more often with low maternal age, high birth order, lower social class, and illegitimacy [13]. In our control cases, retinal hemor- rhage an.d subdural hemorrhage of the optic nerve occurred in only one case with severe head trauma. This implies that retinal hemorrhage and subdural hemorrhage of the optic nerve are not common in non-abused children. If intraocul.ar hemorrhage is seen, the possibility of child abuse should be considered, even if the case comes from the history of Sudden Infant Death Syndrome originally. Immediate and accurate diagnosis is required to pre- vent further damage to the child [14]. The “Battered Child Syndrome” should be borne in mind in the differential diagnosis of ocular conditions of children not only by the clinician, but also by the ocular pathologist [3] and the forensic pathologist.

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