1. Ocular findings of AHT
2. Pathophysiology of ocular and brain injury during AHT
3. Ocular findings of Normal Vaginal Delivery and differences from AHT ocular findings
Lecturer: Dr. Donny Suh, Ophthalmologist from The University of Nebraska, USA.
DR SUH: Well, good morning or good evening, depending on where you are. Again, my name is Donny Suh, the chief of pediatric ophthalmology, at the Children’s Hospital and Medical Center, also associate professor as the Truhlsen Eye Institute. I want to thank you for joining me this morning. Just a brief introduction. I live in Omaha, which is right here. Between Nebraska and Iowa. We are actually known for lots of farmland, beautiful golf courses, and this is the beautiful downtown of Omaha, and also the world-famous Omaha Zoo. Here is the Truhlsen Eye Institute at the University of Nebraska, and also the Children’s Hospital and Medical Center. I’ve been involved with Orbis since 2003. This is my picture. My first Orbis trip in 2003. And it’s truly been a great pleasure, in so many different ways. But the reason I enjoy Orbis so much is I get to share all the knowledge. So it’s not just me teaching. But I always learn far more than what I contribute. And this is definitely one of my favorite activities. That I’m involved in. Of course, this would not be possible without the support of our wonderful Orbis staff. That are coming from all over the world. And these are some of the Orbis staff, as you can see here. By the way, Lawrence, can you hear me okay?
>> Yep, we can hear you.
DR SUH: Okay, perfect, perfect. So I truly believe that dreams can come true by working together, and Orbis definitely makes this possible. So without further ado, I would like to — I actually have a very interesting case that I would like to share with you. And we’re gonna have a further discussion. And I’m gonna ask, before we start, I may actually ask about four to five questions, to get your feedback. Because, of course, the audience is from all over the world, and we — with different backgrounds — and I would like to get some feedback from you of what you’re familiar with. Before I start the talk. But first, let me present the case, and then we’ll provide some questions. First, I have a five month old child that was admitted with unresponsiveness, and we were consulted. And one day prior to presentation, the patient had a mild fever, diarrhea, and vomiting overnight, and became unresponsive by following morning. CPR was initiated, and was brought to the emergency room. On exam, patient was hypothermic, bradycardic, hypoxic, and had a Glasgow coma scale of 3, which meant virtually unresponsive. And the patient had a soft tissue swelling over the right parietal region. And patient was subsequently sedated and intubated, and full body CT scan was performed, it was unremarkable, and laboratory testing was performed, and the patient had hypernatremia and thrombocytopenia with INR of 2. So the patient was diagnosed with DIC, which I’m gonna discuss later. Disseminated intravascular coagulation. And as we all know, these patients do not have a very good prognosis. The patient was immediately started on infusion of red blood cells and fresh frozen plasma, platelets, and vasopressors. Antibiotics were initiated, along with antivirals. MRI of the brain was performed, which showed diffuse brain edema with inferior tonsillar herniation, with a diminished size of vasculature of Circle of Willis. That’s when we were consulted. Pupils were fixed and dilated, 4.5 millimeters, had right parietal localized soft tissue erythema, edema 3×3 centimeters. Otherwise unremarkable. On examination, the patient had these small focal areas of hemorrhages. And that’s the optic nerve right here. Multifocal hemorrhages of various sizes, involving the macular, perimacular, and peripheral areas. And if you look closely, there’s some white center areas here. This is a different view of the right eye. And this is the left eye. So in summary, patient has a diffused multifocal retinal hemorrhages. With just a little bit of disc edema on the right eye. But the left eye was virtually unremarkable. So at this point, one day following the eye exam… Unfortunately, the patient ceased spontaneous breathing and passed away. So I would like to ask some questions from the audience. What are the potential causes of retinal hemorrhages in this case? First, this is potentially a CPR induced hemorrhage from chest compression, anemia retinopathy, because the patient was anemic. DIC coagulopathy induced hemorrhage, normal vaginal delivery hemorrhage, increased ICP induced hemorrhage, abusive head trauma, and others. And if you could type the answer in the box, I would appreciate it. Okay, great. Let me go to the next question. Have you seen a case of abusive head trauma induced retinopathy? Yes or no? Lawrence, we don’t have to wait the full 30 seconds. We can probably go a little quicker. Perfect. So 58% of the audience has never seen it. Do you believe shaking a baby can induce retinal hemorrhage? Yes or no? Let’s just wait 10 seconds. Perfect. Yes, okay. How common is unilateral retinal hemorrhage in abusive head trauma or shaken baby syndrome? Doesn’t happen, 10%, 15 to 25%, 50%, or others? Okay. Perfect. So it’s pretty evenly distributed. Did you ever have to testify in court for an abusive head trauma case? Yes or no? Okay. Thank you. Could this be a normal vaginal delivery retinal hemorrhage? Yes or no? Likely or unlikely? Thank you. Okay. For the next — I’m gonna say about 40 minutes — I’m just gonna kind of go over some of the general knowledge on abusive head traumas, and some of the differential diagnoses, and the pathophysiology, and a study that we have performed, that we just submitted for publication. And then we’re gonna summarize everything, and then we’re gonna have a Q and A session afterwards. So the retinal hemorrhage in infants — the differential diagnosis can be quite extensive. As we can see here. I don’t want to go through the entire list. But this list is actually getting longer and longer, as more of the physicians are reporting anecdotal experiences of different conditions. For example, there are some recent reports of osteogenesis imperfecta, there’s some collagen vascular disease in young patients, developing retinal hemorrhages. There’s just more and more case reports that are being presented. But just in general, overall, I would say these are good categories. Retinal hemangiomas. Congenital. CMV infections, with other types of viral infections. Bacterial meningitis. Juvenile X-linked retinoschisis, various types of coagulopathy, anemia, leukemia, increase in intracranial pressure for various reasons, including Terson syndrome, hypoxia, and changes in sodium concentrations. But in this particular case, I would like to focus on — it could be actually — the patient, remember, as you recall, had a chest compression with CPR. So it could be an increased intrathoracic pressure, which I’m gonna discuss a little bit. It could be DIC, it could be from abusive head trauma, or it could actually be from a normal vaginal delivery. Because this can actually occur 25% to 50% of the cases. And actually, I’m gonna talk about that in detail. The retinal hemorrhages in CPR are due to increased intrathoracic pressures. Sometimes people refer to it as a Purtscher retinopathy. This is due to transient increased intrathoracic pressure in victims, who typically also have rib fractures. And it’s the cotton wool spots with the white retinal patches, with a few retinal hemorrhages. But truly, it is localized to the macular area. And the posterior pole. And most cases of CPR-induced retinal hemorrhages — these patients typically have a significant coagulopathy that coexists. So in this particular patient, with the diffuse retinal hemorrhages, with no white retinal patches, no cotton wool spots, it’s probably unlikely. Could this be from a DIC? DIC is a systemic activation of blood coagulation, which results in generation and depositions of fibrin, leading to microvascular thrombi. That actually results in extensive consumption of the coagulation protein and platelets, inducing severe hemorrhages or bleeding elsewhere. So you actually have areas of thrombus, and you actually have areas of bleeding. And this can be diagnosed based on serological testing. But it is truly — the ultimate diagnosis comes from a clinical — it is a clinical diagnosis. What causes DIC in infants? The number one, the most common cause, is severe sepsis. And then second is — most common — is traumatic brain injury. So DIC can develop, as many as a third of the traumatic brain injury. Even trivial head trauma history can produce coagulation changes, according to some of the studies. And pediatric abusive head trauma even without the signs of DIC shows abnormal coagulations in 71% of the children. So first, could this be a DIC? First, the infection. The sepsis was truly ruled out. Because the patient had extensive cultures. Of blood, serum, and urine. And it all came back negative. There was no signs of any infections. Could this be a traumatic brain injury as a result of possibly abusive head trauma, resulting in DIC? Then you have to think — okay, why would the retinal hemorrhages be isolated to just one eye? And second is that usually these patients with traumatic brain injury-induced DIC typically have other signs of hemorrhages. Because they have a coagulopathy. So it would be more generalized, rather than just localized to the one part of the retina. So they would have lid ecchymosis or conjunctival hemorrhage, or facial bruising, or other types of findings. And this particular patient did have a small parietal edema. So this could actually — is something that you should consider. But could this be actually just an actual case of abusive head trauma? Well, just a brief background. The abusive head trauma actually went through different names in the past. Initially it was called battered infant. And later it was called battered child syndrome. Whiplash shaking infant, shaken baby syndrome, and non-accidental trauma. Now we’re using the term abusive head trauma. So this entity has actually been recognized for over 50 years. And unfortunately, the abusive head trauma — it is the single most common cause of death due to child abuse, and about 4 to 5 children die per day. And it is the most common cause of traumatic death in children under the age of 12 months. And 80% of the survivors, even if they survive, many times they have permanent sequelae in the forms of motor, intellectual, and visual deficits, with cortical visual impairment. Victims are typically younger than 2, and 30% of the cases of abusive head trauma may go unrecognized. Why is that? Well, first of all, sometimes the physical manifestations may not be evident. Because as some of you believe, just a non-physical contact abuse can potentially cause these retinal hemorrhages. So if they don’t have any physical manifestations, it may actually just go unrecognized, if they don’t come into the medical setting. And second reason actually — the main reason I wanted to share this case with everybody — is that I truly believe that there’s a significant cultural barrier. What do I mean by that? I actually have been involved with Orbis for the last — Orbis and also other medical mission programs — for the last 17 years. Truly all over the world. And whenever I bring up this topic, most doctors have never seen it, actually. And if you actually go through the peer reviewed Chinese journals, I personally actually have not seen any cases of abusive head trauma. If one of the audience disagrees with that, please let me know. Because I personally could not find any cases of this particular entity in peer reviewed Chinese journals. And also in countries like India, this is just not something that is well recognized. And for the United States, this is a graph — this is a map that shows incidences of abusive head trauma. The darker the color, the higher the incidence. And so this is from the Omaha World-Herald, from 2014. And shows that the highest incidence of abusive head trauma occurs in Sarpy County in Nebraska. This is right next to where I live, and most of these patients end up at my medical centers. And fourth is Douglas County. This is where I live. So I actually see these unfortunate cases. And that’s actually part of the reason I got interested in this topic, and I’ve done some extensive research. So just quickly, the pathophysiology, the injury — it’s thought to be caused by direct impact. And as you can see here — or from an indirect impact. From the direct impact, as you can see, one can easily understand how this can cause skull fractures, edemas, and potentially retinal hemorrhages, if there was a direct impact. But indirect impact — this is where the head has no direct impact, and you’re simply shaking. So can brain or eye be injured and develop these types of hemorrhages even with no direct contact? Some question this, and some believe that this is actually not possible. So I would like to — and actually, I’m doing some studies to prove that indirect contact can actually cause these types of damages. And I’m gonna share that with you in just a little bit. First of all, how does this happen? These are some of the potential explanations. There’s an increase in CSF. There’s an increase in fluid, due to incomplete myelinization of the brain and optic nerve that allows for greater movement of the brain. And also, the neck is extremely flexible, because they don’t have the well developed neck muscles at this time. And also, their cervical spine is not hardened. Is not stiff. So they can actually develop cervical spine injuries as well. Because of the proportionally large head, large and heavy head. And with significant movement, the cervical spine can actually be injured. And this actually potentially can create a greater range of motion, with the torsional force to create acceleration and deceleration. So what does that mean? So with the acceleration and deceleration, first, with the forward movement, this abrupt deceleration — so as the head moves forward, abrupt deceleration can cause the brain to collide inside the skull. So this is the initial injury. And then second, this CSF, the water, which is denser than the brain, can rush into the site of impact, forcing the brain to move backwards in the opposite direction, and that causes a second wave of injury. So some people call this a coup and contrecoup injury. So that’s what happens to the brain. So here, let’s talk about what actually happens in the eye. So, again, the pathophysiology — these are some of the potential explanations — first, there’s an increased intracranial pressure from brain damage that can occur from various hemorrhages. Subdural, subarachnoid, intraventricular. So this edema can cause an increase in venous pressure at the optic nerve level, which causes obstructions of the retinal vasculature, that leads to rupture of the retinal vessels. So that’s one. Second is that linear acceleration. So this repetition of acceleration and deceleration, this linear acceleration, induces a shearing force at the vitreoretinal interface. And as we all know, the vitreous is bound to the retina at the retinal vessels, the macula, the optic nerve, and the vitreous base. So this shearing force can cause a disruption of the vitreoretinal interface. And that shearing force can tear the blood vessels and cause retinal hemorrhages. And also, this type of movement can disrupt the autonomic supply to the retinal vessels, affecting the vascular integrity and autoregulations. So that’s the linear acceleration. Now, there’s also an angular acceleration component, which I think is probably far more important. So here — there’s a significant torsional force that’s induced by the angular acceleration and deceleration. With the patient’s large, heavy head, with a soft neck as a hinge. And minimal head motion can create a large head movement. As a torque. And then this creates a torsional force — which has a far greater effect on the shearing force of the vitreoretinal interface of the entire retina, with minimal effort and minimal movement. So if this is a hint — so with minimal movement — I’m just barely moving my finger — there’s a greater range of motion of the head, and this creates a significant torsional force. Now, I want to actually talk about that just a little bit more in detail. Here, this is the hourglass. And this is the oil, and that’s water. And that interface is separated by the oil and water — is separated at the interface here. And as you move this back and forth, in a linear fashion, with linear accelerations and deceleration, that interface does get disrupted. But it’s actually pretty minimal. So here I’m actually shaking… So that interface is typically violated minimally. So there isn’t significant disruption. But here, if you actually hold the hourglass at the base, and just rotate it in this fashion, just with a minimal effort, as you can see… The vitreoretinal — the interface of the oil and water can get disrupted very, very easily. And so what does that mean? Okay. So when a baby is shaken, the translational force, plus a significant torsional force, plays a significant role. And probably for the shearing force, more of it actually comes from the torsion. So here’s another video. So here’s the baby that’s being shaken. And here — the baby’s shaken at 0.5 to 1 hertz. Which means it’s 1 cycle per minute. And at a low frequency, probably these patients develop small microhemorrhages that resolve very, very quickly. Because as you shake, and as you increase to 2 hertz… More significant hemorrhages. And then as you go up to 3 to 4 hertz… Which we speculate is the frequency of these babies potentially being shaken — these hemorrhages will become larger and more significant. Because the shearing force becomes more perpendicular, or more normal. Okay? This actually was developed with the help of our excellent iEXCEL Development Team. So retinal hemorrhages in abusive head trauma, with indirect injury, meaning no physical contact of the head — the retinal hemorrhages can be very helpful in diagnosis of abusive head trauma with little or no evidence of trauma and poorly documented history. So here at the University of Nebraska, we’re developing a computer generated finite element model. There are some finite element models that are available out there, but we’re actually going down to the cellular level. And we’re actually looking at the vitreoretinal interface, and we’re calculating the force that’s being induced by the linear and angular acceleration. And we’re in the process of developing this. The traditional thinking is that the retinal hemorrhages are considered a hallmark of abusive head trauma since the 1960s, and with a specificity of 94%. And diffuse retinal hemorrhage that extends into the periphery of the retina indicates, again, abuse. And other specific retinal findings such as vitreous hemorrhage can be very specific for abuse. Well, the problem with this is that the normal vaginal deliveries can induce retinal hemorrhages. And I actually have witnessed and seen some of these cases. And these are actually photographs of some of the normal vaginal delivered babies. Not C-section. Not vacuum-assisted. These are just normal vaginally delivered babies with hemorrhages that look like this. So this actually concerned us. And with the help of — this actually concerned us. And we actually did further investigation. And this is actually, again, a potential pathophysiology of the normal vaginal delivery retinal hemorrhages. The compression of the head that acutely influences — the compression of the head as the baby goes through the vaginal canal. This increases the intracranial pressure within the birth canal. May cause the retinal hemorrhages, due to increase in venous pressure. And also, most babies have coagulopathy, with the vitamin K deficiency. And that’s why they’re actually given vitamin K, around the time of birth. And also, most babies have, actually, the neonates have elevated prostaglandins, specifically prostaglandin E. In fetal circulation. They already have elevated PGE. But also some of the medications that are actually given to the mom during delivery can elevate the prostaglandin level, which are vasodilators, and also inhibits aggregation of blood platelets. And that in itself, along with the lower blood viscosity, which is present in neonates, increases the chance of these patients — increases the chance that these babies, these neonates, of developing these retinal hemorrhages, as they’re born. So it’s multifactorial. But there’s really no vitreoretinal tractional force that’s causing these retinal hemorrhages. We wanted to look at the patterns of the retinal hemorrhages a lot more in detail. So the dilemma in this situation is that the false-negative diagnosis of abusive head trauma may lead to some children at risk, because they have to go back to potential abuse situations. But the false positive is just as disastrous, because you can actually destroy the family dynamics. And the family. So we actually did a study. We were aiming to study — to analyze the patterns of abusive head trauma, and also normal vaginal delivery groups, to elucidate the difference and aid the clinician. So we did a retrospective review of all cases of potential child abuse in three years, here at UNMC. And we found 165 cases. And then of those, 31 cases were confirmed cases of abusive head trauma. With the perpetrator confessions, clinical-physical findings, witnessed abuse, and confirmed during legal proceedings. And the retinal hemorrhages were analyzed of these 31 patients. And this is what we found. And then for the normal vaginal delivered groups, with the help of my previous fellow, Dr. Soi Young Kim, in 2015-2016, we looked at 20,389 healthy neonates. Again, no C-sections, no vacuum assisted. These are normal vaginally delivered babies. They went through eye screening. All consecutive babies went through eye screening. And we obtained the retinal images, using a RetCam. And this is what we found. So they do share some common clinical findings. So we actually analyzed the differences of these two groups. Very carefully. So these — in these two cohorts, we actually looked at the number of hemorrhages — so we actually physically counted these hemorrhages within the photographs. And we looked at the sizes of the retinal hemorrhages, and we also looked at the retinal hemorrhages and determined the retinal layers. Whether it’s preretinal, intraretinal, or subretinal, based on the patterns and shapes of the retinal hemorrhages. And then we looked at the macular optic nerve involvement, and also involved zones. And then looked at the severity of the retinal hemorrhages, and we gave it a score that was modified from CHOP grading scale. And then we looked at the vitreous hemorrhages, retinal folds, and retinal detachments. So this is the grading scale that we used. So if the retinal hemorrhages were — the lesion was 1 disc diameter or less, it would get a score of 1. So if there’s any retinal hemorrhages that has these type of retinal hemorrhages, of this size, that would give a score of 1. And if they would have anything bigger than that, less than or equal to 2 disc diameters, they would get another point. 2 disc diameters, they would get another point. And then macula, if there’s any hemorrhages within the macular area of 2 disc diameters from the fovea, they would get another point. Peripapillary, another point, and if they had any retinal hemorrhages outside of that peripapillary area, they would get another point. So each eye can have the potential of 6 points. With a maximum of 12 points for both eyes. So let’s look at this photograph here. So you can see that these hemorrhages — there’s a lot of small intraretinal hemorrhages. And you can see how this right here is about 1 disc diameter. So this patient would actually get 1 point. Because I don’t see any hemorrhages that’s much greater than the 1 disc diameter. So the patient would get 1. And the patient actually has a hemorrhage in the macular area, peripapillary area, and also outside of that area. So there would be 1 here, and 3 points from the extent. So the patient would get a score of 4. So what did we find from the study? One, that 31 patients with abusive head trauma that were confirmed — we looked for retinal hemorrhages. 20 of the 31 patients developed retinal hemorrhages. And 75% of those patients had retinal hemorrhages in both eyes. But 25% actually had it in just one eye. And then of those over 20,000 in the NVD group, the retinal hemorrhages were found in 25% of the cases. It was in both eyes in 66, and 33% just in one eye. And there was no difference in the laterality, in both groups. And the retinal hemorrhage size were significantly larger in the AHT. So 3.1 disc diameter versus 0.96. It was statistically significant. And RH involving all three layers was significantly more common in AHT, versus 0.6 in the NVD group. In the NVD group, 92% of the cases were all purely intraretinal. There were no hemorrhages in preretinal and subretinal in 7.8% of the cases. And other things. Both macula and optic nerve were involved in AHT. In 77 versus 30%. And it was statistically significant. And vitreous hemorrhages were present in 54% of AHT. But some of the patients with NVD actually did have vitreous hemorrhage. Very important. And the grading scales. In AHT, it was 7.15. But in the NVD group, it was 3.59. And of course, it was statistically significant. And optic nerve was found only in AHT group. And the patients in the AHT group had other clinical findings, besides the retinal hemorrhages. The patients had subdural hematoma, loss of consciousness, seizures, and other things. So these patients had complete neurological and physical examinations, and they all were able to find other clinical findings that would support the diagnosis of AHT. But of course, in the NVD group, there were no other clinical findings. These are healthy babies with no other medical conditions. But there were some surprising results. Number one is that the number of retinal hemorrhages were not statistically different between the two groups. And also, the retinal hemorrhage-involved zones, whether macular, peripapillary, and periphery — the zones were not significantly different in these two groups of 0.34. And in the patients with the NVD retinal hemorrhages, they all — the majority of the retinal hemorrhages resolved within 4 weeks, when they came in for their initial examinations. And 95% of the cases actually resolved within 4 weeks. And out of those 10,000 cases, only 2 severe cases with vitreous hemorrhage required 12 weeks to resolve completely. So that’s 3 months. So what do we learn from this? Retinal hemorrhages in abusive head trauma and NVD do share some common findings, but have very distinct characteristics. So first, in the NVD group, up to 25% of the NVD groups do develop retinal hemorrhages. So this is real. And most retinal hemorrhages are intraretinal, and resolve spontaneously. Usually by 4 weeks. But rarely persist beyond 6 weeks. And abusive head trauma group — significantly more severe, with a higher grading scale, involved the macula and optic nerve more frequently, and more commonly, all three layers were involved. And much higher incidence of vitreous hemorrhage. And they all had other clinical findings. So why is there a difference? First is that in the NVD group, the force is circumferential around the head. It’s circumferential, unidirectional, and translational. It’s non-repetitive vector force on the retina. Versus the abusive head trauma group — the force is translational, but it’s also torsional, and the degree of repetition — the repetition plays a significant role, causing more stress and fatigue on the retinal vesicles. Therefore, the retinal hemorrhages in abusive head traumas are more likely to have more severe retinal hemorrhage features, and slower to resolve. And previously thought that the bilateral and numerous retinal hemorrhages that extend into the periphery were highly suggestive of abusive head trauma, but our studies do not agree with that statement. The bilaterality and the number and the peripheral retinal hemorrhages were not significantly different in both groups. But what was important — more important predictive factor — were retinal hemorrhage size, retinal layer involvement, and vitreous hemorrhage, with a higher score. So this is actually the last slide. These are key points. The indirect head impact, with no external physical injury, can result in retinal hemorrhages. And abusive head trauma may result in normal retinal exam. So just because they have a completely normal retinal exam does not rule out a potential abusive head trauma. In our cases, actually, there was a significant portion of the patients — did not have any retinal findings with the confirmed cases of abusive head trauma. And unilateral retinal hemorrhage does not rule out abusive head trauma. And complete physical and neurological evaluation is critical. Our case is still in court. The family is still under investigation. And the final verdict is still pending. And I want to thank you for taking your time to watch this webinar. This is actually my first time doing it. And I really would love to hear some of your feedback and how I can improve. You know, I’ve never given a talk in this fashion. This is actually a little bit challenging, because I always have to make eye contact, when I talk. But I would love to hear your feedback of how I can make things better. But I would love to have some of your questions. Any questions or thoughts?
>> So, Dr. Suh, we don’t have any questions yet, but we had some questions asked at the time of registration. Maybe we can go over those. Can you see my screen?
DR SUH: Let me just see. Actually, I went over these. I read these questions before my talk. And I actually addressed these questions. But can the audience ask any questions now?
>> Yep, we just got two in.
DR SUH: Perfect.
>> You can open the Q and A box on your side.
DR SUH: Perfect. Well, thank you. Any questions? I would love to hear any questions.
>> So we can stay on for a few minutes and see if questions come through.
DR SUH: Thank you for the compliment. Yes. The Valsalva retinopathy is definitely — that’s real. And I actually have seen cases of Valsalva retinopathy-induced retinal hemorrhages. So this would be something that would be similar to the CPR-induced retinopathy, like, something that would be similar to the Purtscher’s retinopathy. But I’m gonna talk based on my experience and what I know. Based on my experience with the Valsalva retinopathy, these retinal hemorrhages are pretty small and localized. This is actually the result of an increase in venous pressure, resulting in retinal hemorrhages. So this would be very similar to the ones that one would find with the Purtscher’s or CPR-induced retinopathy. So these patients would typically — and I think that this is… Most of these hemorrhages are very localized to the macula or the optic nerve area. And more to the posterior pole. Obviously there is no component of the vitreoretinal traction with the shearing force, so the patterns would look very different. Thank you for your question, Luis. And then… In my center, dilated fundus exam is not routinely done for neonates, and visual assessment is not common in infants, so how do you suggest we look out for abusive head trauma? As I suggested, I think this is truly teamwork. So these patients would typically come in to the emergency room, or would be admitted to the hospital with, for example, new onset seizures, loss of consciousness, so if there’s any hint of potential abuse, and with any type of — with or without any external signs — they should consult ophthalmology, and then ophthalmology should evaluate that patient with the dilated examinations. Now, is dilated examination essential? And is it a must? No. In certain situations, neurosurgeons would like to assess their mental status, along with the pupil, on a daily basis. Sometimes they prefer that we don’t dilate the patients’ eyes. And so in those cases, many times you can actually see the fundus without dilated pupils. But it’s definitely more preferred. So I would recommend that, again, like I said, it’s teamwork. If there’s any clinical suspicion of potential abuse, they should consult ophthalmology. And ophthalmology should evaluate the patient. And the visual functions in these patients — these are infants. So you just want to make sure the patient reacts to light, patient can fixate and follow, depending on the age. And do a careful fundus examination. Preferred dilated. Okay? And then — are there incidence where the retina hemorrhages fail to resolve? Yes. Unfortunately, like I said, I actually do see quite a bit of these cases. And I actually had two cases where we had to go in and drain the blood. Because these patients are younger patients, and typically, I observe for about three months. But if I do not feel that the blood is — there’s no signs of any blood that’s resolving, then a vitrectomy occasionally is required. So yes, in very extensive retinal hemorrhages, they do fail to resolve, and surgery is required. If you wait longer than three months, potentially could it go away? Yes, but you have to think about the risk of amblyopia as well. And you have to know what is going on behind the retina as well. So you have to do an ultrasound, make sure the retina is flat under the hemorrhage, and if there’s any signs of retinal detachments or retinoschisis, that needs to be addressed. Documenting with iPhone or Android smartphone or with any camera? That is an excellent idea. We’re actually doing a study on that right now, as we speak. By the way, I have no — I forgot to mention — I have no financial interests in any of the things that I’ll be talking about. There are various devices that are available. I actually personal use a device called a DI. D, then EYE. D-EYE. It’s a device that goes on your phone, a very small device that goes on your phone, and you can actually take pictures. Especially with a dilated pupil, it’s actually very, very easy. And most of the time, you’re not gonna be able to document the photographs in the periphery. But with the phone, you can probably capture 60, 70 degrees, and most of these patients — it would be very unusual for patients to have hemorrhages just in the periphery, sparing the posterior pole. Obviously there’s a reason for that, because that’s where most of the blood vessels are. And that’s where the majority of the traction occurs. So with the phone, with the smart — with the device — you should be able to take good quality photographs of the fundus. Especially with the retinal hemorrhages and things. So if you don’t have access to a RetCam, which is quite expensive, I think a phone is a good, good alternative. Especially in court. If you ever have to testify. Having images can really save a lot of time and effort. Sidra, okay. How long does it take on average for NVD retinal hemorrhages to resolve? And is there any long-term detrimental effect on vision in newborns with retinal hemorrhages? Or after recovery, these patients do well? Good question, Sidra. I believe, based on my experience, the NVD retinal hemorrhages resolve very quickly. I don’t think it takes a month. I think it’s within, like, actually — sometimes I would see these patients in the NICU. They would resolve within two to three days. So the majority of cases — I think they resolve very, very quickly. So it’s very, very unusual that it takes a month or six weeks. But based on what we have found, 99 — I’m gonna say 99.9% of the time, actually, they resolve within 4 to 6 weeks. But as far as we know, there’s no detrimental effect of these small hemorrhages, because they resolve very quickly. And after recovering, they do extremely well. Uchenna. What dilating drops are preferred in neonates? For me, we always use a cyclomydril, because it has a lower concentration of the phenylephrine and the cyclogyl. So in dark eyes, like when I go to Africa or India, with very dark eyes, you may actually have to put two sets of eye drops, and wait for the eyes to dilate. In rare situations, I may actually have to put three sets. But just make sure you monitor their vital signs. The cyclomydril. Uchenna — any documentations of the macular hole formations in abusive head trauma? Yes. So these tractions can cause a retinoschisis or retinal tear or retinal folds. We will be doing an experiment on a human retina from a cadaver, and we’re gonna be separating the vitreous from the retina, and we’re gonna actually — we’re trying to calculate the force it requires to separate the two. And actually, Dr. Bethany… Dr. Bethany Coates from the University of Utah is actually currently doing that experiment right now, as we speak. And we’re planning on repeating that study here. So those things can occur, but the macular hole formation — personally, I’ve never seen it. But I can see how that could potentially happen. But the force is great enough to separate the macula, if the force is significant enough to cause a macular hole to pull the macula off the vitreous, which actually has very tight adhesions — I would think the patient probably will have significant vitreous hemorrhage that would probably obscure the view of the macular hole. And so unless you’re doing OCT, in these neonates, it may be difficult to document. To the best of my knowledge, I don’t think it’s ever… To the best of my knowledge, I don’t know if that’s ever been documented. We have two RetCams in my city, but they’re secluded to the hospital. Smartphones are instruments that could be used with a 28 or 30 diopter lens to document in many more places. Just need to go to YouTube or papers to become self-trained. I agree, Luis. Perfect. The one that I talked about is one particular device. But there’s an app that you can purchase through the iPhone. That particular program is not available for Android. It’s actually for iPhones. So you could actually use an iPhone, and using a 28 or 30-diopter lens — and you can actually take photographs with your iPhone. And I think that’s an excellent way to document. I completely agree. Okay. Any other questions? Well, it’s been an hour. It’s truly been a pleasure. I really enjoyed the webinar, and I hope you guys have a great day.