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Certain eye injuries used as “diagnostic” hallmarks of child abuse may be misleading, suggests a new study by US researchers.

“Certain eye findings have been considered diagnostic for shaken baby syndrome (SBS),” says Patrick Lantz, who led the study at Wake Forest University Baptist Medical Center in North Carolina, US. “This isn’t supported by objective scientific evidence and could result in innocent caregivers going to jail.”

Lantz, a forensic pathologist, and colleagues looked into the causes of a condition called “perimacular retinal folds” – where the retina at the back of the eye buckles.

The researchers’ investigation was prompted by the death of a 14-month boy at their medical centre who had the condition after a television set crushed his head. Child Protection Services suspected child abuse and removed the baby’s three-year-old brother from his family.

Examining the medical literature, the team found the condition was deemed diagnostic of a baby being shaken to death, sometimes whatever the circumstances.

“Statements indicate that perimacular retinal folds result when an infant is shaken, and that they have no other cause in young children with head injuries,” says Lantz. But the team could find no “scientifically valid” comparative or experimental studies to back this up, he says.

Greasy smudge

Child abuse experts Jennian Geddes and John Plunkett describe the new work as “disturbing reading”. They say the team “reveal major shortcomings in the literature”, in an editorial accompanying the study in the British Medical Journal.

The baby boy was rushed to hospital after apparently stepping on an open drawer, causing the television to fall, but died within 18 hours. The ophthalmologist who examined the baby the next day spotted the buckling of the retina and declared it could have come only from shaking.

Suspicion that the fallen television could have staged as a cover-up led to an autopsy, conducted by Lantz’s team. “It looked typical of a crush injury,” Lantz told New ¾«¶«´«Ã½.

The team also successfully re-enacted the accident, bringing in the 19.5 kilogram television set and placing a comparable weight to the baby on an open drawer. The television screen even revealed a greasy smudge corresponding to where it hit the child’s head.

“At that point we were pretty sure that was what happened,” says Lantz. However, despite the conclusions of the autopsy and both a local child abuse expert and the police believing the father’s story, the baby’s brother was still taken away from the family.

Animal model

Lantz and colleagues then did a literature search to see if the eye condition had been reported previously for accidents. None of the 42 studies they found had documented accidental injury and all were purely observational studies.

In fact, says Lantz, the language used to describe perimacular retinal folds changed from documenting its occurrence in cases of SBS in the early 1990s to saying it was diagnostic of SBS by the late 1990s.

He believes a multi-centre study needs to be done to look for the eye condition in child abuse victims and matched children who have suffered accidents. “It’s really important not to look at an individual finding out of context, but to look at the whole picture,” he says. The child was eventually returned to his family.

The team will also examine eye symptoms in monkeys to gather further evidence. Some baby monkeys growing up in captivity are prone to falling from their mothers’ arms, sometimes fatally. Lantz and colleagues will be examining the eyes and brains of such monkeys later in 2004.

Journal reference: British Medical Journal (vol 328, p 754)