Vitreoretinal traction is a major factor in causing the haemorrhagic retinopathy of abusive head Injury? – Yes

Retinal haemorrhage is a cardinal manifestation of abusive head injury characterized by repetitive acceleration–deceleration forces with or without blunt head impact (Shaken Baby syndrome). That shaking alone, in the absence of head impact, can result in severe, if not fatal, manifestations of this syndrome has been well demonstrated.^{1, 2} The unique nature of repetitive acceleration–deceleration forces in accumulating forces experienced by the eyes has been supported by finite element analysis and corresponds to the areas of the eye where there is a predilection for retinal haemorrhage to appear in abusive injury: the peripheral and macular retina.^{3, 4} Isolated accidental blunt head impact injury is rarely associated with retinal haemorrhage,^{5, 6} and when retinal haemorrhage does occur, the haemorrhages are few in number and largely confined to the posterior pole, with the exception perhaps of fatal head crush injury^{7, 8} and severe fatal motor vehicle accidents.⁹

Over the last 35 years much research has been conducted to aid us in understanding the pathophysiology of retinal haemorrhage in abusive head injury. Multiple research lenses have been used to examine this issue and each continues to indicate the important role of vitreoretinal traction. In part, this realization comes from the absence of viable alternative theory. There appears to be no correlation between retinal haemorrhage in abusive head injury and intracranial haemorrhage, increased intracranial pressure, or increased intrathoracic pressure.¹⁰ Although intracranial haemorrhage is commonly associated with retinal haemorrhage (Terson's syndrome) in adults, it appears to be rare in childhood¹¹ and not associated with the severe haemorrhagic retinopathy seen in approximately two-thirds of abusive head injury characterized by repetitive acceleration–deceleration forces.¹⁰ Theories of increased intracranial or intrathoracic pressure leading to a restriction of venous outflow from the eye do not explain the absence of a clinical pattern of retinal haemorrhage consistent with venous obstruction in abused children and the very low incidence of papilledema.^{10, 12} Models of increased intrathoracic pressure, which would theoretically result in retinal haemorrhage through a restriction of venous outflow, if not retrograde flow, such as coughing,¹³ vomiting,¹⁴ and seizures¹⁵ also fail to demonstrate retinal haemorrhage.

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