Test 17  (paediatric ophthalmology) 

 

Refer to the picture above for question 1,  2 & 3.

1. You are asked to examine the fundi of a baby with suspected 
     non-accidental injury and find the above appearance. 
     The following are possible causes:

a. coagulopathy 

b. normal vaginal delivery

c. proliferative diabetic retinopathy 

d. glutaric aciduria 

e. optic nerve glioma

Answera.T   b.T  c.F  d.T e.F
Diabetic retinopathy does not occur in baby.
Glutaric aciduria is a metabolic disorder which can
give rise to retinal haemorrhages and mistaken for shaken baby syndrome.
Optic nerve glioma does not cause retinal haemorrhages.

2. The paediatrician suspects shaken baby syndrome and order some
    radiological investigations. The following pictures are consistent 
    with the suspicion:

a. 

b. 

c. 

d. 

e. 

Answera.T   b.T   c.T   d.F  e.F
Subdural haematoma, rib fracture and retinal 
haemorrhages are the most common signs of shaken baby syndrome.
a. shows fracture rib in the left lower rib cage.
b. is a bone scan showing abnormal uptake in the 
right rib cage and the left humorous bone. In children,
the epiphyses region show increased intake and any 
such uptakes outside the epiphyses areas suggest healing process such as following fractures.
c., d. and e. are CT scan. c shows subdural haematoma, 
d. shows haemorrhagic infarction (note the wedge shaped 
opacification) and e. shows extradural haemorrhage (this usually result from direct bone trauma)

3. The final diagnosis was shaken baby syndrome. The following are 
     true about the ocular features:

a. retinoschisis is a cause of ocular scarring

b. the retinal haemorrhages are confined to 
    the superficial layer

c. retinal haemorrhages are necessary for the diagnosis
    of shaken baby syndrome

d. the main cause of visual loss in this condition is retinal
    haemorrhages.

e. ERG is useful in distinguishing between ocular and 
    brain causes of visual loss.

Answera.T   b.T  c.T  d.T  e.T
Although retinal haemorrhages are often encounter 
in shaken baby syndrome, they are not necessary for the diagnosis of shaken baby syndrome.
Ocular scarring can result from vitreous and retinal haemorrhages as well as retinoschisis.
The retinal haemorrhages have been reported in the superficial, intraretinal and subretinal layers.
Brain damage appears to be commoner than retinal haemorrhages as a cause for poor vision.
Normal ERG suggests the cause of poor vision is in the brain.

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This is the fundal appearance of a child with  mental retardation. Refer to this picture for question 4 & 5.

4. The mother of this child may have the following skin lesion 
     in her first trimester:
 

a.	b.
c.	d.
e.

Answera.F  b.T  c.F  d.F  e.F
Rubella (German measles) causes rash which is erythematous and flat as in b.
a. shows Koplik's spots in the buccal mucosa. They are seen in measles but not in rubella.
c. is chicken pox.
d. is erythema multiforme with the characteristic target lesions.
e. is urticaria showing raised erythematous areas.

5. The following signs may be seen:
 

a.	b.
c.
d.
e.

Answera.T   b.F  c.T   d.T  e.T
Congenital rubella is associated with deafness and 
therefore hearing aid in a., bilateral cataracts as in c., 
increased incidence of keratoconus in adolescence 
as in d. which shows the Vogt's striaes. Strabismus is common due to poor vision as in e. (convergent strabismus).
b. shows cerebral calcification which is a feature of congenital toxoplasmosis.

 
 

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