Epiretinal Membrane Formation Is a Late Manifestation of Shaken Baby Syndrome Anna L. Ells, MD, FRCS(C), Amine Kherani, MD, FRCS(C), and David Lee, Ad Dip(MSc) Shaken baby syndrome is a constellation of injuries resulting from the intentional shaking type movement of a child who is usually younger than 3 years old. This rapid acceleration– deceleration movement of the head is responsible for lesions attributed to shearing forces placed on the vitreoretinal structures and men- ingeal vessels across the dura. 1 The ophthalmic find- ings include intraocular hemorrhages, perimacular retinal folds, and peripheral retinoschisis in the pres- ence of intracranial injuries such as subdural hemato- mas without obvious external signs of head trauma. 2 We describe a case of late development of an epiretinal membrane in a child with a history of shaken baby syndrome and propose a differential diagnosis list for epiretinal membrane formation in the pediatric age group. CASE REPORT A 6-week-old infant, previously healthy, presented to the emergency room with seizures and decreased level of con- sciousness. Her injuries included multiple subdural hema- tomas, bilateral occipital lobe contusions, and scattered intraretinal hemorrhages in the posterior pole of the right eye only. No perimacular retinal folds or retinoschisis were identified. Forensic investigation confirmed child abuse, and the perpertrators were prosecuted by the crown prosecutor. At 2 years of age, the patient was seen in the eye clinic. She had severe developmental delay, cerebral palsy, and central visual impairment. Flash visual evoked potentials were absent to stimulation of both eyes. On examination, she had an inconsistent fix-and-following reflex with roving eye movements. There was no signif- icant refractive error. The retina demonstrated slight vitreous condensation over the area of the macula in the right eye and bilateral optic nerve atrophy. The left macula was unremarkable. She was seen again at age 3 years, and her ophthalmo- logical assessment was unchanged compared with the pre- vious year’s assessment. At age 4 years, her visual status was unchanged; however, retinal examination of her right eye showed a large epiretinal membrane extending over the entire macula (Figure 1). The epiretinal membrane caused significant traction and dragging, thus disrupting the macular architecture. Bilateral optic nerve atrophy was unchanged (Figures 1 and 2). A membrane peeling procedure would have improved the retinal architecture, however, after careful review of the patient’s clinical status, it was decided that vitrec- tomy surgery would not improve her cortical visual impairment, optic atrophy, and current level of func- tioning. Therefore, intraocular surgery was not recom- mended. DISCUSSION Shaken baby syndrome represents one specific form of child abuse. In the United States, 1800 children are diagnosed with shaken baby syndrome per year, a third of whom die of their injuries. 3 The occult nature of shaken baby syndrome means that patients with milder involvement may escape early clinical detection and present with a late manifestation of the syndrome, such as an epiretinal membrane. Epiretinal membrane formation as a late manifestation of shaken baby syndrome has been reported in only 1 previous article. 4 Other ocular sequalae From the Division of Opthalmology, Alberta Children’s Hospital, University of Calgary, Calgary, Alberta, Canada. Submitted December 16, 2002. Revision accepted December 16, 2002. Reprint requests: Anna Ells, MD, FRCS(C), Pediatric Ophthalmology, Alberta Children’s Hospital, 1820 Richmond Rd, SW, Calgary, Alberta T2T 5C7, Canada. Copyright © 2003 by the American Association for Pediatric Ophthalmology and Strabismus. 1091-8531/2003/$35.00 + 0 doi:10.1016/S1091-8531(03)00005-3 FIG 1. Wide-angle image of the right eye with an epiretinal mem- brane over the macula. Note retinal vascular tortuosity from the puckering epiretinal membrane as well as optic nerve atrophy. Journal of AAPOS June 2003 223