Is rotational trauma the only relevant pathogenic mechanism in hemorrhagic retinopathy of shaken baby syndrome?

The pathogenesis of ocular hemorrhage in abusive head trauma/shaken baby syndrome (AHT/SBS) is complex. Whereas severe hemorrhagic retinopathy has a robust association with AHT/SBS, mild disease is less specific. We report the ocular and cerebral findings in an 8-month-old girl with spastic torticollis who presented following confessed, violent sagittal plane acceleration-deceleration with impact. Autopsy revealed subdural hemorrhage over the convexities, ischemic brain injury, and preexisting polymicrogyria. Ocular examination showed extensive but unilateral retinal hemorrhage, extending broadly to the ora serrata, with perimacular retinal folds and retinoschisis. The retina of the right globe was entirely normal. The findings in this case, suggest that movement of the globe within the orbit with acceleration-deceleration, in this case greater on one side due to torticollis, may be the primary factor for severe hemorrhagic retinopathy associated with AHT/SBS. The findings argue against putative global mechanisms, such as intracranial hypertension.