Statistically the condition is most common in young males.

Patients have a history of blunt ocular trauma.

The condition is usually asymptomatic. Decreased vision may occur with macular involvement. The retina appears whitened, while the retinal vasculature remains unaffected. The retina regains its normal appearance within weeks (Fig. 8-1). Occasionally, changes to the retinal pigment epithelium (RPE), such as stippling or clumping, may be seen after the retinal whitening resolves.

Be mindful of other findings seen in trauma such as hyphema or microhyphema, choroidal rupture, retinal hemorrhage, retinal dialysis, avulsed vitreous base, and vitreous hemorrhage.

Other entities that may mimic commotio retinae include branch retinal artery occlusion, white-without-pressure, and shallow retinal detachment.

Diagnosis is based on clinical examination.

Optical coherence tomography (OCT) may demonstrate increased reflectivity in areas of damaged photoreceptor outer segments.

Retinal whitening resolves without visual compromise. However, permanent visual acuity loss can sometimes occur if macular retinal pigment epithelial disruption is present.

Choroidal rupture occurs as a result of trauma, most commonly in young males.

Patients have a history of blunt ocular trauma.

The characteristic finding is subretinal hemorrhage, with whitish, crescent-shaped lesions around the optic disc (Fig. 8-2A). In the acute setting, choroidal ruptures may be associated with other findings from blunt ocular trauma such as hyphema, iris sphincter ruptures, commotio retinae, vitreous hemorrhage, retinal tears, retinal dialysis, and orbital fractures.

Later, choroidal neovascularization (CNV) may occur at the edge of the rupture site (Fig. 8-2B).

Myopic lacquer cracks and angioid streaks may have a similar appearance.

Other causes of subretinal hemorrhage include CNV, retinal arterial macroaneurysm, Valsalva retinopathy, and anemia.

Diagnosis is based on clinical examination.

Visual prognosis depends on the location of the choroidal rupture with respect to the fovea and any associated subretinal or subretinal pigment epithelial hemorrhage.

Secondary CNV can occur at anytime during the follow-up period and can cause visual acuity loss.

The injury occurs as a result of trauma, usually in young males.

Patients have a history of blunt ocular trauma.

A semitransparent, sometimes pigmented, curvilinear ribbon-like structure may or may not be completely separated from the retinal periphery (Fig. 8-3).

The presence of an avulsed vitreous base is pathognomonic for ocular trauma.

An avulsed vitreous base may be associated with hyphema, iris sphincter tears, commotio retinae, vitreous hemorrhage, retinal tears, retinal dialysis, or orbital fractures.

Avulsed vitreous base should be distinguished from retinal dialysis.

Other entities that may mimic this condition include old vitreous hemorrhage.

Diagnosis is based on binocular indirect ophthalmoscopy with scleral depression.

No treatment is necessary. Patients should be observed for the subsequent development of trauma-related ocular problems such as retinal breaks and angle-recession glaucoma.

There is a trend for higher incidence in areas where a solar eclipse was directly observable. Solar maculopathy is more common among individuals involved in sun-worshiping religious groups. Loss of the ozone layer has been associated with solar retinopathy among sunbathers in the United States.

Patients have a history of sungazing.

There is an abnormal foveal reflex.

Often, a sharply demarcated yellow or reddish spot is visible in the fovea (Fig. 8-4).

Retinal pigment epithelial changes (focal hyperpigmentation) may be evident in the foveal or parafoveal area at later stages.

Pseudomacular hole, photic maculopathy, and macular dystrophy or degeneration may have a similar appearance.

Diagnosis is based on clinical examination.

Fluorescein angiography will reveal nonspecific retinal pigment epithelial window defects centered on the fovea.

OCT may demonstrate disruption of foveal inner and outer photoreceptor segments.

Good visual recovery occurs in most patients, but it may take weeks or months for vision to improve.

No treatment is needed.

The condition can occur in persons of any age.

Patients usually have a history of recent strenuous physical exertion, coughing, vomiting, or straining (e.g., with constipation).

Single or multiple intraretinal hemorrhages (often underneath the internal limiting membrane) are noted in the posterior pole (Fig. 8-5). There may be a decrease in visual acuity when the hemorrhage is localized in or over the foveal region.

Subconjunctival hemorrhage may be associated with this condition. Significant vitreous hemorrhage is rare.

Retinal macroaneurysm, diabetic retinopathy, venous occlusion, anemia, anticoagulant therapy, retinal tear, or posterior vitreous detachment with associated hemorrhage may mimic the findings of Valsalva retinopathy.

Diagnosis is based on clinical examination.

B-scan ultrasonography is performed to evaluate for underlying retinal detachment or retinal tear in the setting of dense vitreous hemorrhage.

OCT may demonstrate hemorrhage underneath reflective signal of the internal limiting membrane.

The visual prognosis is good.

Management consists of observation, only, in most cases. Hemorrhages will resolve spontaneously.

Vitrectomy may be considered for nonclearing vitreous hemorrhage (but is rarely indicated).

The condition is most common in infants and toddlers.

Recently, often multiple episodes of violent shaking of the infant precede findings, although it is often difficult to obtain a history of abuse from the caretaker. Caretakers may refuse diagnostic evaluation.

Subretinal, intraretinal, or preretinal hemorrhages are noted in one or (more commonly) both eyes (Fig. 8-6A). The preretinal hemorrhages are typically globular as opposed to flat (Fig. 8-6B). Other signs include poor visual or pupillary response. No single ocular finding is pathognomonic.

Ecchymosis, long bone and rib fractures, lethargy, or developmental delay are common associated findings. Often the child has physical findings that do not match the reported mechanism of the injuries.

Birth trauma: Intraretinal hemorrhages may be seen in newborns, especially with the use of forceps in the delivery. These hemorrhages resolve over the course of weeks and are often not associated with neurologic sequelae.

Leukemia and intraocular infections may also mimic the ocular findings of shaken baby syndrome.

Clinical examination: Evaluation for delayed neurologic development and systemic signs of child abuse

Head CT to evaluate for intracranial hemorrhage

Bone scan is more sensitive in detecting fractures and exposes the child to less radiation while providing a whole body skeletal survey. Bone scan findings may tailor subsequent x-ray studies.

X-ray studies: Fractures at different stages of healing, leg fractures prior to bipedal ambulation (prior to 12 months of age), and posterior rib fractures are highly suspicious for child abuse.