Editor,—We read with interest the paper by Greenet al.1 We agree with the authors about the importance of ophthalmoscopic examination in the ‘battered child syndrome’. However, we feel that some considerations on the pathogenesis should be discussed.

Firstly, we believe, based on personal clinical and not autoptical cases, that there is a possible association between subdural and intraocular haemorrhages. Nevertheless, we want to underline that intraocular haemorrhages could be isolated manifestations in battered child syndrome; sometimes not due to a direct bulbar trauma.2

Traumas of various types, even not ocular, may involve the retinal vascular system, as previously described by Purtscher at the beginning of this century.3

Several unilateral or bilateral retinopathies similar to those observed by Purtscher have been reported after compressive thoracic injuries (for example, seat belt injuries), head trauma, and violent deceleration.4-6

Various pathogenetic mechanisms of these retinal vascular alterations have been reported—sudden rise in intrathoracic venous pressure,4 arterial angiospasms, retinal vessel occlusion by gas, and lipid embolisms or aggregates of granulocytes.

In the case of shaking, the pathogenesis of retinochoroidal haemorrhage basically can be caused by: (1) transient blood flow arrest due to rapid bending of the neck or rapid movement of the head, both resulting in direct trauma of the carotid-ophthalmic vascular system and/or retinal vasospasm. This mechanism is the same as the one that occurs in some cases of whiplash lesions; (2) acute thoracic compression probably due to a rapid muscular contraction with closed glottis, resembling a Valsalva’s manoeuvre. Such compression would give rise to a venous pressure wave transmitted to the eye, as a result of the lack of antireflux valves between the caval vein and the eye. The unilaterality or bilaterality of the symptoms may be explained by the anatomical distribution of the …