Purpose: To compare postmortem orbital findings in pediatric accidental head injury to Shaken Baby Syndrome (SBS). Design: Retrospective study. Methods: setting: Institutional. study population: Thirty-six patients underwent postmortem modified exenteration with sectioning of the orbital contents; 18 victims of SBS and 18 cases of fatal accidental head trauma. observation procedure: In all cases of children who died from accidental head trauma, the orbital tissues were separated to expose the optic nerve sheath. Patients with gross evidence of hemorrhage within the sheath were included. All cases of SBS were included. After accidental head injury, exenteration was performed only if optic nerve sheath hemorrhage was suspected on gross examination. All children younger than 18 years old with head injury as primary cause of death were included. SBS is defined as having at least two of the following: (1) typical abnormal findings on neuroimaging, (2) typical skeletal injury, (3) retinal hemorrhages, (4) history of abusive shaking with or without blunt head trauma, or (5) an inadequate history to explain the observed injuries. main outcome measure: Presence or absence of orbital hemorrhage. Results: Orbital tissue injury is more common in SBS than accidental head trauma without orbital fracture. In addition, optic nerve sheath and optic nerve intradural hemorrhage are also significantly more common in SBS (P < .0001). Conclusions: Our study reports new evidence of injury to orbital tissues in SBS and supports the concept that these finding are due to unique acceleration-deceleration forces of this type of abusive head injury.