First Case Report of the Use of Postmortem Wide-Angle Fundus Photography in Abusive Head Trauma

Abstract

Retinal hemorrhages commonly cooccur with abusive head trauma (AHT). While wide-field fundus photography is crucial for documenting retinal hemorrhage in living children, in fatal cases, a pathologic examination is traditionally used. This report describes the case of a 4-year-old girl who died of head trauma suspected to have been caused by physical abuse. Before the autopsy, wide-field fundus photography using scanning laser ophthalmoscopy (SLO) was performed to document retinal hemorrhages. Imaging revealed that retinal hemorrhages were predominantly located at the posterior pole and in the peripheral retina of the right eye. The autopsy confirmed cranial injuries, including acute subdural hematoma. Pathologic examination of the eyes revealed hemorrhages beneath the internal limiting membrane and within the inner to outer nuclear layers of the retina. The cause of death was determined to be head trauma leading to an acute subdural hematoma. This case confirms that wide-field fundus photography using SLO can be performed postmortem, supplementing pathologic findings. Postmortem fundus photography, particularly using SLO, has the potential to reduce the risk of artifact introduction during the preparation of traditional specimens. Additional case studies are required to further refine the use of this technique and establish its potential forensic application in the diagnosis of AHT.

Retinal hemorrhages often cooccur with cases of abusive head trauma (AHT). The distribution pattern and severity of retinal hemorrhage are critical for estimating the mechanism of head injury;^1,2 however, more objective evidence is needed. A recent report has emphasized the importance of wide-field fundus photography for documenting retinal hemorrhage in living children.^3,4 In fatal cases, a pathologic examination is traditionally regarded as essential.⁵ However, preparing pathologic specimens requires a certain level of expertise.⁶ Specifically, we encountered instances in which the artifacts generated during this process compromised the generation of objective evidence (Fig. 1). We have previously explored methods such as fundus photography to provide supplementary documentation for pathologic findings in autopsy cases.⁷ In this report, we demonstrate the feasibility and potential utility of postmortem wide-angle fundus photography in a case of abusive head trauma.

FIGURE 1.

Artifact findings of the retina resulting from the preparation of the pathologic specimen [hematoxylin-eosin (HE) staining]. The choroid is absent, and the retina is extensively detached, with partial loss.

CASE REPORT

The decedent was a 4-year-old girl living with her mother and 2 older sisters. After being placed in an infant care facility shortly after birth, she lived with her family for ∼1 year before her death. The decedent was diagnosed with a pervasive developmental disorder. Five days before her death, her mother forcefully pulled a blanket from under her while she was standing, causing her to fall backward and impact the back of her head on a wooden floor. Four days before her death, her mother pushed her from behind while she was standing on a desk ∼30 cm high, causing her to fall forward and hit her face on the floor. Two days before her death, she exhibited difficulties walking and speaking, but no medical assistance was sought. The day before her death, she lost consciousness and was admitted to the emergency room. On arrival, she was diagnosed with an acute right subdural hematoma (Fig. 2A) and underwent emergency surgery, but succumbed shortly following the procedure. The ophthalmologist confirmed the presence of retinal hemorrhages in her right eye. However, fundus photography was not performed, owing to the short time elapsed before her death. Physical abuse was suspected, and an autopsy was performed ∼1 day postmortem. All described injury events were explicitly qualified as allegations based on maternal testimony during judicial proceedings and documented investigative records. These statements were recorded in official court documents and corroborated by investigative reports from the police and child protection authorities. The court formally recognized these statements as part of the judicial proceedings.

FIGURE 2.

A, Head computed tomography (CT) scan of the child taken upon admission to the emergency hospital. B, Photograph of the right cheek of the child taken during autopsy. C, Photograph of the occipital region of the child taken during autopsy. The dashed circle indicates the area of the yellowish contusion. D, Photograph of the right eye of the child taken during autopsy.

Autopsy Findings

The deceased was 95 cm tall and weighed 11.8 kg, indicating underweight status. Contusions with a slightly yellowish discoloration were present on the right side of her face (Fig. 2B), left occiput (Fig. 2C), and back. The conjunctiva and sclera showed no signs of injury (Fig. 2D). A surgical incision closed with staples on the right side of the head was observed. No skull fractures other than craniotomy scars were observed. The brain weighed 1438 g, with softening and hematoma adhesion observed in the right hemisphere. Numerous small hemorrhages were noted in the subcortical area of the right cerebral hemisphere, along with herniation of the cingulate and hippocampal gyri. Secondary hemorrhages were observed in the midbrain. No diseases or malformations other than head trauma and subsequent infections were found to have contributed to the cause of death of this child.

Postmortem Fundus Photography

Before the autopsy, noninvasive imaging of both eyes was performed using an Optos California Camera (P200DTx; Optos), which uses confocal scanning laser ophthalmoscopy (SLO) to capture peripheral retinal images in a single shot. Retinal hemorrhages were predominant at the posterior pole and in the periphery of the right eye (Fig. 3A, B).

FIGURE 3.

A, Postmortem fundus photograph of the right eye taken using Optos. The white arrowhead indicates hemorrhage in the peripheral retina. The white dashed circle indicates the peripheral retinal hemorrhages corresponding to the hemisected eye photograph (C). B, Postmortem fundus photograph of the left eye. C, Hemisection of the right eye. The arrow indicates retinal hemorrhage, and the arrowhead indicates optic nerve sheath hemorrhage. The white dashed circle indicates the peripheral retinal hemorrhages corresponding to the postmortem fundus photograph (A). D, Hemisection of the left eye. E, Histopathologic findings of the posterior retinal pole (hematoxylin and eosin staining).

Postmortem Ocular Examination

The eyes were fixed in 10% formalin for 48 hours and then sectioned. Prominent hemorrhages were observed in the retina, particularly at the posterior pole and in the peripheral regions of the right eye (Fig. 3C, D). In addition, optic nerve sheath hemorrhage was observed in the right eye (Fig. 3C). Pathologic examination revealed hemorrhages in the superficial layers and the inner to outer nuclear layers of the retina at the posterior pole (Fig. 3E). Retinal hemorrhages were also noted in the superficial layers of the peripheral retina. Severe papilledema leading to retinal hemorrhage was not observed in either eye. Optic nerve sheath hemorrhages (peripapillary scleral hemorrhages), predominantly in the right eye, were also observed (Fig. 4A, B).

FIGURE 4.

A, Histopathologic findings of the right optic nerve (hematoxylin and eosin staining; asterisk indicates hemorrhage). B, Histopathologic findings of the left optic nerve (hematoxylin and eosin staining; asterisk indicates hemorrhage).

Toxicology Findings

We performed a drug screening test using gas chromatography-mass spectrometry, which detected lidocaine in the blood and urine.

Cause of Death

The cause of death was determined to have likely resulted from an acute subdural hematoma resulting from head trauma.

DISCUSSION

In this study, extensive postmortem wide-angle fundus photographs were successfully captured for the first time, allowing direct comparison with the macroscopic findings of the retina.

Retinal hemorrhages resulting from head trauma, whether accidental or nonaccidental, are commonly observed at the posterior pole and in the peripheral retina^1,2,8 (Fig. 5A, B). The distribution of these hemorrhages cannot be solely explained through the lens of hemodynamics. In children, the vitreous body is firmly attached at the posterior pole, along the retinal vessels, and at the peripheral retina.^8,9 Retinal hemorrhages due to head trauma frequently occur at these sites of strong vitreoretinal adhesion. Studies have indicated that vitreoretinal traction due to vitreous movement during head trauma likely contributes to retinal hemorrhages, as supported by biomechanical modeling.^1,8,10–12

FIGURE 5.

A, Schematic diagram of the typical distribution pattern of retinal hemorrhages caused by head trauma. The red circles represent retinal hemorrhages. Hemorrhages are distributed at the posterior pole and in the peripheral retina in a manner that cannot be explained by retinal hemodynamics. Schematic diagrams were created using iCeye (Mimir Sun-Bow Ltd., 2009). B, Hemisection photograph of the eye showing typical retinal hemorrhages due to head trauma (4-month-old, suspected AHT). C, Schematic diagram of the typical distribution pattern of retinal hemorrhages caused by intracranial pressure or chest compression during cardiopulmonary resuscitation. The hemorrhages are primarily located at the posterior pole along the central retinal vein. D, Fundus photograph showing retinal hemorrhages due to increased intracranial pressure (60-year-old, cerebral infarction).

In contrast, retinal hemorrhages resulting from increased intracranial pressure or chest compressions during cardiopulmonary resuscitation are typically confined to the region surrounding the optic disc in the posterior pole, which is attributable to vascular congestion (Fig. 5C, D).^1,13,14 However, despite the clear differences in the distribution of retinal hemorrhages caused by head trauma and elevated intracranial pressure, in Japan, enucleation is often avoided during forensic autopsies out of respect for the feelings of the bereaved, resulting in limited pathologic assessment of the peripheral retina. Therefore, overcoming the challenges associated with examining and documenting the peripheral retina in infants is crucial for the accurate diagnosis of AHT.¹⁵ Although peripheral retinal hemorrhages can be confirmed during autopsy through pathologic examination, noninvasive imaging has been less successful in documenting this evidence in living children. Notably, recent advances in wide-angle fundus photography have improved the capture of peripheral retinal images, which are critical for AHT cases.³

Postmortem fundus examination using an indirect ophthalmoscope allows observation for up to ∼72 hours after death under favorable conditions.¹ Indirect ophthalmoscopy is highly portable and, with adequate training, can be performed in any facility.¹⁶ However, sharing findings, particularly those in the peripheral retina, and documenting images remain challenging. This highlights the importance of objective documentation, even in autopsy cases. Moreover, traditional fundus cameras cannot capture postmortem fundus images, even in the presence of minimal corneal and vitreous opacities. Although smartphone-based postmortem fundus photography is considered the best method to date, its field of view is limited, making it difficult to examine the peripheral retina.⁷ Recently, wide-angle fundus imaging using SLO technology has become feasible in living individuals.^4,17,18 The Optos system is equipped with 2 low-power lasers and specialized optical technology, enabling high-resolution image acquisition with a single, noncontact capture, even through a pupil as small as 2 mm.^18,19 This system can capture up to 200 degrees or 82% of the retina. SLO technology is less affected by media opacities, such as cataracts or vitreous hemorrhages, allowing for the acquisition of high-quality images.¹⁹ We hypothesized that this technology could also be applied for postmortem wide-angle fundus imaging, avoiding the effects of postmortem corneal and vitreous opacities. We have successfully applied SLO to capture wide-field images of the retinas of postmortem eyes. Compared with macroscopic findings, SLO provided complementary documentation of retinal hemorrhages in the peripheral retina (Fig. 3A, C). SLO is not superior to traditional pathologic examination but provides valuable supplemental evidence.

In the present case, the presence of retinal hemorrhages concentrated in the posterior pole and peripheral retina of the right eye suggests that these hemorrhages were caused by head trauma. Asymmetry in ocular findings associated with head trauma has been documented. It is presumed to result from variations in acceleration forces exerted on each eye, depending on the direction of the external force applied to the head.^3,8,20 Although optic nerve sheath hemorrhage is a characteristic finding of AHT,^21,22 it can also occur in severe head trauma from motor vehicle accidents and falls, where severe stress is applied to the junction of the optic nerve and the globe.^8,23 The predominance of ocular findings in the right eye suggests that greater acceleration forces were applied to that side; however, the precise biomechanical interpretation remains speculative.

Determining the occurrence of abuse based solely on autopsy findings is challenging. While optic nerve sheath hemorrhages can occur from accidental falls from a height, they are unlikely to result from typical household falls. However, considering the consistency between the mother’s statements and the injuries observed in the child, we concluded that the head trauma was likely caused by abuse.

CONCLUSION

We report a case of AHT in which we successfully captured extensive postmortem fundus photographs that provided complementary supporting evidence to the pathologic findings. Although pathologic examination provides comprehensive information, postmortem fundus photography, particularly SLO, offers supplementary documentation unaffected by artifacts introduced during specimen preparation. However, a major limitation of this report is its single-case nature, underscoring the need for further studies involving multiple cases to confirm the general applicability and reliability of postmortem wide-angle fundus photography. In addition, the primary limitation of this technique is its inability to detect optic nerve sheath hemorrhage, a key indicator for diagnosing AHT. In addition, the high cost of the equipment and its lack of portability restrict its implementation to only a limited number of facilities. Therefore, this method should not be considered a substitute for pathologic examination. Future efforts will focus on accumulating additional cases to refine the conditions under which these images can be obtained, including the postmortem interval.