Fatal child abuse detected by systematic post-mortem fundus photograph in sudden death in infancy

In case of SUDI, fatal child abuse must be considered and eye examination is systematically required, especially, as in this case, shaken baby syndrome does not necessarily imply the presence of visible external traumatic lesions or limb fractures. Although fundus photography is the gold standard in living children, pathological examination is the reference for screening for RH in deceased children: the American Academy of Pediatrics recommends post-mortem eye removal for pathological examination in the case of SUDI that has not clearly resulted from a witnessed severe accidental head trauma or readily diagnosed systemic medical conditions [8]. Indeed, only a few post-mortem fundus examinations have been described in deceased children and these cases have a number of limitations. In particular, classic indirect ophthalmoscopy does not allow image acquisition while indirect ophthalmoscopy associated with a smartphone is challenging and requires specific training [9]. While endoscopy bypasses post-mortem opacification of cornea and lens it is invasive and it requires training and a specific endoscope [10, 11].

In 2023, Ducloyer et al. described for the first time the technique and advantages of RetCam PMFP in deceased children [12]. It allows the assessment of a larger area of retina than with indirect ophthalmoscopy [13]. The interpretation is immediate, so the detection of RH as soon as the child has arrived at the hospital can promptly alert the clinicians and the justice system, as in the case described here. As it is non-invasive, it does not raise issues of eye removal which includes the problem of consent from family and caregivers, the need for a trained pathologist which can delay autopsy results, and the risk of enucleation artifacts [14‐16]. Moreover, PMFP will not jeopardize eye removal for the pathological examination which would be required in the case of RH or if the image quality is insufficient. Indeed, Ducloyer et al. found that the quality of the images was not sufficient to state presence or absence of RH in 17% of cases, mainly when PMFP was performed more than 18 h after death [12]. The other limitation of PMFP is the impossibility to document histological specific findings such as optic nerve sheath/intrascleral/extraocular muscles/orbital fat haemorrhages, age estimation of the bleeding and the probability of bleedings at more than one time point [14].

In summary, this is the first case report in which the appearance of RH related to AHT is shown with fundus photographs taken after death. Furthermore, it highlights the many advantages of the RetCam PMFP as a screening test when performed as soon as a SUDI case arrives at the hospital. In SUDI cases, systematic eye examination is required as signs of trauma may not be evident in the context of the death, assessment of the death scene and external examination of the body. Pathological examination of the eye remains the gold standard to document any suspicion of child abuse and further studies are needed to assess under what conditions the absence of RH on PMFP of sufficient quality could avoid the removal of ocular and orbital tissue, which is difficult and traumatic.