Post-mortem fundus photographs in sudden unexpected death in infancy: An overview of the typical findings.

PURPOSE: To show post-mortem fundus photograph (PMFP) features seen in sudden unexpected death in infancy (SUDI), to detect retinal hemorrhages, which are a crucial hallmark for abusive head trauma (AHT).

METHODS

Single-center, retrospective study with SUDI cases included by a French SUDI referral center in the French national registry for SUDI cases between 2017 and 2025. All available PMFP, the final diagnosis and the post-mortem interval between death and PMFP were collected.

RESULTS

Of the 78 SUDI cases recorded in Nantes, 65 underwent a fundus examination, of which 46 had PMFP available. The mean age at death was 4.5 ± 4.9 months, 30 children were male (65%). The main PMFP features were retinal changes resembling central retinal artery occlusion and macular and/or peripheral white radial retinal folds. The presence of a macular fold was associated with a longer post-mortem interval (presence versus absence of a macular fold: 12.2 ± 7.2 h [range: 4-30] versus 4.5 ± 1.6 h [range: 3-9], p < 0.001). Retinal hemorrhages were found in four non-abusive cases with non-specific fundus features and in two confirmed AHT cases, with AHT-suggestive features.

CONCLUSION

The normal post-mortem fundus in children under two years old shows a "central retinal artery occlusion" pattern, followed by the appearance of macular or peripheral white radial retinal folds, that should not be mistaken for circumferential perimacular retinal folds and hemorrhagic retinoschisis cavities that have been described in AHT cases. PMFP allow detecting and documenting retinal hemorrhages, which may be indicative of infanticide.