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Usefulness of postmortem ocular findings in forensic autopsy
Legal Medicine 5 (2003) S288–S291 www.elsevier.com/locate/legalmed
Usefulness of postmortem ocular findings in forensic autopsy Masatake Tsujinaka a,*, Takashi Nakazawa a, Kayoko Akaza a, Isao Nakamura a, Isao Ohya b, Yasuo Bunai a b
a Department of Legal Medicine, Gifu University School of Medicine, 40 Tsukasamachi, Gifu 500-8705, Japan Department of Legal Medicine, Graduate School of Medicine, Kanazawa Medical University, Uchinada, Ishikawa 920-0293, Japan
Abstract We report three autopsy cases in which the eyeballs were removed and examined macroscopically and microscopically after being cut using the alternate gross examination technique. The first case was a 67-year-old woman who was killed by ligature and manual strangulation. A postmortem opthalmological observation of the left eyeball revealed tiny hemorrhages and congestion in the pars plicae of the ciliary body. These changes were considered to arise by a mechanism similar to that by which facial hemorrhages arise during strangulation. The second case was a 54-year-old man who died from a cerebral contusion received during a traffic accident. A postmortem opthalmological observation of the eyeball using a surgical microscope revealed papilledema and retinal hemorrhages resulting from a rise in intracranial pressure. The third case was a 77-year-old woman who died from cardiac tamponade caused by a stab wound to the heart. A postmortem ophthalmological examination revealed that she had undergone cataract surgery and an intraocular lens implantation. However, her relatives did not know when and where she had received the surgery. An intraocular lens was removed and its material and shape was examined. Based on an examination of the lens, we were able to locate the hospital where she had received the surgery 4 years earlier. This suggests that postmortem opthalmological observations may be useful for forensic pathology and personal identification. q 2002 Elsevier Science Ireland Ltd. All rights reserved. Keywords: Forensic autopsy; Eyeball; Papilledema; Retinal hemorrhages; Intraocular lens
1. Introduction Recently, some forensic pathologists have referred to postmortem ocular findings in cases of ‘shaken babies’ [1]. However, little attention has been paid to postmortem ocular findings in forensic pathology. Postmortem ophthalmological observation can provide useful information, especially when the corpus can only be examined externally. Some postmortem ocular findings can indicate pathological conditions, such as general arteriosclerosis, a rise in * Corresponding author. Tel.: 181-58-267-2250; fax: 181-58267-2957. E-mail address: [email protected] (M. Tsujinaka).
intracranial pressure, and diabetes mellitus. Moreover, evidence of cataract surgery with intraocular lens implantation can provide information useful for personal identification in forensic autopsies, since several materials and shapes of intraocular lenses and several kinds of surgical methods are available. In this paper, we describe the usefulness of postmortem ophthalmology in forensic pathology.
2. Case Reports 2.1. Case 1 A 67-year-old woman was found dead in her house
1344-6223/03/$ - see front matter q 2002 Elsevier Science Ireland Ltd. All rights reserved. doi:10.1016/S134 4- 6223(02)0015 2-9
M. Tsujinaka et al. / Legal Medicine 5 (2003) S288–S291
Fig. 1. The eyeball has been cut using the alternative gross examination technique described by Gilliland et al.
one evening. An autopsy revealed a horizontal ligature mark and pressure marks on the neck. The face was congestive, and many petechial hemorrhages were observed in the face and palpebral conjunctivae. Three stab wounds were observed around the umbilicus. However, the hemorrhage from these injuries was not lethal. From these findings, it appeared that she had been strangled with a ligature and by hand and then stabbed during the agonal period. The left eyeball was removed because a postmortem ophthalmoscopic observation revealed changes only in the left eye. The eyeball was cut using the alternative gross examination technique of Gilliland et al. [2] (Fig. 1). The anterior and posterior parts of the eyeball were observed with a surgical microscope, and congestion and tiny hemorrhages in the pars plicae of the ciliary
Fig. 2. Photomicrograph showing congestion and a tiny hemorrhage (arrow) in the pars plicae of the ciliary body (H–E stain).
S289
Fig. 3. Retinal hemorrhages.
body were noted. A histological examination also revealed congestion and tiny hemorrhages in the pars plicae (Fig. 2). 2.2. Case 2 A 54-year-old man was involved in a traffic accident in the morning. Although he looked well after the accident, he was found dead in bed 3 days later. An autopsy revealed a subarachnoid hematoma originating from contusions in the right insula and the inner surface of the right temporal lobe. Since only the left eye showed changes during a postmortem ophthalmoscopic observation, the left eyeball was removed and cut using the alternative gross examination technique. Observation with a surgical microscope revealed papilledema and retinal hemorrhages (Fig. 3). A histological examination also revealed papilledema and retinal hemorrhages (Fig. 4).
Fig. 4. Retinal hemorrhages (H–E stain).
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M. Tsujinaka et al. / Legal Medicine 5 (2003) S288–S291
Fig. 5. The shape of the lens was changed by warming.
2.3. Case 3 A 77-year-old woman with two stab wounds to the chest was found. A forensic autopsy revealed that a stab wound had injured the heart, and the victim had died from cardiac tamponade. Pressure marks were also observed on the neck. The face was congested, and many petechial hemorrhages were observed in the face and palpebral conjunctivae. A postmortem ophthalmological observation revealed that she had undergone cataract surgery with intraocular lens implantation and had subsequently developed a Soemmering ring cataract. A small incision in the sclera without suture was present, and the cataract surgical technique was identified as phacoemulsification. The intraocular lens was removed, and its material and shape were examined. The examination revealed that the lens was 6 mm in thickness and that its shape could be changed by warming. From these results, the lens was determined to be a MA60BM Acrysofemodel made by Alcon Lab. (Fig. 5). The patient’s relatives had no knowledge of when and where she had received the surgery. We attempted to find the hospital using only the above information about the surgery and without disclosing her name. We were able to find the hospital and determine that she had received the surgery 4 years earlier.
3. Discussion In the present study, the eyeballs were cut using the alternate gross examination technique of Gilliland et
al. [2], and the anterior and posterior parts of the eyeball were observed using a surgical microscope prior to fixation in formalin for histological observation. Compared with other procedures, this procedure has the advantage of being able to observe the eyeball while still in a fresh condition. In case 1, tiny hemorrhagic foci and congestion were observed in the pars plicae of the ciliary body. Recently, Saad et al. [3] reported the occurrence of retinal bleeding during strangulation. However, they did not describe any changes in the ciliary body. The changes in the ciliary body in case 1 were considered to arise by a mechanism similar to that of changes in the palpebral conjunctivae and face during strangulation. These changes were useful postmortem ocular findings, suggesting that the victim had been strangled. In case 2, retinal bleeding and papilledema were observed. These changes are known to arise during an increase in intracranial pressure and were useful postmortem ocular findings, suggesting the presence of a lesion in the intracranial space. In case 3, the deceased had undergone phacoemulsification, a relatively new surgical technique that was rarely used 10 years ago. An examination of the intraocular lens revealed that the lens was an MA60BM Acrysofemodel made by Alcon Lab. In Japan, this type of intraocular lens was approved for use in 1994 [4]. Moreover, the postmortem opthalmological observation revealed that the victim had suffered from a Soemmering ring cataract, which had developed more than 1 year after the cataract surgery. However, her relatives had no knowledge of where she had received the surgery. We attempted to locate the hospital using the above information about the surgery without disclosing her name. We discovered that the type of lens found during the autopsy was used by four cataract surgery institutions in the region where she had lived. We questioned these institutions about patients who had received cataract surgery between 1994 and 2001 and were able to identify the victim. She had undergone surgery 4 years earlier at one of the institutions. Thus, postmortem ocular findings showing evidence of cataract surgery and intraocular lens implantation may be useful for identifying victims. In forensic autopsies, ocular findings are often overlooked. In the present cases, however postmortem ophthalmology findings provided useful information.
M. Tsujinaka et al. / Legal Medicine 5 (2003) S288–S291
The technique used for postmortem ocular observations is simple, and postmortem ophthalmology can provide useful findings indicating the presence of intracranial lesions, arteriosclerosis, diabetes mellitus and other diseases, as in antemortem ophthalmology. Kelly and Alan [5] have reported that diabetic retinopathy was identified in 14% of autopsy cases. Moreover, the number of elderly people in Japan who are undergoing cataract surgery with intraocular lens implantation is increasing. Postmortem ocular findings showing evidence of surgery are expected to become useful for the identification of victims.
S291
References [1] Riffenburgh RS, Sathyavagiswaran L. The eyes of child abuse victims. Autopsy findings. J Forensic Sci 1991;36:741–747. [2] Gilliland MGF, Robert F. Retinal hemorrhages. Replicating the clinician’s view of the eye. Forensic Sci Int 1992;56:77–80. [3] Saad S, Martin LF, Mike G, Deborah A. Diffuse unilateral hemorrhagic retinopathy associated with accidental perinatal strangulation. Retina 2001;21:252–255. [4] Tetsuro O. Acrylic foldable intraocular lens (Alcon). Jpn J Ophthalmol Surg 2002;15:311–316. [5] Kelly JB, Alan DP. Unexpected autopsy findings arising from postmortem ocular examination. Arch Pathol Lab Med 2001;125:1193–1196.
Usefulness of postmortem ocular findings in forensic autopsy Masatake Tsujinaka a,*, Takashi Nakazawa a, Kayoko Akaza a, Isao Nakamura a, Isao Ohya b, Yasuo Bunai a b
a Department of Legal Medicine, Gifu University School of Medicine, 40 Tsukasamachi, Gifu 500-8705, Japan Department of Legal Medicine, Graduate School of Medicine, Kanazawa Medical University, Uchinada, Ishikawa 920-0293, Japan
Abstract We report three autopsy cases in which the eyeballs were removed and examined macroscopically and microscopically after being cut using the alternate gross examination technique. The first case was a 67-year-old woman who was killed by ligature and manual strangulation. A postmortem opthalmological observation of the left eyeball revealed tiny hemorrhages and congestion in the pars plicae of the ciliary body. These changes were considered to arise by a mechanism similar to that by which facial hemorrhages arise during strangulation. The second case was a 54-year-old man who died from a cerebral contusion received during a traffic accident. A postmortem opthalmological observation of the eyeball using a surgical microscope revealed papilledema and retinal hemorrhages resulting from a rise in intracranial pressure. The third case was a 77-year-old woman who died from cardiac tamponade caused by a stab wound to the heart. A postmortem ophthalmological examination revealed that she had undergone cataract surgery and an intraocular lens implantation. However, her relatives did not know when and where she had received the surgery. An intraocular lens was removed and its material and shape was examined. Based on an examination of the lens, we were able to locate the hospital where she had received the surgery 4 years earlier. This suggests that postmortem opthalmological observations may be useful for forensic pathology and personal identification. q 2002 Elsevier Science Ireland Ltd. All rights reserved. Keywords: Forensic autopsy; Eyeball; Papilledema; Retinal hemorrhages; Intraocular lens
1. Introduction Recently, some forensic pathologists have referred to postmortem ocular findings in cases of ‘shaken babies’ [1]. However, little attention has been paid to postmortem ocular findings in forensic pathology. Postmortem ophthalmological observation can provide useful information, especially when the corpus can only be examined externally. Some postmortem ocular findings can indicate pathological conditions, such as general arteriosclerosis, a rise in * Corresponding author. Tel.: 181-58-267-2250; fax: 181-58267-2957. E-mail address: [email protected] (M. Tsujinaka).
intracranial pressure, and diabetes mellitus. Moreover, evidence of cataract surgery with intraocular lens implantation can provide information useful for personal identification in forensic autopsies, since several materials and shapes of intraocular lenses and several kinds of surgical methods are available. In this paper, we describe the usefulness of postmortem ophthalmology in forensic pathology.
2. Case Reports 2.1. Case 1 A 67-year-old woman was found dead in her house
1344-6223/03/$ - see front matter q 2002 Elsevier Science Ireland Ltd. All rights reserved. doi:10.1016/S134 4- 6223(02)0015 2-9
M. Tsujinaka et al. / Legal Medicine 5 (2003) S288–S291
Fig. 1. The eyeball has been cut using the alternative gross examination technique described by Gilliland et al.
one evening. An autopsy revealed a horizontal ligature mark and pressure marks on the neck. The face was congestive, and many petechial hemorrhages were observed in the face and palpebral conjunctivae. Three stab wounds were observed around the umbilicus. However, the hemorrhage from these injuries was not lethal. From these findings, it appeared that she had been strangled with a ligature and by hand and then stabbed during the agonal period. The left eyeball was removed because a postmortem ophthalmoscopic observation revealed changes only in the left eye. The eyeball was cut using the alternative gross examination technique of Gilliland et al. [2] (Fig. 1). The anterior and posterior parts of the eyeball were observed with a surgical microscope, and congestion and tiny hemorrhages in the pars plicae of the ciliary
Fig. 2. Photomicrograph showing congestion and a tiny hemorrhage (arrow) in the pars plicae of the ciliary body (H–E stain).
S289
Fig. 3. Retinal hemorrhages.
body were noted. A histological examination also revealed congestion and tiny hemorrhages in the pars plicae (Fig. 2). 2.2. Case 2 A 54-year-old man was involved in a traffic accident in the morning. Although he looked well after the accident, he was found dead in bed 3 days later. An autopsy revealed a subarachnoid hematoma originating from contusions in the right insula and the inner surface of the right temporal lobe. Since only the left eye showed changes during a postmortem ophthalmoscopic observation, the left eyeball was removed and cut using the alternative gross examination technique. Observation with a surgical microscope revealed papilledema and retinal hemorrhages (Fig. 3). A histological examination also revealed papilledema and retinal hemorrhages (Fig. 4).
Fig. 4. Retinal hemorrhages (H–E stain).
S290
M. Tsujinaka et al. / Legal Medicine 5 (2003) S288–S291
Fig. 5. The shape of the lens was changed by warming.
2.3. Case 3 A 77-year-old woman with two stab wounds to the chest was found. A forensic autopsy revealed that a stab wound had injured the heart, and the victim had died from cardiac tamponade. Pressure marks were also observed on the neck. The face was congested, and many petechial hemorrhages were observed in the face and palpebral conjunctivae. A postmortem ophthalmological observation revealed that she had undergone cataract surgery with intraocular lens implantation and had subsequently developed a Soemmering ring cataract. A small incision in the sclera without suture was present, and the cataract surgical technique was identified as phacoemulsification. The intraocular lens was removed, and its material and shape were examined. The examination revealed that the lens was 6 mm in thickness and that its shape could be changed by warming. From these results, the lens was determined to be a MA60BM Acrysofemodel made by Alcon Lab. (Fig. 5). The patient’s relatives had no knowledge of when and where she had received the surgery. We attempted to find the hospital using only the above information about the surgery and without disclosing her name. We were able to find the hospital and determine that she had received the surgery 4 years earlier.
3. Discussion In the present study, the eyeballs were cut using the alternate gross examination technique of Gilliland et
al. [2], and the anterior and posterior parts of the eyeball were observed using a surgical microscope prior to fixation in formalin for histological observation. Compared with other procedures, this procedure has the advantage of being able to observe the eyeball while still in a fresh condition. In case 1, tiny hemorrhagic foci and congestion were observed in the pars plicae of the ciliary body. Recently, Saad et al. [3] reported the occurrence of retinal bleeding during strangulation. However, they did not describe any changes in the ciliary body. The changes in the ciliary body in case 1 were considered to arise by a mechanism similar to that of changes in the palpebral conjunctivae and face during strangulation. These changes were useful postmortem ocular findings, suggesting that the victim had been strangled. In case 2, retinal bleeding and papilledema were observed. These changes are known to arise during an increase in intracranial pressure and were useful postmortem ocular findings, suggesting the presence of a lesion in the intracranial space. In case 3, the deceased had undergone phacoemulsification, a relatively new surgical technique that was rarely used 10 years ago. An examination of the intraocular lens revealed that the lens was an MA60BM Acrysofemodel made by Alcon Lab. In Japan, this type of intraocular lens was approved for use in 1994 [4]. Moreover, the postmortem opthalmological observation revealed that the victim had suffered from a Soemmering ring cataract, which had developed more than 1 year after the cataract surgery. However, her relatives had no knowledge of where she had received the surgery. We attempted to locate the hospital using the above information about the surgery without disclosing her name. We discovered that the type of lens found during the autopsy was used by four cataract surgery institutions in the region where she had lived. We questioned these institutions about patients who had received cataract surgery between 1994 and 2001 and were able to identify the victim. She had undergone surgery 4 years earlier at one of the institutions. Thus, postmortem ocular findings showing evidence of cataract surgery and intraocular lens implantation may be useful for identifying victims. In forensic autopsies, ocular findings are often overlooked. In the present cases, however postmortem ophthalmology findings provided useful information.
M. Tsujinaka et al. / Legal Medicine 5 (2003) S288–S291
The technique used for postmortem ocular observations is simple, and postmortem ophthalmology can provide useful findings indicating the presence of intracranial lesions, arteriosclerosis, diabetes mellitus and other diseases, as in antemortem ophthalmology. Kelly and Alan [5] have reported that diabetic retinopathy was identified in 14% of autopsy cases. Moreover, the number of elderly people in Japan who are undergoing cataract surgery with intraocular lens implantation is increasing. Postmortem ocular findings showing evidence of surgery are expected to become useful for the identification of victims.
S291
References [1] Riffenburgh RS, Sathyavagiswaran L. The eyes of child abuse victims. Autopsy findings. J Forensic Sci 1991;36:741–747. [2] Gilliland MGF, Robert F. Retinal hemorrhages. Replicating the clinician’s view of the eye. Forensic Sci Int 1992;56:77–80. [3] Saad S, Martin LF, Mike G, Deborah A. Diffuse unilateral hemorrhagic retinopathy associated with accidental perinatal strangulation. Retina 2001;21:252–255. [4] Tetsuro O. Acrylic foldable intraocular lens (Alcon). Jpn J Ophthalmol Surg 2002;15:311–316. [5] Kelly JB, Alan DP. Unexpected autopsy findings arising from postmortem ocular examination. Arch Pathol Lab Med 2001;125:1193–1196.