Histologic features of Lange's folds: implications for diagnosing retinal folds due to vitreoretinal traction in pediatric eyes.

To describe the histologic features of the internal limiting membrane (ILM) on Lange’s folds, compare them with perimacular retinal folds, and determine whether these features indicate vitreoretinal traction from ocular acceleration-deceleration (shaking) in suspected abusive head trauma or shaken baby syndrome. We performed a retrospective, single-center autopsy case series of fifteen neonates, infants, and young children with hemorrhagic retinopathy identified by postmortem indirect ophthalmoscopy (2016–2024). Histological evaluation focused on ILM attachment at retinal fold apices and separation from adjacent retina. Decedents ranged from birth to 55 months (mean, 10.3 months); manners of death included natural (n = 6), accidental (n = 5), homicide (n = 1), and undetermined (n = 3). None involved abusive head trauma. In all cases, Lange’s folds had the ILM attached at fold apices and detached from adjacent retina, a pattern previously attributed to vitreoretinal traction from ocular acceleration-deceleration in abusive head trauma or shaken baby syndrome. ILM attachment at retinal fold apices with adjacent retinal separation lacks diagnostic specificity for vitreoretinal traction from ocular acceleration-deceleration. These findings highlight the risk of misinterpretation and underscore the critical need for prudent, evidence-based evaluations in suspected child abuse investigations. KEY POINTS: • Vitreoretinal traction (VRT) has been proposed as a mechanism contributing to retinal fold formation in suspected abusive head trauma. • Histopathologic findings of internal limiting membrane (ILM) attachment at retinal fold apices, with separation from the adjacent retina, have been cited as supportive of VRT. • The configuration of the ILM on Lange’s folds and adjacent retina resembles histological features described on pathological retinal folds. • A definitive causal relationship between repetitive ocular acceleration–deceleration forces (shaking) and retinal fold formation via VRT has not been established. • ILM attachment patterns on retinal folds are insufficient to confirm VRT as the etiologic mechanism, underscoring the need for cautious interpretation of ocular findings in clinical and forensic assessments.