A case of Chopper assault injury managed with three stage surgical

proceduresDr Harshavardhan Ghorpade

MS, DNB, FRCS(Glasgow), FICO, FCOSFellowship Cornea and Ocular surface, Nottingham, UK and Ghent, Belgium.

Director, DOVS, Fortis Hospital, Vashi, Navi MumbaiConsultant Cornea and Refractive /Director, Cornea transplant services ,

Director ,Saroj Specialty Eye Clinic, Vashi, Navi Mumbai

Prof. Dr Sunil Moreker, MSConsultant, Oculoplasty and Glaucoma.

DOVS, Fortis Hospital, Vashi, Navi MumbaiCPD /CME committee member, International Council of OphthalmologyNo Financial Disclosures

Vashi, Navi Mumbai

Introduction:-

• Mutton chopper injury in eye has always historically led to loss of eyesight permanently from as early as 1926

• Vision recover in eyes with No perception of light was not usually seen historically a decade ago

OUR CASE :-

• 25 year old male had a scuffle on the street leading to a person attacking him with a mutton chopper in Nov 2013. A large CLW across the right side of his face and extending to the right eyeball from temporal sclera to nasal cornea with Iris, lens and vitreous prolapse. Vision? No PL. The other eye was normal.

• CT scan showed no e/o FB

• Taken for eyeball repair surgery including, iris excision, lensectomy (leaving a rim of capsular bag), vitrectomy and sclera corneal suturing.

Vashi, Navi Mumbai

Initial presentation:-

The eye view The side viewMarginal lid tear

Suspected Bony chop off

CLW corneoscleral With iris dialysis And prolapse as well as lens rupture and tear up to equator

Hyphaema

Extensive muscle tear with tissue loss

Vashi, Navi Mumbai

CT 3 D reconstruction :- bone ‘chopped off’

Front view Inferior view

Vashi, Navi Mumbai

Methods:-Primary repair- suturing and healing by primary intention

Vashi, Navi Mumbai

Immediate post operativeVashi, Navi Mumbai

Corneal Scar with Sulcus supported non aniridia lens and iridodialysis seen along with vitreous haemorrhage and traction on USG B Scan

Vashi, Navi Mumbai

Methods:-First four months and phase 2 :-• Bscan postop showed vitreous haemorrhage, no

RD, no CD

• Kept on antibiotics, steroids and hypotonics and discharged after 10 days. IOP monitored.

• Followed up for 4 months and referred to Retina specialist for non resolving vitreous opacities and inflammation. Vision achieved was 3m.

• Intravitreal kenocort administered in April 2014 and followed up after 1 week with vitrectomy and secondary sulcus fixated IOL on the remainder capsular bag rim. 1 month follow up showed clearing of VH on Bscan and vision improving to 6/60

Phase three surgical management• Patient maintained vision of 6/60, but with photophobia, due

to aniridia and corneal scarring. Maintained on low potency steroids. IOP well maintained around 14.

• Planned for Keratoplasty with lens exchange placing an aniridia lens. IOL power determined from other eye.

• Operated in March 2015 for the same. PK with Aniridia lens placement in sulcus with vitrectomy.

• Postop vision improved with decreased photophobia and IOP maintained. Bscan normal.

• Postop 3months 6/24. Post op 5 months 6/12. Planned for suture adjustments and BCL 6 months postop. Vision expected o reach 6/9. No photophobia at present, IOP normal.

Vashi, Navi Mumbai

Result : Minimal Scars /clear keratoplasty/ Aniridia IOL/No vitreous haemorrhage/No Glaucoma/ Vision 6/9 -3

Aniridia lens retroilluminationClear Corneal transplant

Minimal scar No Vitreous Hameorrhage

Centered Aniridia lens

Clear centered graft

Vashi, Navi Mumbai

Discussion : No glaucoma inspite of UBM showing Iridodialysis 5 O’clock to 9 O’clock and Angle recession and corneal graft clear

Iridodialysis seen

Cyclodialysis seen

Zonular tear seen

Angle recession seen

..but

No glaucoma as CyclodialysisCleft formed

Lid no notch and noabnormality in surface

So Cornea remains clear

Vashi, Navi Mumbai

- Discussion: Eyes with No PL• Ciliary body damage, closed funnel retinal detachment, and choroidal damage are independent risk factors

but traumatized eyes with No perception of light may recover light perception or better vision if appropriate interventional measures are used for treatment of the injured ciliary body, retina, and choroid (1)

• Visual recovery to light perception or better on postoperative Day 1 increases the likelihood of having a long-term improvement in visual acuity even in eyes presenting with no perception of light (2). This was applicable in our patient as he perceived light on day 1

• Globe rupture , open globe III ,scleral wound ≥10 mm , ciliary body damage , severe intraocular haemorrhage , closed funnel retinal detachment or retinal prolapse and choroidal damage are 7 risk factors which are possible predictors of poor prognosis but in spite of that traumatized eyes with no light perception can be anatomically restored with LP or better vision if vitreoretinal surgery is attempted, and a favourable anatomic and visual outcome is increased by having a decreased number of these risk factors.(3).Our patient had two .

• Pre-operative visual acuity of No light Perception should not be an indication for primary enucleation or evisceration for severely traumatized eyes and these are what we used as a guiding principles to save the vision of this young man

References:-

1. Feng K, Shen L, Pang X, Jiang Y, Nie H, Wang Z, Hu Y, Ma Z. Case-control study of risk factors for no light perception after open-globe injury: eye injury vitrectomy study. Retina. 2011 Nov;31(10):1988-96

2. Soni NG, Bauza AM, Son JH, Langer PD, Zarbin MA, Bhagat N. Open globe ocular trauma: functional outcome of eyes with no light perception at initial presentation. Retina. 2013 Feb;33(2):380-6.

3. Feng K, Hu YT, Ma Z. Prognostic indicators for no light perception after open-globe injury: eye injury vitrectomy study. Am J Ophthalmol. 2011 Oct;152(4):654-662.e2

4. Agrawal R, Wei HS, Teoh S. Predictive factors for final outcome of severely traumatized eyes with no light perception. BMC Ophthalmol. 2012 Jun 19;12:16

Vashi, Navi Mumbai

Conclusion: -• Meticulous management at primary stage even in cases with ?no PL

with complex fractures and multiple tears which fair poor on triage, can be managed with extremely good recovery of vision provided attention is given to all aspects including corneal condition, angle status, traumatic glaucoma, traumatic iridodialysis and effective aniridia, vitreous haemorrhage in addition to orbit and oculoplasty including lid suturing without notching because that will be essential for corneal graft survival if need be. • No eye should probably be given up as unsalvageable because there

can be cases like this which can achieve 6/9 P vision at end of one year

Vashi, Navi Mumbai