Dr Harshavardhan Ghorpade, MS, DNB, FRCS(Glasgow), FICO, FCOS.

1. A case of Chopper assault injury
managed with three stage surgical
procedures
Dr Harshavardhan Ghorpade
MS, DNB, FRCS(Glasgow), FICO, FCOS
Fellowship Cornea and Ocular surface, Nottingham, UK and Ghent, Belgium.
Director, DOVS, Fortis Hospital, Vashi, Navi Mumbai
Consultant Cornea and Refractive /Director, Cornea transplant services ,
Director ,Saroj Specialty Eye Clinic, Vashi, Navi Mumbai
Prof. Dr Sunil Moreker, MS
Consultant, Oculoplasty and Glaucoma.
DOVS, Fortis Hospital, Vashi, Navi Mumbai
CPD /CME committee member, International Council of OphthalmologyNo Financial Disclosures
Vashi, Navi Mumbai

2. 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

3. Initial presentation:-
The eye view The side view
Marginal 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

4. CT 3 D reconstruction :- bone ‘chopped off’
Front view Inferior view
Vashi, Navi Mumbai

5. Methods:-Primary repair- suturing and
healing by primary intention
Vashi, Navi Mumbai

6. Immediate post operative
Vashi, Navi Mumbai

7. Corneal Scar with Sulcus supported non aniridia
lens and iridodialysis seen along with vitreous
haemorrhage and traction on USG B Scan
Vashi, Navi Mumbai

8. 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

9. Result : Minimal Scars /clear keratoplasty/ Aniridia
IOL/No vitreous haemorrhage/No Glaucoma/
Vision 6/9 -3
Aniridia lens retro
illuminationClear Corneal transplant
Minimal scar No Vitreous Hameorrhage
Centered Aniridia lens
Clear centered graft
Vashi, Navi Mumbai

10. 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 Cyclodialysis
Cleft formed
Lid no notch and no
abnormality in surface
So Cornea remains
clear
Vashi, Navi Mumbai

11. - 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

12. 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