INTRODUCTION

An axe, though considered a primitive hand tool, serves as a biomechanical wedge capable of causing both sharp and blunt force trauma. Assaults involving such tools are uncommon but often result in devastating injuries. In the Indian legal context, such assaults fall under serious criminal charges, including IPC Sections 307, 326, 302, and 498.

Ocular trauma due to axe-related assaults is rare, especially in female victims. Most reported cases involve males and are often associated with alcohol-related violence. Open globe injuries (OGIs), particularly those involving rupture and prolapse of intraocular contents, are ophthalmic emergencies that demand urgent intervention and carry a poor visual prognosis. This case is a stark example of intimate partner violence leading to complex craniofacial trauma and irreversible vision loss.

CASE REPORT

A 28-year-old female from Chatpara, Bongaigaon, Assam, India, presented to our outpatient department after sustaining a violent assault with a metallic axe by her husband at home. The patient had initially been managed at a local healthcare facility, where she received resuscitation and primary surgical wound closure. She was subsequently referred to our center for further evaluation and definitive care.

Imaging findings

CT brain

Comminuted displaced fractures in the left frontal bone, right frontal bone, and left parietal region [Figure 1].

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Figure 1:

Computed tomography of the brain showing cranial fractures (red arrow).

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CT face with 3D reconstruction

Comminuted displaced fractures of the bilateral zygomatic bones.

Fracture of the mandible involving the symphysis menti and paramedian bodies of both hemimandibles.

Chip fractures of the hard palate (right side) and anterior nasal spine.

Irregular configuration and soft tissue swelling of the LE ball.

Fractures of the superior orbital ridge and cranial vault, with associated dental damage [Figures 2 and 3].

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Figure 2:

Computed tomography of the face highlighting ocular injury and orbital fractures (red arrow).

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Figure 3:

3D reconstruction of facial fractures (red arrows).

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Figure 4 shows the preoperative condition of the patient, while Figure 5 illustrates the immediate postoperative appearance.

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Figure 4:

Preoperative facial appearance.

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Figure 5:

Immediate postoperative appearance.

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DISCUSSION

According to Zhou Y et al.,¹ open globe injuries are full-thickness defects of the eyewall and are often differentiated by the mechanisms of injury from which they are caused: sharp or blunt trauma. They are ocular emergencies and can lead to substantial visual morbidity. Without timely intervention, damage is irreversible and leads to permanent vision loss. On inspection, any extruded intraocular tissue is diagnostic of an open globe injury. The dark coloured uvea frequently prolapses, typically from zone II, and is highly visible against the sclera, while beads of vitreous are transparent and may be difficult to identify.¹ Zachariades N et al.² reported blindness after facial fractures to occur with an incidence that ranges between 0.67% and 3% depending on the reporting institution. Vision loss was more frequently encountered in Le Fort III level fractures (2.2%), followed distantly by Le Fort II level fractures (0.64%) and zygomatic fractures (0.45%).² Marta A et al. also found that home was the most common location of trauma (46.3%).³ Vaca EE et al.⁴ found blindness associated with penetrating injury, zygomaticomaxillary complex fracture, admission Glasgow Coma Scale score less than or equal to 8, and globe injury spanning all three eye zones. They also recommend that orbital fracture repair not be delayed in the hopes of eventual visual recovery in cases of high-velocity projectile trauma.⁴ Schmidt GW et al.⁵ stated that the presence of a relative afferent pupillary defect and poor initial visual acuity were the most predictive of complete loss of vision; the presence of lid laceration and posterior wound location also predicted poor visual outcomes.⁵ Moharana B et al.⁶ also stated prognostic factors to be globe rupture, posterior segment injury, and presence of orbital fracture, with the velocity of impact as an additional predictor of visual outcome. Ocular trauma is a major cause of uniocular blindness in India, with incidence rates ranging from 4.5% to 7.5%. It has significant financial implications and severely affects the physical and psychological well-being of the patient.⁶ Chotprasert N et al. also found that patients with ocular loss tend to have physical and psychosocial difficulties.⁷

CONCLUSION

Severe facial and ocular trauma secondary to assault demands immediate and comprehensive management. This case demonstrates the importance of early recognition, surgical intervention, and long-term reconstructive planning in optimizing outcomes for patients with such complex injuries.