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Dr. Debajit Deka, Dr. SAURABH DESHMUKH, Dr. KRATI GUPTA, Dr. Samirkumar Maganbhai Serasiya

Introduction

Fireworks are commonly used in both developed anddeveloping countries to celebrate festive occasionsrelated to tradition, religion, or culture. These occasions include Independence Day in the United States,Guy Fawkes’ night in Australia, Britain and NewZealand, Deepawali in India, New Year in China andItaly, the Prophet’s birthday in Libya, and the HariRaya festival in Malaysia [1]. Fireworks are devicesdesigned for the purpose of producing a visible oraudible effect by combustion, deflagration, or detonation [2].

There are various types of firecrackers including bottle rockets, sparklers, aerial devices,bullet bombs, and fountains.Fireworks can often cause ocular injuries to activeusers and bystanders. Such injuries are commonworldwide and have been well documented. Theinjuries can be serious and even life-threatening. InIndia the festivity of Deepawali is invariably vitiatedby spurious quality fireworks and their negligenthandling leading to firework-related ocular injuries[3]. There are noestablished rules and regulations forfireworks in India.

A study conducted from 1994 to 2001 of 116 eyesof 102 patients who suffered ocular trauma on NewYear’s Eve in Austria found that males (69 %) andchildren <18 years (49 %) were commonly affected[4]. Although parental supervision and the use of safefireworks should help in preventing injuries, previousstudies have shown that 54 % of firework-relatedinjuries occurred despite parental supervision [5, 6]. Inaddition, sparklers, considered by some as one of thesafer types of fireworks, have been found to cause10–17 % of firework-related injuries [7].

The present study was carried out to note the ocularfirecracker injuries sustained over the past 5 yearstogether with cause, type and severity of injury, complications and final visual outcome.

Materials and methods

This was a retrospective study conducted at a tertiaryeye care hospital in North East India. Case records of all thepatients who presented with injuries from fireworks inthe past 5 years (2005–2009), during Deepawali, wereevaluated. The demographic profile of patients including age and sex were noted. Note was made of causeand time of injury, time of presentation and intervention.

Visual acuity at presentation and anterior andposterior segment findings were recorded. Note wasalso made of any diagnostic, therapeutic and surgicalinterventions performed as per patient requirement.Ultrasound (A- and B-scan) was carried out to assessposterior segment status, particularly, retinal detachment, vitreous haemorrhage and to rule out retainedintraocular foreign body (IOFB) in patients with hazymedia. An X-ray of the orbit was performed to rule outretained IOFB in suspicious cases. All patients wereclassified on the basis of ocular trauma classificationsystem [8]. Final visual outcome at last visit whereveravailable was noted.

Results

One hundred and one patients suffered from fireworkrelated ocular injuries between 2012 and 2017. Ofthese, 79 were male (77.5 %) and 22 were female(21.6 %) with a mean age of 17.60 ± 11.9 years(range 3–55 years). Fifty-four percent of these patientswere ≤14 years and most of them had used firecrackerswithout any supervision.

The mean time of presentation after injury was 8.9 h (range 1–48 h). Of the 101patients (Fig. 1), 17 had open globe injury (OGI) and84 had closed globe injury (CGI). Mean log MARvisual acuity at presentation was 0.64 in CGI patientsand 1.22 in OGI patients (p = 0.00); this differencewas statistically significant. Fountains were the mostcommon tool in CGI and bullet bombs were the mostcommon in OGI. Of the patients whosustained trauma, 49 were igniting the firecrackersthemselves, 38 were innocent bystanders and in 14patients the cause of trauma remained unknown.

Eighty-four patients had CGI; most of thesepatients had corneal abrasion (23 patients), deposits on thecornea, conjunctiva and fornix (22 patients), lid laceration(8 patients) and facial burns mostly by fountains.Hyphema (21 patients), iridodialysis (3 patients), anglerecession (2 patients), vitreous hemorrhage (3 patients),optic nerve injury (2 patients), and Berlin’s edema (2patients) were noted and managed conservatively. Surgical intervention was required in four patients who hadsubluxated lens and two patients with retinal detachmentwho underwent scleral buckling. Patients with hyphemawho had uncontrolled intraocular pressure (IOP) andendothelial staining were managed surgically by hyphemadrainage. Patients with angle recession were followed up

for IOP assessment and disc evaluation.

Of the 17 patients with OGI, 16 were male and onewas female; eight of them were\14 years of age. Thepatients with OGI underwent surgical intervention.The mean time between injury and intervention was16.11 h (range 6–56 h). Seven had Zone I injuries, sixhad Zone II and four had Zone III. Globe rupture(Type A) was present in three patients where primaryrepair was not possible and evisceration was performed. None of these patients had perception of lightand visually evoked potential in these patients showedlow amplitudes. Penetrating injury (Type B) waspresent in 11 patients (69 %) and primary repair wascarried out under general anesthesia.

All the patientsreceived intravenous antibiotic and tetanus toxoid.Orbital X-rays and B-scans were performed in allpatients to rule out IOFB and orbital wall fracture. Sixpatients underwent surgery for traumatic cataract withlens capsule rupture. Three patients had Type Cinjuries (penetrating injury with IOFB)—one patienthad an IOFB in the lens which was removed with lensaspiration during primary repair, the second patientunderwent pars plana vitrectomy and IOFB removal,and the third patient had endophthalmitis and underwent core vitrectomy and IOFB removal.

Patients presenting[24 h after injury and with anIOFB received intravitreal vancomycin (1 mg/0.1 ml)and ceftazidime (2.25 mg/0.1 ml) prophylactically toprevent endophthalmitis. Seven patients with doubtfulopen globe injury underwent exploration although noscleral laceration was found. Grade of injury wasgrade IV in 75 % of patients (perception of light) andthree patients had grade V (no perception of light). Ofthe three patients who developed permanent blindness,two were\14 years of age.

Three patients underwentoptical penetrating keratoplasty after 6 months andgained good vision. One patient had retinal detachment and underwent pars plana vitrectomy.The mean log MAR visual acuity at last follow-upwas 0.09 and 0.58 for CGI and OGI groups, respectively. There was significant improvement in visualacuity in both groups, although the difference inthe final visual outcome was statistically significant(p = 0.00) between the two groups. The patients withCGI had better visual outcome than patients with OGI.

Final records of visual acuity were not available fornine patients.The factors associated with a poor final visualoutcome in our study were poor initial visual acuity,OGI, IOFB, retinal detachment and development ofendophthalmitis, while most patients with closedglobe injuries regained good vision.

Discussion

Of all reported ocular injuries, 1.6–2 % are due to injuryby firecrackers [9]. Firework injuries occur in mostsocieties. A similar study was published from ourdepartment which included Deepawali injuries overthree consecutive years between 1997 and 1999 [10].The trend of ocular trauma in our department is shown inFig. 2. The age, sex distribution and cause of injury inthe present study are consistent with our previous study.In our present study, 77.5 % of patients were male,while in our previous study 83 % were male [10].

Accordingly, in a study by Sacu et al. [4], 68 % ofpatients were male. Children were also more commonlyaffected (55 %), consistent with other studies [4, 10].The incidence of OGI in our previous study(1997–1999) was 7.1 %; however, this increased to16.8 % between 2005 and 2009 in our present study.The trend for OGI has increased with the introductionof spurious fireworks. Fountains and bullet bombswere the most common cause of injury in both ourstudies while bottle rocket was the commonest causein another study [11]. Three patients (2.9 %) developed permanent blindness in our present study, whileone patient (2.3 %) lost an eye in our previous study[10]. In a study from Austria [4], two patients (1.7 %)lost their vision.

In a study of 26 patients with firework-relatedinjuries from the Rajendra Prasad Center [11] in India,it was concluded that visual outcome is better in eyeshaving better initial best-corrected visual acuity orclosed globe injury and if relative afferent pupillarydefect, bottle rocket injury, IOFB, and endophthalmitis are absent.

These results are consistent with ourresults. An analysis of accidents involving fireworks inmost of the studies shows that most accidents occurbecause of uncertainty over the timing of the explosionand the use of poor quality fuse leads.An estimated 85,800 pediatric firework-relatedinjuries were treated in emergency departments inthe USA during a 14-year study period [12]. Injuredchildren had a mean age of 10.8 years, and 77.9 %were male. Firework users accounted for 49.5 % of theinjuries with bystanders accounting for 22.2 %. Themost commonly injured body sites were the eyeball(20.8 %), face (20.0 %), and hands (19.8 %), andburns were the most common injury type (60.3 %).

In Australia, the Dangerous Goods Act was introduced in1985 [13]. Under section 54 of this Act [14],some fireworks are not banned. These include Chinesefirecrackers, sparklers, model rocket motors, toy pistolcaps, and other novelty fireworks. However, the use ofChinese firecrackers and display fireworks are limitedto licence holders who must be at least 21 years of age.Anyone who assists with restricted fireworks must alsobe at least 18 years old. Such legislation strictlyrestricting the use of fireworks by children should alsobe introduced in India.

Despite the increase in popularity of large organized displays, 75 % of the serious injuries occurred atsmall group or family displays [15].Fireworks cause serious preventable injuries mostlyamong males, pediatric firework users and bystanders.Most injuries to children are due to manipulated ormisused fireworks and are totally preventable. It issuggested that to reduce ocular morbidity combinationfireworks should be banned and manufacturers shouldbe forced to improve the fuse leads.

Use of protectiveeyewear and keeping at a safe distance can preventfirework ocular injuries.The government should promote safer publicfireworks and parents should be advised to take theirchildren to these displays rather than allowing fireworks to be used by or near their children. Finally,public awareness using print and electronic media candecrease firework-related ocular injuries significantly.Conflict of interest The authors do not have any proprietaryor financial interest in any procedure or product mentioned inthis manuscript.

References

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  2. Berger LR, Kalishman S, Rivara FP (1985) Injuries fromfireworks. Pediatrics 75:877–882
  3. Barhanpurkar S, Kumar P, Kapadia P (2005) Profile offireworks related ocular injuries (FROI) from western India.Indian J Community Med 30:98–99
  4. Sacu S, Se´gur-Eltz N, Stenng K, Zehetmayer M (2002)Ocular firework injuries at new year’s eve. Ophthalmologica 216(1):55–59
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  10. Arya SK, Malhotra S, Dhir SP, Sood S (2001) Ocular fireworks injuries, clinical features & visual outcome. Indian JOphthalmol 49:189–190
  11. Singh DV, Sharma YR, Azad RV (2005) Visual outcomeafter fireworks injuries. J Trauma 59:109–111
  12. Witsaman RJ, Comstock RD, Smith G (2006) Pediatricfireworks-related injuries in the United States: 1990–2003.Pediatrics 118:296–303
  13. The Dangerous Goods Act (1985) Acts of Parliament, 1985.No 10189, Victoria, Australia
  14. The Dangerous Goods (Explosives) Regulations (1988)Statutory Rules 1988, vol. 2, No 272, Victoria, Australia
  15. Vernon SA (1988) Fireworks and the eye. J R Soc Med8:569–571Int Ophthalmol123

 

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