Firework and Shrapnel Eye Injuries

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Article initiated by:

Benjamin Kuhar, Sara L. Hojjatie, Deborah.Im

All contributors:

Shu Feng, MD, Anna Murchison, MD, MPH, Zeba A. Syed, MD, Grant A. Justin, MD, Gangadhara Sundar, MD, Michael T Yen, MD, Boonkit Purt, MD

Assigned editor:

Boonkit Purt, MD, Gangadhara Sundar, MD

Review:

Assigned status Up to Date

 by Gangadhara Sundar, MD on June 27, 2024.

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Introduction

Fireworks are used for recreation as well as religious, cultural, and patriotic celebrations around the world. However, consumer firework-related injuries can be devastating and lead to permanent vision loss, limb amputations, and, in some cases, death.  Firework-related injuries are especially prevalent in the United States during New Year’s Eve and Fourth of July celebrations. They are also quite common around the world where they have both religious and cultural connotation combined with either poor regulation or enforcement. There is limited large-scale data on the incidence of firework injuries in the literature. Of all the firework-related injuries requiring surgery or hospitalization in one study, the globe was the second-most affected body region.

Epidemiology

Firework injuries are responsible for about 2% of all reported ocular injuries. The 2021 Fireworks Annual Report from the United States Consumer Product Safety Commission reported 11,500 injuries treated in the U.S. during the 2021 calendar year. However, according to the summary, “this number is not complete and should be considered a minimum.” Out of 11,500 injuries, an estimated 8,500 were treated from June 18 to July 18, 2021.

The American Academy of Pediatrics reported that ocular injuries constitute 20% of all firework-related injuries, with some studies reporting upwards of 31 percent. Out of all the ocular firework-related injuries in the United States, 65.9% of individuals were 18 years or younger, and 71.9 – 89% were male. With regards to age, the injury rate was higher in children ages 10-19 years old. These incidents occur in all societies and are more common around the Fourth of July and New Year’s Eve. Studies show that 99 percent of all ocular firework injuries occur from consumer-grade and homemade fireworks.

Children are commonly bystanders than active users of fireworks compared to adults in severe firework-related injuries. This highlights a need for a public health intervention to prevent serious morbidity and vision loss in children and adolescents. Countries with more restrictive firework legislation has significantly less eye trauma. In the United States, consumer-grade fireworks are widely available, although firework restrictions differ by state. A systematic review notes that regions with a more restrictive firework legislation have an 87% lower ophthalmic injury rate.

Etiology

Two large US based studiescategorizing most common types of ocular injuries from fireworks are listed in Table 1. Injuries were reported from a multi-center retrospective review of 1007 individuals with firework-related ocular injuries in the United States from 1999 to 2017 and a 11-year experience of a US level 1 trauma center from 2003 to 2013.

Table 1. Types of ocular firework-related injuries
	Injuries, No. (%) (n = 1007)7	Injuries, No. (%) (n = 100)6
Eyelid injuries	n/a	39 (39)
Ocular burn	633 (62.9)	0
Ocular foreign body	118 (11.7)	5 (5)
Conjunctival irritation	97 (9.6)	0
Other severe eye traumab	46 (4.6)	n/a
Hyphema	35 (3.5)	42 (42)
Ruptured globe	28 (2.8)a	17 (17)
Globe laceration [SLH3]	17 (1.7)	n/ac
Subconjunctival hemorrhage	13 (1.3)	n/a
Traumatic iritis	11 (1.1)a	0
Corneal injury (including abrasion)	7 (0.7)	67 (67)
Vitreous hemorrhage	n/a	19 (19)
Retinal injury	1 (0.1)	17 (17)
Lacrimal injury	1 (0.1)	0
Glaucoma	n/a	15 (15)
Cataract	n/a[DI5]	13 (13)
Orbital fracture	1 (0.1)a	12 (12)
Optic neuropathy	0	3 (3)
a one patient experienced ruptured globe, traumatic iritis and orbital floor fracture. b Includes hyphema, globe laceration, subconjunctival hemorrhage, traumatic iritis, corneal injury, retinal injury, and lacrimal injury. c Globe lacerations were included in ruptured globe numbers in this study.

Overall, the most common globe injuries noted in these two large studies were ocular burns, eyelid injuries, corneal injuries, and vitreous hemorrhages. Of those with open globe injuries, the majority were full-thickness lacerations including both the cornea and sclera, one patient sustained bilateral globe ruptures.  Out of 1007 individuals with firework-related ocular injuries seen in US emergency departments, 90.5% were treated and released without transfer, while 8.7% required admission or transfer to another hospital.

In the United States, rocket and mortar-type fireworks were significantly associated with ruptured globe and other forms of severe trauma (hyphema and corneal injury) while firecrackers were associated with ocular burn and public displays with foreign bodies. Importantly, ocular injuries from professional firework displays are rare—the majority of injuries occur at home.

Of note, the distribution of injuries may vary from country to country due to different restrictions on types of fireworks. For example, roman candles, small bottle rockets, and launching tubes for rockets are banned in the Netherlands; however, these types of fireworks are the major source of serious ocular injury in the United States. A multi-center study including tertiary care hospitals in 5 countries and private ophthalmology practices of 388 patients reported 219 (85%) closed globe injuries and 34 (13.2%) open globe injuries related to fireworks. Of the open globe injuries, 47% were ruptures, 38% penetrating, 12% perforating and 12% IOFBs.

Incident descriptions obtained from telephone investigations for firework-related injuries discovered that malfunction, specifically errant flightpath, early detonation, or tip over, was the most common hazard pattern to have caused injury.

Primary Prevention

The American Academy of Ophthalmology and other global societies recommend staying a safe distance away from fireworks, to not pick up misfires, supervision of children, wearing eye protection and to watch professional firework displays instead of using consumer fireworks. Likewise several developed nations around the world have strong regulations which are enforced minimising or even preventing globe injuries from fireworks. However, in developing nations where there are strong cultural or religious practices, owing to poor regulations or enforcement, these preventible injuries are unfortunately still rampant.

Homemade or illegal fireworks can have greater explosive powder and lead to more severe injuries. Due to the greater force generated by homemade explosives, these injuries can often be life-threatening. Federal agencies conduct annual surveillance testing on consumer fireworks to look for noncompliant fireworks, which have fuse violations, presence of prohibited chemicals, and an overload of pyrogenic materials.

Risk Factors

Risk factors for ocular trauma include lack of protective eyewear, lack of parental supervision, and close distance to fireworks. Other risk factors include using consumer-grade fireworks, as professional fireworks only cause 1 percent of firework-related injuries. Injuries to bystanders are very common, making up 65% of people injured according to one study.

Diagnosis

History

Almost all patients will report recent trauma to the eye involving fireworks or shrapnel fragments. A complete history includes date and time of injury, mechanism of injury, use of eye protection, and use of substances such as alcohol or recreational drugs. It is important to determine the mechanism of injury, as well as the size, weight, velocity, force, and composition of the object, as well as the type of firework in order to determine the need for possible emergent surgery.

Pertinent ocular history, especially history of previous ocular surgery, presence of vision deficits in other eye, and a medical history, including current medications, allergies, tetanus status, is important to know at time of evaluation. It is also pertinent to ask the timing of the patient’s last meal in preparation for possible surgery.

Physical examination

It is important to document visual acuity prior to performing any dilated exam or procedure. Evaluate for optic nerve function by evaluating for pupillary response and color plates. Pay attention to extraocular motility, globe malposition, and areas of chemosis as this might help localize the shrapnel’s entry site. Be careful not to cause extrusion of intraocular contents if an open globe exists. Slit lamp exam should help locate and assess the depth of the foreign body. Inspect closely for possible entry sites and look out for low intraocular pressures in the involved eye, signifying an open globe.Seidel testing will indicate a conjunctival, scleral, or corneal laceration and may reveal an open globe injury. In patients with globe injuries calculation of the Ocular Trauma Score with prognostication based on presentation may be useful. Likewise in patients with Open Globe injuries, the Retinal Detachment-Open Globe injury index is also useful for prediction of posterior segment complications.

A complete slit lamp biomicroscopic examination and fundus examination should be done in all patients at the time of presentation and on follow-up visits.

Symptoms

Patients typically complain of foreign body sensation, ocular pain, decreased vision, redness, tearing, and photophobia.

Diagnostic procedures

A CT scan of the face and orbits should be strongly considered in the case of projectile injuries to exclude intraocular or infraorbital foreign bodies. Thin cut (1-mm sections) axial, coronal, and parasagittal views are preferred. Avoid MRI in the case of a possible metallic foreign body. B-scan ultrasonography and ultrasound biomicroscopy can also be considered to evaluate for IOFB, retinal detachment or in the case of poor view of the fundus.

Differential diagnosis

The most common injuries include corneal abrasions(67%), hyphema, and eyelid injuries. Ruptured globes occur in about 17% of cases. It is also important to consider thermal and chemical burns from firework material.

Management

Management for all types of possible firework injuries are beyond the scope of this article, and relevant articles will be listed below under “Additional Resources.”

General treatment

Evaluation of other life-threatening injuries or injuries outside of the orbit should be evaluated and co-managed with the appropriate services. Hand or other orthopedic injuries may need to be more urgently managed, and co-management with orthopedic surgery is necessary. In cases of extensive facial or skull fractures, co-management with neurosurgery, otolaryngology and oral and maxillofacial surgery may be needed. Periocular or facial burns may be co-managed with internal medicine or dermatology.

The treatment for firework injuries depends on the specific injuries present. Exploration in the OR may be required depending on the extent of injury. If open globe injury is suspected, protect the eye from further examination or trauma with an eye shield. CT scan of the brain and orbits (axial, coronal, and parasagittal views with 1-mm sections) to evaluate for IOFB should be obtained urgently, to determine the need for pars plana vitrectomy. Systemic antibiotics, typically cefazolin or vancomycin or moxifloxacin should be administered in addition to tetanus prophylaxis.

In cases where chemical injury is suspected, the pH should be evaluated and, if above or below pH 7-7.4, should be remedied with copious irrigation using saline or Ringer lactate solution. Irrigation should be continued until a neutral pH of 7.0 to 7.4 is achieved. After the exclusion of open globe injury, particulate matter may be irrigated or manually removed.

Surgery

Globe exploration should be performed in suspected globe rupture or penetrating trauma, with possible early vitrectomy if intraocular foreign bodies or retinal detachment is suspected. Surgical removal of intraocular foreign bodies has associated risks, performed by expert hands, which must be weighed against the complications of leaving the object near important structures in the eye. Endophthalmitis when suspected or present should also be managed based on standard guidelines. Threshold for secondary intervention and repeat procedures should also be low and performed early to avoid significant PVR or and other consequences.

Prognosis

The outcomes of these events depend on the mechanism of the injury. Open globe injuries commonly lead to vision loss, disorganised globe and even enucleation in severe cases. Open globe injuries and patients with poor visual acuity at presentation have the worst visual prognosis. Long-term effects of trauma may include corneal scarring with irregular astigmatism, cataract or angle-recession glaucoma, exposure keratopathy, phthisis bulbi, and blind disfigured eyes. Less severe injuries such as corneal abrasions typically have a more favorable prognosis. Visual acuity may range from 20/20 to no light perception, and in a study looking at 18 globe ruptures from firework injuries, 10 (59%) of eyes were no light perception at last follow-up.

Additional Resources

• Gudgel D, Steinemann TL. Fireworks Eye Safety. American Academy of Ophthalmology. EyeSmart/Eye health. https://www.aao.org/eye-health/tips-prevention/injuries-fireworks-eye-safety. Accessed December 05, 2019.
• Anterior Segment Trauma: Evaluation, Considerations and Initial Management
• Eyelid Laceration 
• Ruptured Globe
• Ocular Penetrating and Perforating Injuries
• Intraocular Foreign Bodies (IOFB)
• Chemical (Alkali and Acid) Injury of the Conjunctiva and Cornea

References

18. Smith, G., Knapp, J., Barnett, T. (1996). The rockets’ red glare, the bombs bursting in air: fireworks-related injuries to children. Pediatrics, 98(1), pp. 1.