Firecracker eye injuries during Deepavali festival: A case series

We report a large series of ocular injuries caused by fire-crackers. This study was a hospital-based, singlecenter, retrospective case series in which the records of 51 patients with ocular injuries were analyzed. Injuries were classified according to Birmingham eye trauma terminology system (BETTS). Visual outcomes before and after the intervention were recorded. Ten patients were admitted for further management. As ocular firecracker injuries result in significant morbidity, public education regarding proper use of firecrackers may help in reducing the incidence of ocular injuries.

Firecracker injuries can cause serious and irreparable damage to vision.In India, fi recracker injuries are common during the festival of 'Deepavali' where traditionally, fi recrackers form an essential part of the celebrations.
[3] We report a series of fi recracker injuries seen during a single week to highlight the importance of fi recrackers as a cause of ocular injuries in India.

Materials and Methods
This was a retrospective case series.All patients with fi recracker injuries who att ended the emergency eye care services of a tertiary eye care hospital in South India, during the 'Deepavali' festival week (from 26 October to 2 November 2008) were included in this study.
The patients underwent a detailed ocular examination.Ultrasonography (USG) A and B scans, Gonioscopy and fundus photography and X-ray orbit was done as and when indicated.The injuries were classifi ed according to Birmingham eye trauma terminology system (BETTS) [Table 1].
Although patients with closed eye injuries were treated on an outpatient basis, most cases with open eye injury were advised admission for further management and observation.Admitt ed cases included patients with corneal and scleral tears, traumatic iridodialysis with hyphema, suspected intraocular foreign body (IOFB), and globe rupture.

Results
Of the 51 patients seen, 40 were males.The age range of these patients was 3 to 70 years (mean of 19 years).Thirty-one patients were less than 20 years of age.The most common cause of ocular injuries were bombs (37%), followed by sparklers (19%) [Fig.1].Bott le rockets and bombs were responsible for the most serious ocular injuries observed in our patients.
Twenty-nine patients were onlookers and 22 patients were actively involved in igniting the fi recrackers.None of the fi recracker victims reported using any protective eye wear at the time of injury.The right eye was involved in 31 cases and left eye in 27 cases.According to the initial assessment of vision at the time of presentation to the hospital two eyes of two patients had no perception of light (PL negative), 13 eyes of 11 patients had visual acuity of hand movement to perception of light (PL positive) while eight patients had counting fi ngers to 20/200 vision [Fig.2].Vision of fi ve patients was not recorded (all were less than seven years of age and not cooperative for vision assessment at initial presentation).The distribution of severe eye injury (hand movement-PL negative) was nearly equal in bystanders and actively involved individuals.According to BETTS, nine cases were open globe injuries and 49 cases were closed globe injuries [Figs.3-7].
In all, 10 patients were admitted to our hospital with fi recracker injuries.All patients except one had visual acuity of hand movement or worse at the time of initial evaluation.Three of these patients underwent surgical repair for scleral tear.Two patients underwent surgery for corneoscleral tear repair.One patient required amniotic membrane graft and autologous serum drops for non-healing epithelial defects [Fig.4].Visual outcome in all these cases was poor (three patients had no PL and two patients had only PL).One patient with total hyphema had visual recovery following anterior chamber wash from visual acuity of hand movements at presentation to 20/40 Snellen at discharge.Four others were treated conservatively as per the standard treatment protocol for ocular burns and chemical injuries. [4]Injured eyes were irrigated with copious amount of normal saline and particulate matter and soot particles were removed with forceps under local anesthesia; pH was monitored before and aft er ocular irrigation.Patients were prescribed antibiotic steroid eye drops (tapered aft er a week), lubricating solution and ointment and cycloplegic eye drops.Later, two patients underwent lid reconstruction for correction of cicatricial entropion.The average number of days of stay of admitt ed patients was seven days (median ϭ six days).Though three patients ended up with no PL, most had a moderate visual recovery [Table 2].

Discussion
][7][8] The injuries reported ranged from conjunctival or corneal burns to globe rupture with interventions ranging from ocular wash to repair of globe perforation.Most of the patients were below the age of 20 years.Unlike the fi ndings in some studies where victims were mostly those who were actively involved in igniting the fi recracker, more than half of the victims in our study were bystanders. [7,9,10]The most common fi recracker causing injury in our study were bombs followed by sparklers and homemade devices.Even though sparklers were reported to cause minimal injuries in one of the studies, were not found to be innocent in our study. [5]Most bott le rocket injuries were of a serious nature.
Many of the injuries were caused as a result of negligence of those igniting the fi recrackers.Some of the severely injured patients reported device malfunction as the cause of their injury.In three cases, the att empt to reignite or recover a failed device was the cause of injury.In one instance, the patient suff ered severe facial and bilateral ocular injuries when he att empted to ignite a homemade device made up of unburnt fi recracker powder [Fig.4].
Ocular injuries by firecrackers are common during 'Deepavali'.Lack of knowledge about safety measures or not following them was a reason for eventualities.Absence of parental supervision, and failure to maintain safe distance from fi recrackers were contributory in some cases of injuries.The other major cause of injury is the common practice of igniting fi recrackers in the streets thus exposing passersby to injury.
The fact that so many cases were seen in a single center highlights the enormous health importance of regulating fi recracker use and enforcing safety precautions.The single most eff ective measure may be to restrict the fi reworks to public open spaces (such as parks or playgrounds).Regulating the quality of fi recrackers and promoting safe use via schools and media will also have a positive impact.

Figure 1 : 2 :Figure 3 :Figure 4 :
Figure 1:Type of fi reworks causing injury Figure 2: Initial visual acuity of the patients attending ocular emergency department; CF -counting fi nger, HM -Hand movement, PL -Perception of light

Figure 5 :Figure 6 :Table 2 :
Figure 5: Clinical photograph of a patient with an open globe penetrating fi recracker injury.Patient underwent primary scleral tear repair

Figure 7 :
Figure 7: Clinical photograph of a patient with burn injuries due to fi recrackers showing superfi cial lid burns, seething of eyelashes, limbal ischemia in the inferotemporal quadrant and melting of cornea.The cornea shows combined chemical and burn injury