The findings indicated that young male children are predominantly affected by unilateral trauma. Bangers followed by rockets in bottle were the main types of fireworks causing ocular injuries. Corneal abrasions ruptured globes, and cataracts were the principal ocular signs. The chief cause triggering ocular injuries was the ignition of the fireworks. Nearly half of affected individuals displayed normal functional vision six months after treatment management. Prompt and standard intervention could reduce blindness by one third.
Several studies were conducted previously on ocular injuries in children and on outcomes of standard management from other parts of the globe, except on an Arab population. With strict laws preventing fireworks in KSA, availability and unsupervised usage is a matter of concern. The current study indicated that additional policies regarding fireworks’ use are required to reduce the incidence of visual morbidity in children.
Ocular trauma is a key reason for causing monocular visual morbidity and blindness. 12–13 Several studies have outlined fireworks-related ocular injuries sustained during ceremonies in different countries8,14−15 Al-Qattan and Al-Tamimi (2016) in their study on hand burns due to fireworks16 in KSA indicated that wherever ଁrework-related injuries were noted, ocular injuries could also be present and needed an evaluation.
In the current study, half of the children were under 10 years of age. This indicates the vulnerability of children to ocular trauma due to ଁreworks. This finding was also corroborated by a few studies done in India.17,18 In the USA 10- to 20- year-old children comprised one-third of injured children.19 This is attributed to lack of supervision, little experience handling fireworks, more risk-taking behavior, and lower ability to respond to dangerous hazards. These observations highlight the need for greater education of children on the dangers that fireworks pose and implementation at earlier school age.
This study also showed that the majorities of the fireworks (40.9%) were bangers followed by rockets in bottle (24.3%) and firecrackers (23.5%). In 13 eyes (11.3%) unknown ଁreworks was employed. In an earlier study, firecrackers were shown to be the most used types of fireworks.12 Use of bottle rockets was not remarkable. Sparklers, another type of fireworks, were found associated with corneal abrasions and burns. The 1999 US Consumer Product Safety Commission (CPSC) study documented that one-third of the fireworks-related injuries were caused by firecrackers and 20% by rockets.10
Severe trauma was reported in 34% of the patients under study, which indicated that about one-third of fireworks-related ocular injuries could cause permanent sequelae. A signiଁcant proportion of patients (85%) required surgical interventions. The most frequently performed surgeries were ruptured globe repair, traumatic cataract extraction, amniotic membrane graft, and removal of intraocular foreign bodies (IOFB) which reflect the severity of these injuries. The ocular injuries varied in presentation and severity. injuries led to a 29% resulted in permanent eyesight loss as evidenced by the mean Snellen visual acuity of > 20/400. Open globe injury, poor initial visual acuity, IOFB, and retinal detachment6,13 were also found associated with poor visual outcomes in previous studies.
Our finding revealed an enucleation rate of 6%. This finding is in agreement with the 3.9% enucleation rate documented by Wisse et al4 in their review of the literature covering 40 years span (1969-2009). This observation highlights the need to save eyes and employ ultra-advanced treatment options in the current dynamic world. Chang et al.6 reported an enucleation rate of 10% between 2003 and 2013 and also more open-globe injuries (17%) vs 6% in the current study. This is likely due to the fact, that Chang et al. studied the experience of the sole level I trauma center for five U.S. states.
In our study, nearly half of the injured eyes had a functional normal vision after the intervention. One-third of eyes developed unilateral blindness after the intervention compared to nearly half at presentation. Overall, children in the current study exhibited enormous improvement in their visual acuity post-treatment. However, a remarkable number of injuries triggered permanent vision loss in the patients. A better recovery to normal vision could be attributed to the absence of both retinal detachment and IOFB, better initial BCVA, and closed globe injury. Visual acuity witnessed noteworthy improvement on account of prompt interventions.
Open globe injury and IOFB were found associated with dismally poor visual outcomes. Poor visual outcomes of interventions following fireworks-inflicted ocular injuries11,13, 15 might arise due to risk factors such as IOFB, retinal detachment, open globe injury, poor initial visual acuity, and development of endophthalmitis. Patients with open globe injuries and retained IOFB warrant a diligent prognosis.
Boys of 6 to 10 years of age in our study seemed to be more vulnerable to fireworks-related ocular injuries. This matches the findings of Malik et al.13 who reported that 54% of boys with fireworks-related injuries were ≤14 years of age. Our study indicates that boys are the major victims of eye injuries in 83.5% of cases caused by fireworks because they are actively involved in lighting fireworks this consistent with findings from previous studies 2,6,17−22 probably reflecting the males to be more adventurous and hostile. We also observed that the active participants were 51.3% while the bystanders were 48.7% of patients. This finding contradicts findings from previous studies.13,22 It can be concluded that active participants are more easily injured than bystanders.
The most common injuries were corneal abrasions, ruptured globes, and cataracts. Ruptured globes occurred in 34% of patients, which is similar to previously reported rates.3 We found corneal abrasions in about 44% of patients, showing conformity with finding by Wisse et al.4
This study has several limitations. It is a retrospective study. All data could not be retrieved from the children’s medical records. Data concerning visual acuity at presentation were especially lacking. Furthermore, children were unable to identify their injury. Due to the long-distance from the hospital, many patients could not be followed up and were lost to follow up.
Firework-related injuries are preventable to a large extent. Studies showed that that country with stricter laws had 87% fewer ocular injuries than those with relaxed rules about private use of fireworks.23 Strict regulations concerning the use of fireworks are needed for a significant protective impact on the children since minors sustain a profound proportion of fireworks- inflicted severe injuries. Ocular fireworks-inflicted trauma could have serious repercussions for patients with ocular morbidity and visual acuity, particularly in severe trauma which affected younger patients.
Minors are undoubtedly placed at a greater risk for severe ocular trauma. The Saudi Arabian laws regulate the free distribution and ban the use of explosives for private fireworks. Pediatricians need to create awareness among parents, community leaders, children, etc. about the dangers involved in fireworks. Public sales of all fireworks should be prohibited. International trade in fireworks for private use needs to be prohibited. Spectators need to keep them away from the area where the fireworks are ignited. In case of eye injury, the eye should not be touched, or no attempt should be made to treat the wound, and emergency medical help should be sought forthwith without brooking any delay. Parents should educate minors, particularly adolescents, about the proper use of fireworks to prevent the burgeoning rates of injuries in minors.