Fireworks-related ocular injuries are an major cause of preventable blindness worldwide.14 Firecrackers are used to express festive moods even though they can cause severe mental and physical morbidity.3 Consequently, firecracker ocular injury is an issue of national importance in different countries.15 Fireworks commonly known as “bangers” or “knockouts” are widely used in India during festivities such as Christmas, New Year, Durga puja, marriage functions, Independence Day, and sporting activities.16,17 In different parts of the world, fireworks are use celebrate national and religious events. Similarly, firework-related injuries are common on New Year's Eve in China, the Prophet's birthday in Libya, and the fourth of July in the USA.18 The use of fireworks and negligence with handling is associated with casualties.19 Ocular injuries secondary to fireworks can result in devastating visual and disfiguring effects.20 Since, India is a large country with social and cultural diversity, the pattern and sequalae of firecracker injuries differs from place to place.3
This study was a tertiary eye care hospital-based, single-center, retrospective analysis of firecracker injuries. We analysed the pattern of injuries, common type of cracker involved, whether actively involved or not, along with presenting ocular examination findings, treatment outcomes, and direct cost involved in medical management. We analyzed 132 eyes of 114 patients. The mean age of our patients was 18.96±15.41 (range 3–71 years). Kumar et al4 analyzed 51 patients and reported the mean age of cracker injury patients as 19 years (range 3–70 years). Similarly, Arya et al5 reported a case series of 42 patients with a mean age of 15.5 years (range 3–33 years). In our analysis, 51 patients (44.73 %) had right eye involvement, and 45 (39.47%) had left eye involvement. A total of 18 patients (15.78%) had bilateral involvement showing that if proper precautions are not taken firecracker injury can have disastrous sequelae. Kumar et al4 also found in their study that the right eye was involved in 31 cases and the left eye in 27 cases. None of the studies have reported bilateral involvement, but we had 15% cases having bilateral ocular involvement. Table 2 depicts the number of patients in various age groups, highlighting that pediatric children are more prone to firecracker-related ocular trauma.
Firework-related injuries have been reported more commonly in males.11,16,17 We also observed male: female ratio of 4:1 in our study. This agrees with the data reported by Mohan et al16 where they found a male: female ratio of 5:1. Similarly, Patel et al21 also found a ratio of 4:1 in their study from South India. This can be correlated with males being more actively involved in outdoor activities and cracker bursting.
Firecracker Injuries in bystanders are also very common (14–61%).22 In our study 61% were bystanders when they sustained the injury. Patel et al21 also reported that 48.9% of their patients were bystanders. Wisse et al11 in their review article also reported that on an average 47% of the cracker injury victims are bystanders.
We also found that 64.91% of the total patients were in the paediatric age group (< 18 years). Arya et al5 also reported that a majority (26/42; 61.9%) of patients in their study were between 6 and 20 years of age. Kumar et al4 found that 31/51 (60.78%) patients were less than 20 years of age. The higher proportion of kids getting injured highlights the long-term impact and higher loss of quality life years, associated with firecracker injuries. We found that 125 eyes (94.69%) had CGI and 7 eyes (5.30%) had OGI. Corneal foreign bodies and contusion injuries (84.09%) were the most common presentations in our study. Arya et al5 also observed corneal abrasions and multiple foreign bodies as the most common presentations. They found OGI in three (7.1%) patients, out of which one (2.3%) had a badly ruptured globe. Chakarborty et al23 also reported 13.3% as OGI while 86.7% cases were CGI. Patel et al21 reported a still higher rate of OGI in 13 (26.53%) patients whereas 33 (67.34%) patients had CGI. They also found that a higher proportion of 22 (44.8%) patients underwent surgical intervention, which can be correlated with a higher incidence of open globe injuries in their study. In contrast, in our study 17/132 (12.88%) eyes required surgical intervention. The varying incidence of OGI can probably be related to the type of crackers used in different geographic regions or some local practices like placing bombs in glass bottles before igniting.
As per the literature review, 5–44% of firecracker injuries usually require hospitalization.14,24 In our study 15% of patients needed inpatient care. Kumar et al4 reported that 19.61% of their patients needed hospital admission, and the average duration of stay for admitted patients was seven days (median six days). In their study, three patients ended up with No PL, though most had a moderate visual recovery.
The presenting visual acuity was ≥ 20/200 in 108 eyes, 20/200 to 20/1200 in 17 eyes, hand movement to perception of light (PL) in 6 eyes, and No PL in 1 eye. The overall mean (SD) baseline visual acuity of the involved eye/eyes assessed on the first visit was 0.54 (± 0.75), which improved to 0.23 (± 0.62) till the last follow-up visit. Pediatric patients (< 18 years) had comparatively better final BCVA which improved from a mean of 0.43(± 0.68) to 0.05(± 0.12) till the last follow-up visit. The p-value was < 0.01 calculated using Wilcoxon signed-rank test for all patients and the pediatric patients separately showed significant improvement pre and post-treatment. At three months follow up, five eyes had poor visual outcomes (< 6/60 BCVA), out of which 3 (2.27%) resulted in No PL. Hence, the prevalence of blindness in our study was 3.79%. Kumar et al7 in their study reported that 3/51 (5.88%) following cracker injury had final BCVA of No PL. Similarly, Arya et al,5 reported that 1/42 (2.38%) patients resulted in the final BCVA of No PL. Vision loss causes a huge burden for the family as well as society. Factors such as hospital stay, psychological impact, loss of school/earning days, and treatment and logistic expenses are also important considerations. We found the mean number of visits paid by patients was 2.54+/-2.13.
Further, it was found that none of the patients in our study were wearing protective eye cover at the time of injury. It is important to understand that injuries from fireworks are very common and can lead to irreversible blindness. There is a need for stringent laws in this regard. The first step can be promotion of public firework displays from a safe distance with mandatory eyewear.25 The banning of fireworks will be a permanent solution, but this has a long way to go. Public awareness about rates and common modes of injuries, safe usage of fireworks, close watch on children, and protective eyewear can prevent the majority of these injuries. As per the best of our knowledge and literature review, this is among the largest hospital-based, single-center, retrospective analysis to date.