Firework and Shrapnel Eye Injuries
Fireworks are used for festivities around the world and are particularly popular in the United States during Fourth of July celebrations. Ocular trauma from fireworks can be devastating, as they can leave young adults with permanent vision loss. Given its preventable nature and cost of care, firework injuries are becoming a growing public health concern.
Firework injuries are responsible for about 2% of all reported ocular injuries. In 2017, fireworks caused nearly 13,000 injuries, up from 11,000 in 2016. About 16 percent of firework injuries involve the eye, with some studies reporting upwards of 31 percent. Males are more susceptible to firework injuries compared to females, with a nearly three times greater injury rate. 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.
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.
Almost all patients will report recent trauma to the eye involving fireworks or shrapnel fragments. It is important to determine the mechanism of injury, as well as the size, weight, velocity, force, and composition of the object.
It is important to document visual acuity prior to performing any dilated exam or procedure. 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.
Patients typically complain of foreign body sensation, ocular pain, decreased vision, redness, tearing, and photophobia.
A CT scan of the orbit should be strongly considered in the case of projectile injuries to exclude an intraocular foreign body. 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.
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.
The treatment for firework injuries depends on the specific injuries present. Exploration in the OR may be required depending on the extent of injury. Surgical removal of intraocular foreign bodies has associated risks, which must be weighed against the complications of leaving the object near important structures in the eye. Concurrent facial fractures or burns should be managed in conjunction with other specialists in these areas.
The outcomes of these events depend on the mechanism of the injury. Ruptured globes commonly lead to vision loss and even enucleation in severe cases. Less severe injuries such as corneal abrasions typically have a more favorable prognosis.
- 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.
- Arya, S., Malhotra, S., Dhir, S., Sood, S. (2001). Ocular firework injuries-Clinical features and Visual Outcomes. Indian Journal of Ophthalmology, 49(3), pp. 189-190.
- American Academy of Ophthalmology. Reports of Eye Injuries from Fireworks has Doubled. https://www.aao.org/newsroom/news-releases/detail/reports-of-eye-injuries-from-fireworks-have-double. Accessed July 20, 2019.
- Chang, I., Prendes, M., Tarbet, K., Amadi, A., Chang, S., Shaftel, S. (2016). Ocular injuries from fireworks: the 11-year experience of a US level 1 trauma center. Eye, 30(10), pp. 1324-1330.
- Moore, J., McGwin, G., Griffin, R. (2014). The Epidemiology of firework-related injuries in the United States: 2000-2010. Injury, 45(11), pp. 1704-1709.
- Adam, M., Ahmed, F., & Wills Eye Hospital (Philadelphia, Pa.). (2017). The Wills eye manual: Office and emergency room diagnosis and treatment of eye disease. Philadelphia: Lippincott Williams & Wilkins.
- 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.