Assessment of Firework-Related Ocular Injury in the US

Local Firework Restrictions and Ocular Trauma

Importance

Fireworks can cause vision-threatening injuries, but the association of local legislation with the mitigation of these injuries is unclear.

Objective

To evaluate the odds of firework-related ocular trauma among residents of areas where fireworks are permitted vs banned.

Design, Setting, and Participants

This case-control study was conducted at a level 1 trauma center in Seattle, Washington, among 230 patients presenting with ocular trauma in the 2 weeks surrounding the Independence Day holiday, spanning June 28 to July 11, over an 8-year period (2016-2022).

Exposures

Firework ban status of patient residence.

Main Outcomes and Measures

Odds of firework-related injuries among residents of areas where fireworks are legal vs where they are banned, calculated as odds ratios (ORs) and 95% CIs.

Results

Of 230 consultations for ocular trauma during the study period, 94 patients (mean [SD] age, 25 [14] years; 86 male patients [92%]) sustained firework-related injuries, and 136 (mean [SD] age, 43 [23] years; 104 male patients [77%]) sustained non-firework-related injuries. The odds of firework-related ocular trauma were higher among those living in an area where fireworks were legal compared with those living in an area where fireworks were banned (OR, 2.0 [95% CI, 1.2-3.5]; P = .01). In addition, the odds of firework injuries were higher for patients younger than 18 years (OR, 3.1 [95% CI, 1.7-5.8]; P < .001) and for male patients (OR, 3.3 [95% CI, 1.5-7.1]; P = .004). Firework injuries were more likely to be vision threatening (54 of 94 [57%]) compared with non-firework-related injuries (54 of 136 [40%]; OR, 2.1 [95% CI, 1.2-3.5]; P = .01).

Conclusions and Relevance

This case-control study suggests that the odds of firework-related ocular trauma were slightly higher among residents of areas where fireworks were legal compared with residents of areas where fireworks were banned. Although these results suggest that local firework bans may be associated with a small reduction in the odds of firework-related ocular trauma, additional studies are warranted to assess what actions might lead to greater reductions.

Ophthalmologic Emergencies: Assessment and Management

There are an estimated 2-3 million emergency department (ED) visits in the United States for eye complaints. Although most patients who present to the ED have nontraumatic eye complaints, many seek treatment for eye trauma, which is a leading cause of unilateral blindness and vison impairment. Given the prevalence of eye-related emergencies, it is imperative that emergency care providers understand how to recognize and treat eye complaints to prevent permanent vision loss and disability. This article covers basic eye anatomy and physiology, discusses a systematic approach to the eye examination, and presents the evidence-based treatment of selected, common nonemergent and emergent eye complaints. For each complaint, essential history questions, examination techniques, differentials, and emergency management have been presented.

The epidemiology of firework-related injuries in the US, 2012-2022

BACKGROUND

This study aimed to examine the epidemiology of firework-related injuries within a national population between 2012 and 2022, including the severity of injury by year, patient demographics, body region injured, firework type, and diagnosis category of injury.

METHODS

Data were collected from the Consumer Product Safety Commission's National Electronic Injury Surveillance System, which is a representative nationwide database that collects data on consumer product-related injuries occurring in the US. Injury rates were calculated based on patient age, sex, body region injured, firework type, and diagnosis category.

RESULTS

A total of 3219 injuries, representing an estimated 122,912 firework-related injuries, were treated in emergency departments within the US from 2012 to 2022. The overall incidence rate of firework-related injuries in the study rose by over 17% from 2012 [2.61 cases per 100,000 people (95% CI 2.03-3.20)] to 2022 and [3.05 cases per 100,000 people (95% CI 2.29-3.80)]. The rate of injuries was highest in adolescents and young adults (age 20-24; 7.13 cases per 100,000 people). Men experienced firework injuries at more than double the rate of women (4.90 versus 2.25 cases per 100,000 people). The upper extremities (41.62%), head/neck (36.40%), and lower extremities (13.78%) were the most commonly injured regions. Over 20% of cases in patients older than 20 were significant injuries requiring hospitalization. Aerial devices (32.11%) and illegal fireworks (21.05%) caused the highest rates of significant injury of any firework type.

CONCLUSIONS

The incidence of firework-related injuries has risen over the past decade. Injuries remain the most common among adolescents and young adults. In addition, significant injuries requiring hospitalization occur most often during aerial and illegal firework use. Further targeted sale restrictions, distribution, and manufacturing regulations for high-risk fireworks are required to reduce the incidence of significant injury.

TFOS Lifestyle Report: Impact of environmental conditions on the ocular surface

Environmental risk factors that have an impact on the ocular surface were reviewed and associations with age and sex, race/ethnicity, geographical area, seasonality, prevalence and possible interactions between risk factors are reviewed. Environmental factors can be (a) climate-related: temperature, humidity, wind speed, altitude, dew point, ultraviolet light, and allergen or (b) outdoor and indoor pollution: gases, particulate matter, and other sources of airborne pollutants. Temperature affects ocular surface homeostasis directly and indirectly, precipitating ocular surface diseases and/or symptoms, including trachoma. Humidity is negatively associated with dry eye disease. There is little data on wind speed and dewpoint. High altitude and ultraviolet light exposure are associated with pterygium, ocular surface degenerations and neoplastic disease. Pollution is associated with dry eye disease and conjunctivitis. Primary Sjögren syndrome is associated with exposure to chemical solvents. Living within a potential zone of active volcanic eruption is associated with eye irritation. Indoor pollution, "sick" building or house can also be associated with eye irritation. Most ocular surface conditions are multifactorial, and several environmental factors may contribute to specific diseases. A systematic review was conducted to answer the following research question: "What are the associations between outdoor environment pollution and signs or symptoms of dry eye disease in humans?" Dry eye disease is associated with air pollution (from NO2) and soil pollution (from chromium), but not from air pollution from CO or PM10. Future research should adequately account for confounders, follow up over time, and report results separately for ocular surface findings, including signs and symptoms.

TFOS lifestyle: Impact of societal challenges on the ocular surface

Societal factors associated with ocular surface diseases were mapped using a framework to characterize the relationship between the individual, their health and environment. The impact of the COVID-19 pandemic and mitigating factors on ocular surface diseases were considered in a systematic review. Age and sex effects were generally well-characterized for inflammatory, infectious, autoimmune and trauma-related conditions. Sex and gender, through biological, socio-economic, and cultural factors impact the prevalence and severity of disease, access to, and use of, care. Genetic factors, race, smoking and co-morbidities are generally well characterized, with interdependencies with geographical, employment and socioeconomic factors. Living and working conditions include employment, education, water and sanitation, poverty and socioeconomic class. Employment type and hobbies are associated with eye trauma and burns. Regional, global socio-economic, cultural and environmental conditions, include remoteness, geography, seasonality, availability of and access to services. Violence associated with war, acid attacks and domestic violence are associated with traumatic injuries. The impacts of conflict, pandemic and climate are exacerbated by decreased food security, access to health services and workers. Digital technology can impact diseases through physical and mental health effects and access to health information and services. The COVID-19 pandemic and related mitigating strategies are mostly associated with an increased risk of developing new or worsening existing ocular surface diseases. Societal factors impact the type and severity of ocular surface diseases, although there is considerable interdependence between factors. The overlay of the digital environment, natural disasters, conflict and the pandemic have modified access to services in some regions.

Pediatric Open Globe Injuries Caused by Firecrackers in a Tertiary Eye Care Hospital in Iran

OBJECTIVE

The aim of the study is to determine characteristic features of open globe injuries caused by firecrackers among pediatric population.

METHODS

In this retrospective cross-sectional chart review, medical records of children with ocular trauma who were hospitalized in Isfahan, Iran, during 2013-2017 were reviewed. We analyzed the collected data before and after propensity score (PS) matching.

RESULTS

Of 396 pediatric patients with open globe injury, 22 injuries (5.9%) were caused by firecrackers. Hyphema, iris prolapse, and lens rupture were noted in 15 (68.18%), 10 (45.45%), and 2 (9.09) eyes, respectively. None of patients had endophthalmitis. The mean age of patients in firecracker group was higher and significant (11.86 ± 4.05 in firecracker vs 7.80 ± 4.68 in nonfirecracker, P < 0.001). Furthermore, most boys were in firecracker group (95.5%, P = 0.005). Patients in firecracker group resided more in urban areas (86.4%, P = 0.054) and had more intraocular foreign body (IOFB) in the eyes (40.9%, P < 0.001). After PS matching, patients in firecracker group had higher IOFB ( P = 0.008). In logistic regression models, patients with corneal lacerations had lower odds for long-time admission (≥4 days) than patients with both corneal and scleral lacerations in crude model (odds ratio, 0.35; 95% confidence interval, 0.17-0.69) and adjusted model (odds ratio, 0.37; 95% CI, 0.18 to 0.74). After PS matching, there was no significant association between risk factors and outcomes.

CONCLUSIONS

The present study showed several differences between the pediatric open globe injuries caused by firecrackers and other mechanisms of injuries, including the age, sex, living place, presence of IOFB, and length of hospital stay.

Occurrence and outcome of firework-related ocular injuries in Switzerland: A descriptive retrospective study

Background

Firework-related ocular injuries (FWROI) are a major cause of preventable visual impairment. This study aimed to analyze the occurrence and outcome of FWROI in Switzerland.

Methods

This retrospective multicenter study included patients with FWROI from seven centers in Switzerland from January 2009 to August 2020. Demographic information, type of injuries, medical and surgical treatments, the best corrected visual acuity (BCVA) at baseline and end of follow-up, occurrence and type of secondary complications, and duration of hospitalization were analyzed.

Results

A total of 105 patients (119 eyes) with a mean age of 27.1 ± 15.9 years were included in the study (71.4% male patients; 29.5% underage). Most injuries occurred around New Year’s Eve (32.4%) and the Swiss national holiday on 1 August (60.9%). The most common anterior segment findings were conjunctival or corneal foreign bodies (58%), whereas Berlin’s edema was the most common posterior segment finding (11.4%). Globe ruptures were found in four patients. The mean BCVA in all patients at first presentation was 0.4 ± 0.8 logMAR and improved to 0.3 ± 0.8 logMAR at last follow-up. A primary surgical intervention was performed in 48 eyes (40.3%). Hospitalization directly after the trauma was necessary for 18 patients for a mean of 5.8 ± 4.1 days, and a total of 4.9 ± 7.6 follow-up visits were needed.

Conclusion

This study provides the first data on FWROI in Switzerland, which are helpful for further preventive and educational programs and comparisons with other countries.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12886-022-02513-9.

Fireworks ocular injury in Saudi children: profile and management outcomes

To explore the demographic profiling, causes, types, complications, management outcomes, and severity of fireworks-inflicted ocular injuries in children in KSA. This is a retrospective study of 115 cases with eye injuries managed at the Emergency Department, of our institution between 2003 and 2019. Demography, clinical features at presentation, mode of management and the Best-corrected visual acuity (BCVA) were evaluated at the last follow up. The study included 117 eyes of 115 children [median age: 9 years; 96 (83.5%) boys;19 (16.5%) girls]. Fifty-six (48.7%) participants were bystanders. The injuries were caused mainly due to bangers (n = 47; 40.9%), rockets in bottle (n = 28; 24.3%), firecrackers (n = 27; 23.5%), and nonspecific reasons (n = 13; 11.3%). The children had presented with various severity levels: corneal abrasion (n = 52; 44.4%); cataract (n = 47;40.2%); penetrating injury (n = 40; 34.2%); secondary glaucoma (n = 22;18.8%); subluxated lens (n = 19;16.2%); limbal stem cell deficiency (n = 14;12.0%); Iridodialysis (n = 12;10.3%), and vitreous hemorrhage (n = 11;9.4%). Management interventions of the eyes under study included: penetrating injury repair (n = 40; 34.2%), lens removal plus intraocular lens implantation (n = 26; 22.2%), removal of foreign body (n = 9; 7.7%). The BCVA after six months was 20/20 to 20/60 in 49 (41%) cases; 20/70 to 20/200 in 27 (23.1%) cases; < 20/200 to 20/400 in 7 (6%) cases, and < 20/400 in 34 (29.1%) of the cases. Out of 51.3% eyes with < 20/200 before management, only 35% recorded severe visual impairment. Fireworks-related eye injuries were mainly observed in boys primarily due to the use of bangers. Visual disability remained in one-third of the managed cases.

Epidemiologic Trends in Oculoplastics-Related Emergency Department Visits in the United States, 2006-2015

PURPOSE

To characterize demographics and trends in oculoplastics-related emergency department (ED) visits.

METHODS

The authors conducted a retrospective, multiyear study of the nationwide ED sample database. The nationwide ED sample was queried for oculoplastics-related International Classification of Disease-ninth revision codes identified from a comprehensive list and categorized based on anatomic location, urgency, and trauma status. Demographics, clinical characteristics, procedure requirement, and cost data were analyzed. Variables associated with inpatient admission were assessed using univariate and multivariate logistic regression.

RESULTS

The authors identified an estimated 4.2 million ED visits in the United States with oculoplastics-related primary diagnoses, of which pathology was 80.8% eyelid/adnexal, 17.4% orbital, and 1.74% lacrimal. Overall, 31.3% of the visits were deemed to be nonurgent. Orbital pathology was more likely to be caused by trauma (70.6%), to be urgent (98.0%), and to require a procedure (45.6%) (p < 0.001). While less than 5% of all patients required hospitalization, predictors for inpatient admission were urgent diagnoses (odds ratio, 14.9; CI, 13.7-16.1), presentation to a level 1 trauma center (odds ratio, 3.19; CI, 2.7-3.79), and presence of orbital pathology (odds ratio, 6.09; CI 5.73-6.47). Incidence of ED visits decreased in all categories; however, total inflation-adjusted charges increased.

CONCLUSIONS

Over half of oculoplastics-related ED visits are for trauma, with orbital pathology being less common but requiring a high level of care. Although trends show a potentially decreasing incidence of oculoplastics-related ED visits, increasing costs and high proportion of nonurgent visits pose an opportunity for mitigating periocular trauma and increasing outpatient access to care, respectively.

Firework injuries are increasing in the United States: An analysis of the National Emergency Department Sample

BACKGROUND

Firework-related injuries cause significant morbidity to persons in the United States and globally. Prior studies have shown that hands and eyes are frequently injured, with loss of hand function and blindness being common after serious injury. Many jurisdictions in the United States have relaxed laws governing sales of consumer fireworks in recent years. Given the increased availability of consumer fireworks, we sought to determine the incidence of firework-related injuries compared with historical controls.

METHODS

Firework-related injuries were identified in the National Emergency Department Sample (NEDS) using the corresponding International Classification of Disease codes for the years 2008-2017. Demographics, timing of presentation, and hospital characteristics were analyzed. Data were weighted to approximate population estimates of injury. Statistical analyses were completed using SAS. The National Electronic Surveillance System was also queried for firework-related visits to check for consistency in observed trends.

RESULTS

There were an estimated 7699 injuries attributed to fireworks in 2017 (2.37 per 100,000 population) compared with 5727 (1.88 per 100,000 population) in 2008. The majority of victims were male (74.6%), and injuries clustered in the pediatric and young adult age groups. The Midwest and South (both 38.1%) had more firework-related injuries compared with the West (15.6%) and Northeast (8.2%) regions. Most visits occurred in July (71.4%) with smaller peaks in June (6.9%) and January (6.0%). Patients were disproportionately seen in trauma centers (34.0%) and teaching hospitals (49.6%).

CONCLUSION

Emergency department visits for firework injuries are increasing in the United States. Pediatric patients and young adult males comprise the majority of victims. Injuries are clustered around the Fourth of July and New Year's holidays. Public health interventions targeted at high-risk groups may reduce the burden of injury.

Epidemiologic trends in pediatric ocular injury in the USA from 2010 to 2019

PURPOSE

Epidemiologic studies related to the demographics and trends of ocular injury in the pediatric cohort in the last decade are limited. This study describes epidemiologic trends in consumer product-related pediatric ocular injuries from 2010 to 2019.

METHODS

This is a retrospective observational study utilizing data from the National Electronic Injury Surveillance System (NEISS). Inclusion criteria include pediatric patients ages 1-20 presenting to NEISS emergency departments with an ocular injury from January 1, 2010, to December 31, 2019. Outcome measures include prevalence of ocular injury related to consumer products stratified by age group, sex, and injury setting.

RESULTS

There were an estimated 636,582 consumer product (CP)-related incidents of ocular injury in children ages 1-20 years with an average age of 9.7 years (SD = 5.92) between 2010 and 2019; 416,378 (65.4%) patients were males with a male-to-female ratio of 1.9:1. The annual incidence of CP-related ocular injury in males decreased from 2010 to 2019 while that in females remained unchanged. The greatest number of injuries occurred in the 1-5-year age group (31%) followed 6-10 group (25%), 16-20 (22%), and 11-15 (21%). Ocular contusion was the most common diagnosis. The most common setting of injury was home (63%). The majority (96%) of patients were treated and released from the ED suggesting a minor injury. Of the 1% of patients admitted to the hospital with ocular injuries, one-fourth were due to an open globe injury. Most ocular injuries occurred in the summer months, and presentation to the ED was more frequent on the weekend than a weekday. Over one-fourth (28%) of injuries were sports-related followed by detergents/chemicals (16%), toys (11%), home workshop equipment (8%), kitchenware (5.0%), and home furniture in (4.4%).

CONCLUSIONS

The frequency and rate of pediatric ocular injuries in the USA decreased during the last decade. Sports and non-powder guns caused the greatest number of eye injuries in the older pediatric cohorts (11-15- and 16-20-year age groups), while detergents/chemicals accounted for nearly 1/3 of all injuries in younger children (1-5 years). Prophylactic measures targeted to specific age groups will be important in reducing eye injuries further.

Feel the Burn! Fireworks-related Otolaryngologic Trauma

OBJECTIVES

Fireworks are used commonly for celebrations in the United States, but can lead to severe injury to the head and neck. We aim to assess the incidence, types, and mechanisms of head and neck injuries associated with fireworks use from 2010 to 2019.

METHODS

A retrospective cross-sectional study, using data from the National Electronic Injury Surveillance System, of individuals presenting to United States Emergency Departments with head and neck injuries caused by fireworks and flares from 2010 to 2019. Incidence, types, and mechanisms of injury related to fireworks use in the US population were assessed.

RESULTS

A total of 541 patients (349 [64.5%] male, and 294 [54%] under 18 years of age) presented to emergency departments with fireworks-related head and neck injuries; the estimated national total was 20 584 patients (13 279 male, 9170 white, and 11 186 under 18 years of age). The most common injury diagnoses were burns (44.7% of injuries), laceration/avulsion/penetrating trauma (21.1%), and otologic injury (15.2%), which included hearing loss, otalgia, tinnitus, unspecified acoustic trauma, and tympanic membrane perforation. The remaining 19% of injuries were a mix, including contusion, abrasion, hematoma, fracture, and closed head injury. Associations between fireworks type and injury diagnosis (chi-square P < .001), as well as fireworks type by age group (chi-square P < .001) were found. Similarly, associations were found between age groups and injury diagnoses (chi-square P < .001); these included children 5 years and younger and adults older than 30 years.

CONCLUSIONS

Fireworks-related head and neck injuries are more likely to occur in young, white, and male individuals. Burns are the most common injury, while otologic injury is a significant contributor. Annual rates of fireworks-related head and neck injuries have not changed or improved significantly in the United States in the past decade, suggesting efforts to identify and prevent these injuries are insufficient.

Injuries, treatment, and impairment caused by different types of fireworks; results of a 10 year multicenter retrospective cohort study

Objectives

The primary aim of this study was to evaluate the number of patients reported to a hospital with injuries from consumer fireworks in the months December–January in the past 10 years, and to describe the association between the type of fireworks, injury pattern, treatment, and permanent impairment.

Methods

A multicenter, retrospective, observational case series. Patients were selected from two hospitals in the Southwest Netherlands: a level 1 trauma center and a specialized burn center. All patients with any fireworks-related injuries treated between December 1 and January 31, during 2007 (December) to 2017 (January), were eligible for participation. The primary outcome was the number of patients with any type of injury caused by fireworks. The secondary outcome measures were patient and injury characteristics, treatment details, and whole person impairment (WPI). The percentage WPI expresses a patient’s degree of permanent impairments as a result of fireworks-related injuries.

Results

Of the 297 eligible patients, 272 patients were included. From 2007 to 2017, between 21 and 40 patients were treated, and no clear increase or decrease was observed in the number of patients and in the number of patients per type of fireworks. Explosive fireworks mainly caused upper extremity (N = 65; 68%) injuries, while rockets (N = 24; 41%) and aerials (N = 7; 41%) mainly affected the head/neck. Decorative fireworks predominantly resulted in burns (N = 82; 68%), and explosive fireworks in soft tissue lacerations (N = 24; 25%), fractures (N = 16; 17%), and amputations (N = 14; 15%). Patients injured by explosive and homemade fireworks were most often admitted to a hospital (respectively N = 24; 36% and N = 12; 80%), and resulted in the highest proportion undergoing surgical procedures (respectively N = 22; 33% and N = 7; 47%). WPI found in this study was between 0 to 95%, with a median of 0%. In 34 (14%) patients, the injuries resulted in a WPI of ≥1%, mostly as a result of explosive fireworks (N = 18; 53%).

Conclusion

This study found no increase or decrease in the number of patients treated in two specialized hospitals. Explosive and homemade fireworks could be considered as most dangerous, as they result into the most hospital admissions, surgical procedures, and into the most injuries with permanent impairment as a result.