Ocular injuries caused by airgun pellets: an analysis of 105 cases

Alcohol and fatal penetration of the cranium by an airgun pellet—a case study from Poland

Background

Airguns with the energy of ejected pellets below 17 J are not considered weapons in Poland, can be purchased without permission, and do not require registration. The mere possession of this kind of airgun does not entail any legal consequences, unless it is used for an unauthorized purpose. Sports and recreational shooting do not have to take place within shooting ranges. However, the improper use of this type of weapon can lead to serious injuries and death. In addition, the impact of high blood alcohol content on pain perception can lead to a lack of awareness of the gunshot.

Case presentation

A 36-year-old woman died a few hours after a head injury inflicted by a 5.50-mm caliber pellet fired from an air gun. The first pellet penetrated perpendicularly through the left temporal bone to the brain. The gunshot tract of this head wound was 6 cm long and ran horizontally and perpendicularly to the surface of the squamous part of the temporal bone. The tract ran through the skin of the skull, the left temporal muscle, and the squamous part of the temporal bone (where the bone was only 1.5 mm thick). The pellet then penetrated the cerebral dura mater, cerebral pia mater on the borderline of the left temporal and frontal lobes, and left lateral wall of the sphenoidal sinus. The victim did not complain of pain due to a high level of alcohol intoxication (0.35 blood alcohol content). The pellet from the second shot (on the foot) penetrated the right foot and was inflicted by the victim.

Conclusion

The victim died not earlier than 3 h after being shot as a result of intracranial injuries that caused hemorrhage. The outcomes of this study indicated that high alcohol content resulted in reduced awareness of the victim and no apparent symptoms of developing intracranial injuries.

A series of 777 pellet gun ocular injuries over a 4-month period in Kashmir

Purpose

To examine the incidence, clinical findings and management of pellet gun-related ocular injuries that occurred during protests in Kashmir region.

Methods

This retrospective study included records from 777 patients diagnosed with pellet gun-related ocular injuries admitted to a tertiary hospital in Srinagar, India, between July and November 2016. By reviewing the clinical records, the following data were collected: demographics, clinical information pertaining to the injury, imaging reports including computer tomography and ultrasonography B-scan, management in the emergency setting, and follow-up treatment.

Results

Mean age was 22.3 ± 7.2 years and majority patients were male (97.7%). In terms of laterality, 94.3% and 5.7% of the patients sustained monocular and binocular injuries, respectively. In terms of the nature of injury, 76.3% of the eyes had open globe injury while 23.7% of the eyes had closed eye injury. Emergency surgical exploration was performed in 67.7% of closed globe injuries while emergency primary repair was done in 91.1% of open globe injuries. The vast majority of patients (98.7%) who required surgery underwent surgical intervention on the day of admission or the next day. Final best-corrected visual acuity (BCVA) after treatment was counting fingers or worse in 82.4% of the eyes.

Conclusion

Pellet gun-related ocular injuries resulted in significant ocular morbidity, mostly manifesting as open globe injuries. Treatment often required surgical interventions, but despite expeditious management, visual prognosis remained poor for most of the patients.

Clinical spectrum and functional outcome of firearm pellet-related eye injuries: A prospective follow-up study

PURPOSE

To determine the prognostic significance of various clinical features and surgical techniques concerning anatomical and visual outcomes in shotgun pellet-inflicted ocular trauma.

METHODS

This prospective follow-up study was done at a tertiary care institute in Kashmir, India. Six hundred sixty-four eyes of 643 patients with firearm pellet-related ocular trauma were followed up for 6 months.

RESULTS

Ocular injury involved one eye in 622 (96.7%) patients and both eyes in 21 (3.3%) patients. Open globe injury (OGI) occurred in 451 (67.9%) eyes with perforating injury being the commonest type (248 eyes, 54.9%). For perforating injuries, entry wounds in the cornea and limbus had the worst prognosis. Closed globe injury (CGI) occurred in 213 (32.1%) eyes. An anatomical success rate of 66.3% (n = 250) was achieved for 56.8% (377/664) eyes requiring an average of 2.8 (SD 0.5) surgeries per eye. OGI was associated with poor outcomes in 259 (57.4%) and CGI with good outcomes in 200 (93.9%) eyes. The visual outcome had a significant association with grade and zone of injury both in OGI and CGI, and with the type of injury in OGI (p < .0001 each). Ocular trauma score (OTS) had a significant association with the degree of vision impairment (p < .0001). WHO category 0 visual impairment was seen in 270 (40.7%) eyes, category 1 in 85 (12.8%), category 2 in 35 (5.3%), category 3 in 30 (4.5%), category 4 in 172 (25.9%), and category 5 in 72 (10.8%) eyes irrespective of type of injury at 6 months post-treatment.

CONCLUSIONS

The perforating injury was the commonest type of injury caused by shotgun pellets. The site of the entry wound in perforating injury had prognostic significance. The outcome was generally poor in OGI and good in CGI.

Orbito-Cranial Gunshot Injuries with Retained Sinonasal Bullets

Introduction

Gunshot injuries to the sino-orbital region are rare. In South Africa, where gunshot injuries are common, sino-orbital gunshot injuries are encountered. Sino-orbital gunshot injuries are associated with trauma to surrounding facial and intracranial structures. Therefore, the management of these injuries may be complex and often requires an interdisciplinary approach.

Aims

To review the management of orbito-cranial gunshot injuries with retained sinonasal bullets.

Patients and methods

Three cases of orbito-cranial gunshot injuries with retained sinonasal bullets were reviewed. Two cases were complicated by cerebrospinal fluid leaks with ensuing meningitis. The retained bullets in all three cases were successfully removed via a transnasal endoscopic approach.

Conclusion

Sino-orbital gunshot injuries are rare, but may be encountered in areas with high frequencies of gun violence. An associated anterior skull base fracture with CSF rhinorrhoea poses a risk for meningitis and a low threshold for diagnosis and treatment of meningitis should be maintained. Retained bullets in the paranasal sinuses do not pose an immediate risk and may be removed on an elective basis.

Perforating ocular trauma due to shotgun pellet - Clinical profile and visual outcome

Purpose:

The aim of this study was to determine visual and anatomical outcome of perforating injuries due to shotgun pellet.

Methods:

This was a prospective observational study carried out between July 2016 and Jan 2019 at a tertiary care referral center in Srinagar, Jammu and Kashmir. A total of 172 eyes with perforating injuries of 170 patients were included in the study and were followed up for 6 months with best-corrected visual acuity, slit-lamp examination for status of anterior chamber and lens, fundus examination for status of retina and media, intraocular pressure measurements, and OCT (optical coherence tomography) and FFA (fundus fluoresceine angiography) in selected cases. The relative improvement of visual acuity after treatment was interpreted by applying paired two-tailed t tests. Prognostic significance of other variables was calculated using Chi-square and Chi-square for linear trend tests, for two dependent outcome variables of good outcome and poor outcome.

Results:

WHO category 4 visual impairment was found in 66 (38.4%) eyes, whereas category 0 was found in 24 (14%) of eyes. Retina was found to be attached 99 (57.6%) of study eyes.

Conclusion:

Perforating injury is a severe form of ocular trauma with grave consequences in terms of functional and anatomical outcome.

Self-sealing posterior scleral perforation in airgun ocular trauma, surgical tip: a case report

Background

Intraorbital metallic foreign bodies have varied clinical presentations. Here, we report the unusual case of intraoperative evidence of spontaneously healed posterior scleral perforation in a severe ballistic trauma without previous instrumental signs of penetrating wound and complete visual restoration after surgery.

Case presentation

The patient was hit by several lead hunting pellets in the chest, abdomen, limbs, face and orbit. Computed Tomography (CT) images revealed the presence of a pellet within the orbitary cavity, close to the optic nerve, with no signs of penetrating ocular wound. While performing vitrectomy for severe vitreous hemorrhage, a point of strong adherence between a old hemorrhage and retinal surface was identified and managed conservatively, as it was attributed to trauma related-impact area. So, lead foreign body took an unusual trajectory impacting the globe and finally lodging back in the deep orbitary cavity, in absence of significant ocular injury and with visual prognosis preservation.

Conclusions

Our findings provide further information on orbital injuries from airguns, a theme of growing popularity and concern. Intraoperative recognition of hardly removable old hemorrhagic clot as self-blockage site of posterior scleral penetrating trauma, allowed for surgical stabilization and minimal solicitation of the area to avoid inadvertent perforation.

Homicide Using an Air Weapon

The debate over the lethality and ownership of modern, high-powered weapons has recently grabbed the headlines. High-velocity air weapons, advertised as starter guns for children, can cause lethal injuries despite non-lethal appearing wounds. Presented is a rare case of a modern, high-powered air weapon used in a homicide. A literature search yielded reports of only three previous murders by air weapon in the United States and only one involving injury to the thorax. In the current case, the killer used a diabolo pellet to penetrate the chest. The pathway tracked through the sternum, piercing the anterior pericardial sac and perforating the right ventricle, which led to a pericardial effusion. The pellet embolized to the left pulmonary artery and eventually the vasculature of the left lung. Cause of death was a penetrating gunshot wound of the chest most likely leading to cardiac tamponade. This case exemplifies several important characteristics of penetrating chest trauma from air guns: first, air rifles, with exit velocities up to 1200 feet per second, can kill and have been used in accidental deaths, homicides and suicides; secondly, diabolo pellets may embolize just as bullets can; and lastly, minor external damage may mask major internal destruction.

Pellet gun injury as a source of ocular trauma; a retrospective review of one hundred and eleven cases

Purpose

To report the demographic data, treatment methods, and outcomes among patients with pellet gun eye injuries.

Methods

This study was a retrospective review of all pellet gun eye injuries coming to Farabi Eye Hospital, a referral ocular trauma center in Iran, from February 2009 to November 2013. Patients' demographics, type of injury, choice of management, complications, and post-treatment visual acuity were recorded.

Results

One hundred eleven patients with a mean age of 25.7 ± 15.6 years entered the study. The most common age group was younger adults (16–45 years old) (61.3%). The mean uncorrected visual acuity after treatment was 2.05 (20/2240) ±1.5 logMAR. The most prevalent ocular zone was zone III (38.7%), and an intraocular foreign body was present in 97 patients (87.4%). Lid laceration and periocular tissue damage were present in 27 patients (24.3%). Lensectomy and vitrectomy were the most common treatment (31.5%). In most patients (87.4%), the injury was non-deliberate, and the most common time of hospitalization was the same day (45.0%). The only statistically significant indicator of post-treatment visual acuity was ocular trauma score (OTS) at admission (P < 0.001). At the end of follow-up, enucleation was performed for 20 patients (18%), and thirty-six patients (32%) had no light perception (NLP) in vision.

Conclusion

Pellet gun injuries were more common among young male patients, and the only statistically significant indicator of post-treatment visual acuity was OTS at admission.

Unique neuro-ophthalmic presentation of gun pellet injury

We describe a unique case of orbital gunshot injury with isolated intraorbital pellets lodged symmetrically in the two apices, causing identical clinical presentation, and absence of any associated globe or cerebral injury. He developed bilateral complete third nerve palsy with bilateral traumatic optic neuropathy. The optic nerve strut prevented the pellets from going into the brain on both the sides.

Vitreoretinal surgery for shotgun eye injuries: outcomes and complications

PURPOSE

To analyse the postoperative anatomic and functional outcomes in addition to complications after vitreoretinal surgery for patients with shotgun eye injuries related to hunting accidents.

MATERIALS

Retrospective review of the clinical records of all cases of shotgun eye injuries presented between January 2000 and January 2011 and with a minimum follow-up of 1 year. Collection of demographics, type of injury, choice of management, complications and final surgical success with final visual acuity is reported.

RESULTS

Twenty eyes of 19 patients (all male) with a mean age of 36.1 years (range 16-60 years) were included in the study. Mean postoperative follow-up was 47.5 months (range 15-118 months). Best corrected visual acuity (BCVA) at presentation ranged from perception of light to 20/200. Ten eyes had a penetrating injury and 10 others had a perforating injury. All the eyes underwent an initial vitrectomy and the intraocular pellet was removed in all the 10 penetrating injuries. Concurrent cataract surgery was performed in 12 cases, internal tamponade was used in 15 cases and a supplemental encircling scleral buckle was inserted in 12 cases. One additional vitreoretinal surgery was required in seven cases (35%) and two additional surgeries required in two other cases (10%). At last follow-up BCVA ranged from NPL to 20/20 and was 20/100 or better in 10 eyes (50%). All patients had a flat retina except for two cases (10%) that developed severe proliferative vitreoretinopathy.

CONCLUSION

These results suggest that vitreoretinal surgery can offer good visual rehabilitation in patients with shotgun eye injuries.

Penetrated sigmoid colon by air gun pellet could be life threatening: A case report

INTRODUCTION

Air and paintball guns have been in existence for over 400 year. Although serious injury or death can result from the use of such guns, previous literature has not mentioned the issue of the penetration of the sigmoid colon by an air gun pellet.

PRESENTATION OF CASE

We report a rare case of a 44-year-old Caucasian woman referred to abdominal surgery after an accidental small wound had occurred in the lower left abdominal quadrant that was caused by an air gun pellet. The blood and biochemical analyses were normal but the CT scan revealed the presence of a foreign body – an air gun pellet in the left iliac region of the abdomen. Clinically, during the initial 24 h significant changes were not noticed. After 42 h, however, pain and local tenderness in the lower left abdominal quadrant was expressed. A laparotomy revealed a retained pellet in the wall of the sigmoid colon and a small leak with colonic content with consecutive local peritonitis also occurred. The foreign body was removed and the opening edges in the colon were excised and closed with the primary suture.

DISCUSSION

The hollow organs of the digestive tract, albeit very rarely penetrated by an air gun pellet, do not typically show all signs of an acute abdomen in the early posttraumatic phase. Such injuries can lead to a pronounced infection, which may cause septic shock if not appropriately treated.

CONCLUSION

For correct diagnosis, a careful approach and several daily clinical observations are required.

The epidemiology and etiology of pediatric ocular trauma

Eighteen million people worldwide have uniocular blindness from traumatic injury. Injuries occur disproportionally commonly in childhood. Every year a quarter of a million children present with serious ocular trauma. For the vast majority the injury is preventable. We review the international literature that identifies high-risk circumstances.

Gunshot wound to the eye and orbit: a descriptive case series and literature review

BACKGROUND

The objective of this study is to report ocular and orbital findings in a series of six patients (8 eyes) with gunshot wounds and to review the literature on the pathophysiology, management, and outcome of such patients.

METHODS

Retrospective case series and review of the literature. Main outcome measures were ocular and orbital injury, surgical intervention, and presenting and final visual acuity.

RESULTS

Six male patients (mean age, 32 years) were enrolled. Three patients with globe concussion and low presenting visual acuity were treated by observation. Two patients (25%) underwent primary enucleation or evisceration. Retinal detachment developed in one patient who had a globe perforation, and he underwent vitrectomy and lensectomy with silicone oil injection. Visual acuity remained unchanged in all but one patient who underwent retinal detachment surgery. Final visual acuity was poor in all patients, with five eyes ending in no perception of light. Four patients had orbital fractures, two of whom underwent orbital reconstruction. One of these patients also underwent drainage of orbital abscess, eyelid surgery, and a dacryocystorhinostomy. The mean follow-up time was 26 months.

CONCLUSIONS

Gunshot wounds to the eye and orbit cause severe open and closed ocular injuries with guarded outcome and poor visual acuity. When feasible, initial wound closure may preserve the globe and allow further surgical rehabilitation. Primary evisceration may be required in cases of a severely ruptured globe. Orbital surgery may be needed in cases of infection, orbital wall disruption with disfigurement, or late enophthalmos.

Air gun pellet remaining in the maxillary sinus for 50 years: a relevant risk factor for the patient?

The authors report the case of a 62-year-old man referred to the department of oral and maxillofacial surgery because of a clinical suspicion of palate carcinoma. Incidentally, diagnostic radiology showed a metallic foreign body in the left maxillary sinus. Anamnestic data revealed that a shot from an air gun accidentally hit the patient's left cheek in 1957. The lead-containing air gun pellet was removed by endoscopic antrostomy and the diagnosis of squamous cell carcinoma was confirmed by histopathological examination. 50 years after the pellet's impact, toxicological blood analysis showed no increased blood lead level. It remains unclear whether the air gun pellet has a potential toxicological effect or is related to the development of the patient's oral carcinoma. In this context the article reviews the literature and discusses the necessity of removing metal-containing foreign bodies, the role of lead in chronic toxicity and its possible carcinogenic effect in humans.

Should airguns be banned?

In this article, we express concerns regarding the availability of airguns, the injuries that they cause and their abuse as weapons of assault. We wish to stimulate debate on this topic and report a 5-year retrospective analysis of all airgun injuries to the head and neck, presenting to Alder Hey Children's Hospital, Liverpool, from June 1998 to June 2003. We identified 16 patients who suffered such injuries with ages ranging from 5 to 15 years. The majority of cases were violent assaults, which is not in accordance with previous published reports. All of these occurred in public places outside the home. Most incidents occurred through the spring and summer period. Six patients required overnight stay in hospital. Nine patients required operative procedures to remove the airgun pellets. Two patients had serious eye injuries resulting in loss of vision. Two patients had penetrating neck injuries requiring exploration of the wound. The remaining group had either skin-penetrating injuries with lodgement of fragments in subcutaneous tissues or non-skin penetrating injuries. This study highlights serious injuries arising from the abuse of airguns as weapons of assault. Airguns are readily available to people without license. Recent legislation has increased the minimum age at which airguns can be carried in a public place, but we believe that stricter legislation is required to produce a reduction in the number of airgun-related injuries.

Ocular air gun injuries: a one-year surveillance study in the UK and Eire (BOSU). 2001-2002

AIMS

The vulnerability of the eye means that ocular air gun injuries figure prominently in the medical literature. This Study reports the results of the first ocular air gun injury surveillance study.

METHODS

Ocular air gun injuries were reported to the British Ophthalmic Surveillance Unit (BOSU; United Kingdom and Eire) for the period November 2001-December 2002 (13 months). Two questionnaires were used to collect demographic details, circumstances of injury, details of injuries, medical management and outcome.

RESULTS

A total of 105 initial and 99 follow-up questionnaires were returned. Eighty-six ocular air gun injuries occurred during the last 12 months of surveillance yielding a corrected, estimated incidence of 91-115 injuries/year. Injuries were most frequent in August/September, and 90% (95/105) of victims were men with mean age of 17.5 years (74% under 18 years). In all, 40% (32/81) of injuries occurred at home and 53% (43/81) in a public place. 23% (19/84) of injuries were deliberate, 66% (69/104) of injuries were severe and 20% (21/105) resulted in ruptured globes. In all, 54% (48/89) required hospital admission and 41 required surgery. A total of 11% (12/105) of eyes were either enucleated or eviscerated. Final visual acuity was <or=counting fingers in 29% (26/91) but >6/12 (Snellen) in 65% (59/91). Moderate/significant cosmetic deformities were recorded in 10% (8/77) and restricted ocular movements in 5% (4/72).

CONCLUSIONS

Ocular air gun injuries damage sight and leave lasting morbidity. The demographics and circumstances of injury are well documented with access to, and unsupervised use of, air guns, appearing the principal risks for injury.

Retained intraorbital metallic foreign bodies

PURPOSE

To document the biological tolerance of retained metallic orbital foreign bodies managed with conservative treatment.

METHODS

A retrospective chart review of 43 patients treated between 1987 and 1993 with retained intraorbital metallic foreign bodies was performed. Age, sex, injury, imaging studies obtained, location of the foreign body, initial and final visual acuity, length of follow-up, treatment, and related adverse reactions and/or complications were recorded.

RESULTS

Fifty cases involving 34 male and 9 female patients ranging in age from 2 through 63 years (median, 25 years) were included. Seventeen cases were the result of gunshot wounds, 17 were from BB gun injuries, and 16 cases were from shotgun injuries. Forty-two patients had CT scans to assess the injury and one patient had plain radiographs. In 37 cases, the metallic foreign bodies were located posterior to the globe. There were 19 ocular penetrating injuries, 11 ocular contusion injuries (sclopetaria, commotio retinae, vitreous hemorrhages), and 20 injuries with no ocular involvement. Initial visual acuity ranged from 20/20 to no light perception, as did final visual acuity. The metallic foreign bodies were retained from 6 months to 68 years (median, 2 years). There were 19 ocular penetrating injuries, including 12 enucleations and 7 primary repairs. When contusion injuries were sustained, treatment consisted of vitrectomy for the removal of persistent hemorrhages (3 cases), exploration of the globe (1 case), and nonsurgical treatment (7 cases). Among the 20 cases with no ocular involvement, only 2 patients had secondary complications that required surgical intervention: One had mechanical strabismus, the other a sterile abscess. Visual acuity remained stable or improved in all cases. There were no late complications from the retained foreign bodies in 36 (95%) of 38 cases when the eye remained intact.

CONCLUSIONS

Retained intraorbital metallic foreign bodies are well-tolerated and typically have minimal adverse visual prognosis. They should be managed conservatively in the absence of specific indications for removal.

Endoscopic management of retained airgun projectiles in the paranasal sinuses

OBJECTIVES/HYPOTHESIS

This article presents 3 cases to illustrate the appropriate management of airgun injuries with retained projectiles in the paranasal sinuses. The indications, techniques, and potential complications of removal of these foreign bodies from the paranasal sinuses are discussed.

STUDY DESIGN

We conducted a case series consisting of 3 patients and a review of the literature.

METHODS

Three consecutive patients who sustained airgun injuries to the face with retained bullets in the paranasal sinuses are presented. Projectiles were present in the maxillary, ethmoid, and sphenoid sinuses. The literature pertaining to this subject is reviewed.

RESULTS

All retained projectiles were removed endoscopically without complications. Stereotactic guidance was used in 2 cases.

CONCLUSIONS

Airgun injuries to the paranasal sinuses are relatively uncommon. Projectiles can safely be removed using endoscopic techniques in selected cases. When possible, foreign bodies in the paranasal sinuses should be removed to prevent long-term sequelae.

Ocular air-gun injury: 19 cases

There have been many calls for preventive action against injuries caused by air-guns. Eye injuries are particularly serious, and we conducted a retrospective study to review their characteristics. Ophthalmic consultants in the south-west region of England and South Wales were asked to recollect any injuries that had resulted from air weapons. Information was recorded on the nature and circumstances of the injury, subsequent management, and long-term effects. 19 cases of ocular injury were identified, sustained at mean age 19.7 years, all in the past decade. 15 of the victims were male. At least 12 shootings were accidental but 2 were deliberate. The injury was self-inflicted in 5 cases, and in 6 the assailant was known to the victim. 9 sustained ruptured globes and 8 had severe contusions. Ultimately 4 individuals required enucleation and 2 evisceration. At last review, visual acuity was no perception of light in 10 (53%) and "counting fingers" or worse in 16. Victims spent an average of nearly 10 days as an inpatient. The characteristics of the incidents that lead to ocular air-weapon injuries are unchanged. Reform of the firearms laws is probably the best way to prevention.

Air gun dart injury in paranasal sinuses left alone

Patients with paranasal sinus foreign body are not commonly seen in otolaryngological practice and papers dealing with this issue are rare in the English literature. One case of penetrating sinus injury due to air gun dart is presented to illustrate the potentially serious consequences of air gun injuries. The clinical presentation, diagnostic pitfalls and the treatment aspects are discussed.

Air weapon fatalities

AIMS

To describe characteristics of a series of people accidentally and deliberately killed by air powered weapons.

METHODS

Five cases of fatal airgun injury were identified by forensic pathologists and histopathologists. The circumstances surrounding the case, radiological examination, and pathological findings are described. The weapon characteristics are also reported.

RESULTS

Three of the victims were adult men, one was a 16 year old boy, and one an eight year old child. Four of the airguns were .22 air rifles, the other a .177 air rifle. Two committed suicide, one person shooting himself in the head, the other in the chest. In both cases the guns were fired at contact range. Three of the cases were classified as accidents: in two the pellet penetrated into the head and in one the chest.

CONCLUSIONS

One person each year dies from an air powered weapon injury in the United Kingdom. In addition there is considerable morbidity from airgun injuries. Fatalities and injuries are most commonly accidents, but deliberately inflicted injuries occur. Airguns are dangerous weapons when inappropriately handled and should not be considered as toys. Children should not play with airguns unsupervised.

Projectile metallic foreign bodies in the orbit: a retrospective study of epidemiologic factors, management, and outcomes

PURPOSE

Intraorbital projectile metallic foreign bodies are associated with significant ocular and orbital injuries. The authors sought to evaluate epidemiologic factors, the incidence of associated ocular and orbital injury, and the nature and necessity of surgical intervention in these cases.

METHODS

Charts of all patients with projectile intraorbital metallic foreign bodies seen at our institution (27) over the preceding 7 years were evaluated with respect to age, sex, type of injury, associated ocular and orbital injuries, location of the projectile (anterior, epibulbar, or posterior), postinjury visual acuity, and surgical intervention.

RESULTS

The majority of patients were male, between the ages of 11 and 30, and had BB pellet injuries. Thirteen projectiles were lodged anteriorly, 4 were in an epibulbar position, and the remaining 10 were posterior to the equator. Twelve of 13 anterior, and 4 of 4 epibulbar foreign bodies were removed surgically, whereas only 2 of 10 posterior foreign bodies required surgery. No case of surgical intervention resulted in a decrease of visual acuity. Associated ocular injuries were both more common and severe in patients with posteriorly located foreign bodies. Final visual acuity was better at presentation and at discharge in patients with anteriorly located foreign bodies.

CONCLUSION

Intraorbital projectile metallic foreign bodies can be a source of significant ocular morbidity. Management of these cases is dependent on the location of the projectile. Ancillary radiographic studies can be helpful. Surgery to remove the projectile should be considered in each case, but foreign bodies that are not readily accessible often may be left safely in place. Closer regulation of the pellet gun industry, with an emphasis on education and protective eyewear use, would be helpful in reducing these injuries.

Air gun pellets in the sinuses

Three cases of penetrating sinus injuries due to air gun pellets are presented in order to illustrate the potentially serious consequences of air gun injuries. Primary surgery was performed in all cases. The clinical presentation, methods of accurate pre-operative localization and surgery are discussed.

Penetrating abdominal air gun injuries: pitfalls in recognition and management

Emergency health care providers often underestimate the potential for pellet and BB guns to inflict life-threatening penetrating injuries. We present four children with intraabdominal injuries caused by air guns and summarize the characteristics of 12 similar cases reported in the literature. In the context of injury potential, the epidemiology of air gun injuries and the mechanical characteristics of air guns are reviewed. In addition, we suggest a general approach to the triage and management of children with air gun-inflicted abdominal wounds. Finally, preventive strategies are discussed.

The context and consequences of ocular injuries from air guns

There is little available information on the context of air-gun inflicted ocular injuries. To address this need, we performed a systematic telephone survey of victims of severe air-gun ocular injuries, collected between January 1986 and August 1992, through the auspices of the National Eye Trauma System and the Alabama Eye Injury Registry. One hundred forty interviews were completed with injury victims or their parents. Pump-action rifles with BB ammunition were the most common weapons. Victims and shooters were predominantly male (91% and 89%, respectively) and their mean age was 13 years. Of the injuries, 95% were inflicted by individuals known to the victim; 40% of these were relatives. People were the intended targets in 45% of the injuries. Ricochets accounted for 26% of the injuries. Of those victims with penetrating injuries, 84% had visual acuity less than 20/200 despite numerous surgical attempts. Adults were present at the scene of the injury in only 11% of the incidents, implying that unrestricted access to these weapons by children is likely the principal risk factor for injury.

Corneal endothelial cell loss induced by air bags

BACKGROUND

Although the automobile air bag is a safety device used to protect drivers from death and moderate-to-severe injury, recently it also has been reported to be associated with some ophthalmic injuries. The authors have encountered a case in which a normal air bag may have caused a driver's corneal endothelial cell loss. In this study, the authors evaluate corneal endothelial cell loss caused by several types of air bags in the hope that air bag technology may be improved.

METHODS

The authors performed impact tests with whole pig eyes fixed in a crash test dummy, using five different types of air bags. The area of damaged corneal endothelial cell was analyzed quantitatively.

RESULTS

The authors found that corneal endothelial cell loss was correlated with the inflator power of the air bag but not with its weight.

CONCLUSION

Although greater inflator power is needed for rapid air bag expansion, the effect on the eye should be considered in further refining this device. There may be greater latitude in the selection of air bag material. The authors believe their technique is applicable to the assessment of many air bag or passenger variables.

Airgun injuries: A national health hazard

Between 1983 and 1989, 41 patients were admitted to King Fahad Hospital (KFH) in Al-Baha, Saudi Arabia with airgun injuries. Of the patients admitted, 83% were under 18 years of age. The majority of injuries (80.5%) were trivial. However, 19.5% had serious injuries that required major surgery. These injuries were considered potentially lethal. Public education via media will probably be effective in reducing the number of injuries caused by these weapons.

Serious childhood injuries caused by air guns

OBJECTIVE

To determine the severity of nonfatal injuries to children caused by air guns and pellet guns.

DESIGN

Case series (hospital chart review).

SETTING

Inpatient wards of the Children's Hospital of Eastern Ontario.

PATIENTS

All children under 18 years of age admitted to the hospital from Jan. 1, 1979, to Dec. 31, 1989, under ICD code E917, E922, E955, E965, E970 or E985 who had suffered air gun injuries.

MAIN OUTCOME MEASURES

Personal data, circumstances of event and clinical data.

RESULTS

The 43 children (37 boys) had a median age of 12 years. The circumstances of the accident were known in 20 cases: 17 children were playing and 3 were cleaning the gun when it went off. Four children thought the gun was unloaded. In five cases the bullet ricocheted into the eye. Nine injuries were self-inflicted. Injury was to the extremities in 21 (49%), the eyes in 15 (35%) and the head and neck in 7 (16%). The median length of hospital stay was 4 days. Six children had long-term disabilities, all the result of eye injuries; two had cataract surgery, and four required enucleation of the eye.

CONCLUSIONS

Air guns can cause serious injury to children. Their sale needs to be banned or at least carefully regulated.

Ocular trauma caused by air-gun pellets: a ten year survey

Forty-one consecutive cases of ocular injury related to air gun pellets occurring over a ten year period have been reviewed retrospectively. The male to female ratio was 7:1 and the average age was fifteen years. Hyphaema was the most common injury (78%) while the main cause of poor final visual outcome was retinal detachment. Thirty-eight percent of the involved eyes had a final corrected visual acuity of less than 6/60 including four eyes (10%) which were enucleated following severe perforating injuries. Neither sympathetic ophthalmitis nor lead poisoning was detected in this study. The fact that these injuries are largely of an accidental nature, predominantly involve young people and appear to be occurring more frequently suggests that present legislation does not offer adequate protection. The authors suggest that the best method of prevention is through a public education campaign aimed at children and their parents.

Pneumatic firearm injuries: trivial trauma or perilous pitfalls?

This report describes an injury due to a pneumatic firearm. Though powder firearm injuries are generally considered serious, pneumatic weapon injuries are often viewed as minor or insignificant trauma. Children and adolescents primarily wield these weapons contributing to their "harmless" aura. However, dramatic increases in muzzle and impact velocities have transformed the newer generation of pneumatic firearms into formidable weapons. Consequently, the literature is replete with increasing incidences of serious injury due to pneumatic weapons.

Penetrating eye injuries

A review of all penetrating eye injuries treated at the Manchester Royal Eye Hospital over four years (1 January 1982-31 December 1985) was undertaken. A total of 202 penetrating eye injuries were seen of which 68 (34%) were in children under the age of 15 years. Airgun, dart, and knife injuries accounted for 28 (41%) of the injuries. Thirty seven patients (54%) achieved a good visual result (6/12 or better) and eight (12%) had enucleations. The period of inpatient treatment ranged from two to 18 days. From the analysis of the activities at the time of the injury, many of the injuries can be considered to be preventable.

Eye injury in sport

Eye injury sustained during sport is increasing in incidence worldwide, reflecting the rise in popularity of sport as recreation. It can account for up to 25% of severe eye injuries. This paper considers the historical context and demography of sports injuries, and the physical mechanisms and results of various types of ocular trauma in relation to sport. It reviews the specific problems associated with the sports considered to be most important in the epidemiology of eye injuries today. Certain sports, such as boxing, have an intrinsic risk of injury so high that some consider the sport should be banned. The risk of injury in many sports can be mitigated by changes in rules, such as the prevention of high sticking in ice hockey. Other sports with high risk of trauma could be made far safer with the widespread introduction of eye protection, and this applies especially to squash and badminton. The various types of eye protection are discussed. There is an urgent need to increase awareness of the risk of eye injury, to teach safe techniques, and to encourage the use of appropriate ocular protective wear in those at high risk of injury, especially the one-eyed.

Epidemiology of severe eye injuries in childhood

The authors conducted a cross-sectional study of all ocular injury cases admitted to a children's hospital between January 1978 and December 1984. Of 222 injuries reviewed, 77 (35%) resulted in some visual deficit. Males were significantly overrepresented in all age groups with an average male:female ratio of 3.5:1. The distribution of injuries was: contusions, 114 (51%); penetrating lacerations, 62 (28%); foreign bodies and burns, 11 (5%); and nonpenetrating lacerations, 35 (16%). Sixteen (7%) ocular injuries were associated with BB gun pellets and six of these children (42%) were blinded in the injured eye as a result. Two other cases of blindness resulted from ocular penetration by homemade "Jinsang Stars," underscoring the adverse influence of media on children's games. Adult supervision could have potentially prevented most cases of permanent visual deficit. The authors suggest that legislation restricting the use of BB guns be passed and that a program of adult and child eye safety education including "eye watch" warnings on potentially hazardous toys be developed.

On the management of retained airgun pellets: a survey of 11 orbital cases

Relevant factors determining the management of inaccessible retained lead airgun pellets are discussed in relation to 11 orbital cases. Although the injuries were of between one month's and 26 years' standing, serum lead levels were normal at under 350 micrograms/l in all instances. This is attributable to the modern alloy composition of the ammunition in question. It is concluded that surgical intervention may be indicated only where there is a mechanical disturbance of ocular motility allied with good visual function.

A five-year survey of ocular shotgun injuries in Ireland

Between November 1980 and September 1985 20 patients in Ireland sustained accidental ocular shotgun injuries severe enough to necessitate hospital admission. Eight patients had contusion injuries and 12 perforating injuries. Contusion damage was disproportionate to the size of the pellet. Through and through perforation of the globe occurred in eight patients; the remaining four patients in this group had retained intraocular pellets. Twelve patients sustained perforating eye injuries. Those that were treated by primary closure alone lost the sight in that eye. Those treated by vitreoretinal surgery recovered vision directly related to where the pellet had its exit from the eye. It was possible to contact 15 of the patients. All 15 were shooting pheasant. It was not possible to relate the distance of the patient from the gun to the severity of the ocular injury.

Ocular injuries associated with the use of airguns

Sixty patients with eye injuries resulting from the use of airguns were admitted to a large eye hospital over an 11-year period. The typical patient was a young male teenager; 70 per cent of patients were under the age of 17, the age at which it is legally permissible to own an air weapon. In 4 cases the missile lodged in the ocular adnexae, in 18 cases there was a penetrating eye injury and in 38 patients blunt nonpenetrating eye injury. The prognosis for visual recovery was poor especially following penetration of the globe; visual acuity was reduced to 6/60 or less in 40 per cent of all eyes and in 18 per cent the injured eye was excised.

Breakdown of the outer blood-retinal barrier in experimental commotio retinae

An animal model has been developed in this study to produce commotio retinae (Berlin's edema) by means of standardized, non-penetrating B.B. pistol injury to the cornea. Parameters have been established to ensure uniform blunt injury, enabling study of the retina and blood-retinal barrier by light- and electron microscopy, including use of horseradish peroxidase as a vascular tracer. Retinal whitening and swelling were found in the peripapillary and central regions, as occurs in the human. The earliest damage involved breakage of the connecting cilia of rods and cones, with rapid disorganization of the outer segments. Later changes included swelling of photoreceptor inner segments and breakdown of the outer blood-retinal barrier at the level of the retinal pigment epithelium. The outer blood-retinal barrier was re-established between 7 and 14 days, and at the longest survival (56 days), incompletely regenerated outer segments were present. This model for commotio retinae provides a new approach for the study of outer-segment regeneration in rods and cones after mechanical injury, as well as mechanisms that underlie re-establishment of the blood-retinal barrier following non-penetrating trauma to the eye.

Eye protection

Eye injuries frequently occur in the home, at work and at play. Many result in legally blind eyes, and most are preventable. Awareness of potential hazards is essential to preventing eye injuries, particularly in children. In addition, protective devices must be used appropriately. We have developed eye protectors that have proved effective in reducing both the overall incidence and the severity of sports eye injuries.

[Gunshot injuries of the brain caused by air pressure guns]

The article describes the historical and legal basis, as well as the ballistic criteria of injuries caused by air-rifle shots to the head. Six of our own cases of craniocerebral air-gun pellet injuries are discussed and critically assessed, using the results communicated in other papers as the basis of the discussion. The different post-traumatic complications, including the histopathological reaction of the brain to lead-pellets, are considered. The literature is reviewed and the indications for stereotactic removal or craniotomy of intracranial air-gun pellets are discussed. Air rifles, while occasionally the cause of serious head injuries, are rarely thought of as lethal weapons. However, this article illustrates the potential penetrating power of the air-gun pellet, a fact not always appreciated by physicians.