Retrospective Analysis of Firecracker Injuries and Review of Literature at a Tertiary Eye Care Hospital in South India

Purpose: To analyze demographics, risk factors, clinical features, functional, anatomical outcomes, and prevalence of blindness in recracker injury patients presenting to a major tertiary eye care centre. Methodology: A retrospective analysis of recracker injury patients who presented to our tertiary eye care hospital was performed from April 2018 to March 2019. A total of 114 patients with a minimum follow-up of 3 months were included. The parameters recorded were demographics, mode of injury, type of cracker, baseline best-corrected visual acuity (BCVA) and on last follow up, detailed anterior and posterior segment evaluation, seidel's test, intraocular pressure, gonioscopy, complications, treatment, functional and anatomical outcomes. Investigations in the form of B Scan, X-ray, or CT scan were undertaken whenever indicated. Results: A total of 132 eyes of 114 patients were analysed. The mean (SD) age of patients was 18.96 +/- 15.4 years (range 3-71 years). Seventy-four (64.91%) patients were less than or equal to 18 years of age. The male-to-female ratio was 4:1. The ratio of right: left eye involvement was 1:1. Eighteen patients (15.79%) had bilateral involvement. A total of 125 eyes had closed globe injury, 7 eyes had open globe injury and 17 patients needed hospital admission for management. The mean (SD) baseline BCVA was 0.54(+/- 0.75). The mean (SD) nal BCVA improved to 0.23(+/- 0.62) till the last follow-up. The nal outcome was good in most patients, except 5 eyes (3.78%) which resulted in near/total blindness. Conclusion: Firecracker injuries are a major cause of irreversible blindness, and these are more common in the younger age group (64.91%). Prompt diagnosis with meticulous management can prevent devastating sequelae. This study was a tertiary eye care hospital-based, single-center, retrospective analysis of recracker injuries. We analysed the pattern of injuries, common type of cracker involved, whether actively involved or not, along with presenting ocular examination ndings, 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 al 4 analyzed 51 patients and reported the mean age of cracker injury patients as 19 years (range 3–70 years). Similarly, Arya et al 5 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 recracker injury can have disastrous sequelae. Kumar et al 4 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 recracker-related ocular trauma. male:


Introduction
Fireworks are a type of low explosive pyrotechnic device used for aesthetic and entertainment purposes. The origin dates back to ancient China and was developed out of military rockets and explosive missiles. 1 In India, recrackers form a Firecracker-related injuries form a major part of ocular injuries presenting to hospitals. Kuhn et al 10 reported that 4.4% of all ocular injuries in the United States were related to recracker injuries. Bottle rockets were associated with 80% of these cases. Arya et al 5 in their study analysed 44 rework-related ocular injury patients for 3 years and found males to be more commonly affected (83.3%). The most common age group involved was 6-20 years. Approximately 7% of patients had open globe injury. Wisse et al 11 in their review article reported that 77% of victims were males, and 82% were young. Though most of the trauma were mild, 18.2% had penetrating injuries or globe contusions, and there was 3.9% enucleation rate. Mean visual acuity was > 10/200 in 56.8%, with severe vision loss (< 10/200) in 16.4%. They also observed that countries using restrictive rework legislation show 87% less eye trauma.
A larger case series with a longer follow-up and nal BCVA will help us understand the variability in presentations and outcomes of cracker-related injuries. 11,12 In this study we report the demographics, varied presentations, risk factors, type of recracker, baseline and last follow up best-corrected visual acuity(BCVA), anterior and posterior segment ndings, associated ocular complications along with treatment, functional and anatomical outcomes along with a review of literature of major studies. While several papers have dealt with recracker injuries, limited studies with large sample size and follow-up outcomes exist on this subject in the literature. None of the studies have analysed functional/anatomical outcomes. Our study includes 114 patients, which is probably the largest sample size reported till now. Additionally, we have done a detailed literature review of recracker injuries. Ocular trauma is also an important cause of nancial burden to the individual and the family, as it involves not only the treatment cost but additionally travel and logistic cost and loss of pay of attenders and patient. Hence, we went a step ahead and analysed the medical treatment cost involved per head in the management of these ocular mishaps. This will help us in understanding the overall impact of such injuries in terms of vision as well as the economical loss to some extent.

Materials And Methods
This was a retrospective analysis of all the recracker injury patients who presented from April 2018 to March 2019 at a tertiary eye care hospital with a minimum follow-up of 3 months. The study complied with the tenets of the declaration of Helsinki and ethical clearance was obtained from the Institutional Review Board (IRB) of the Institutional Ethical Committee (IEC) of the hospital. The medical case records of all the patients were obtained from the Electronic Medical Record of the hospital.
The case records were analyzed for demographic pro le, risk factors, type of cracker uncorrected and best-corrected visual acuity using Snellen or Cardiff visual acuity charts, detailed slit-lamp anterior and posterior segment ndings, intraocular pressure by non-contact tonometry, Goldmann 3 mirror gonioscopy in required cases, seidel's and forced seidel's test, treatment with anatomical and functional outcomes along with the prevalence of blindness post cracker injury. Investigations in form of an Ultrasonography B scan was performed in all patients with hazy media on the rst presentation itself. Imaging in the form of an X-ray or CT scan were advised to rule out any intraocular foreign body as and when needed. The nal functional visual outcome was de ned as BCVA on the last presentation and anatomical outcome was de ned as preservation of the globe. Additionally, a detailed retrospective comparative analysis of published literature was also done with our data. The inclusion criteria were: 1) All patients with a history of cracker injury who presented within the study period with a follow-up of 3 months. Exclusion criteria were: 1) Incomplete medical records. 2) Loss to follow-up patients before 3 months 3) Younger kids for whom vision assessment was not possible.
If needed the injured eye/s was/were irrigated with copious amount of normal saline and particulate matter or soot particles were removed with a cotton bud or sterile forceps under topical anaesthesia under aseptic precautions. Based on the presentation, patients were classi ed either as closed or open globe injury based on the Birmingham eye trauma terminology system (BETTS). 13 The closed globe injury patients were managed conservatively with topical steroids, antibiotics, cycloplegics, antiglaucoma and anti-in ammatory drugs, and open globe injury patients required hospital admission and underwent surgical repair as per the indications. Informed consent for any surgical intervention if warranted was obtained from the patient or parents/legal guardian in the case of pediatric patients. Patients were prescribed medical treatment in form of topical antibiotics (Moxi oxacin 0.5%/ Gati oxacin 0.5%), steroids drops (Loteprednol 0.5%/ Prednisolone 1%), lubricants drops (Carboxymethyl cellulose 0.5%/ Hydroxymethyl cellulose 0.5%) or ointment or cycloplegic eye drops (Cyclopentolate 1%/ Homatropine 2%), based on the initial assessment. The closed globe injuries were majorly managed on an outpatient basis, except traumatic optic neuropathy or 8 ball hyphema, which necessitated admission and management under close observation. All open globe injury cases including the corneal/scleral/corneoscleral tears/globe ruptures were admitted for surgical management. Intravenous antibiotics (Ceftriaxone 1gram/500mg based on body weight BD for three days) and intramuscular injection Tetanus toxoid (0.5ml stat) were administered in all OGI, after enquiring the immunization history. All the post-operative patients were followed up on day1, day 7, 1 month, and 3 months.

Statistical Analysis
The statistical analysis was done using Microsoft excel 2017. The mean(SD) and frequency(%) were used to describe the summary data. Visual acuity was compared by Wilcoxon signed-rank test. A P-value less than 0.5 was considered statistically signi cant. All the statistical analysis were performed by STATA 14.0 (Texas).

Results
A total of 153 patients were analysed out of which 132 eyes of 114 patients were included in our study based on the inclusion and exclusion criteria. The mean (SD) age of patients was 18.96 +/-15.4 years (range 3-71 years). A total of 74 (64.91%) patients were less than or equal to 18 years of age, while 40 (35.09%) were above 18 years. The age-wise distribution of patients is depicted in Fig. 1 below. The male-to-female ratio was 4:1. Fifty-one 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. The detailed demographics are described in Table 2. Figure 1 depicts the number of patients in each group. The maximum patients belonged to the 9-18 years age group (41 patients − 35.96%) and least were 3 each in 39-48 years and > 59 years age group.  Classifying the injuries according to the BETTS classi cation, 13 a total of 125 eyes had CGI and 7 eyes had OGI (Fig. 3af). Detailed distribution based on the type of injury is illustrated in Fig. 2.. A total of 17 cracker injury patients were admitted to the hospital for management. Surgical management was performed in seven OGI patients and these included scleral tear repair 1 (0.75%), corneoscleral tear repair 1 (0.75%), corneal tear repair + lens aspiration + PCIOL 2 (1.5%), corneal tear repair + lens aspiration 1 (0.75%), macular hole surgery + cataract extraction + corneal tear repair 1 (0.75%), and evisceration 1(0.75). Additionally, few patients with CGI needed surgical intervention in from of conjunctival tear repair in 1 (0.75%), anterior chamber wash in 2 (1.5%), foreign body removal and glue with BCL application 2 (1.5%), cataract extraction + PCIOL 3 (2.27%) and retinal detachment surgery 2 (1.5%). In case an eye was deemed inappropriate for primary IOL implantation these were left aphakic for the in ammation to settle down and IOL was implanted after 30-90 days of quiescence. PL. Hence, the prevalence of blindness in our study was 3.79%. Detailed analysis of patients presenting and nal BCVA has been summarised in Table 3. Table 4 contains data of patients who had low visual recovery following trauma. We have done a detail literature review and also compared our data with the previously published data (Table 5)

Discussion
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, recracker 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, reworks are use celebrate national and religious events. Similarly, rework-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 reworks and negligence with handling is associated with casualties. 19 Ocular injuries secondary to reworks can result in devastating visual and dis guring effects. 20 Since, India is a large country with social and cultural diversity, the pattern and sequalae of recracker injuries differs from place to place. 3 This study was a tertiary eye care hospital-based, single-center, retrospective analysis of recracker injuries. We analysed the pattern of injuries, common type of cracker involved, whether actively involved or not, along with presenting ocular examination ndings, treatment outcomes, and direct cost involved in medical management. We analyzed 132 eyes of 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 recracker-related ocular trauma.
Firework-related injuries have been reported more commonly in males. 11,16,17 We also observed male: Firecracker Injuries in bystanders are also very common (14-61%). 22 In our study 61% were bystanders when they sustained the injury. Patel et al 21 also reported that 48.9% of their patients were bystanders. Wisse et al 11 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  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 reworks are very common and can lead to irreversible blindness. There is a need for stringent laws in this regard. The rst step can be promotion of public rework displays from a safe distance with mandatory eyewear. 25 The banning of reworks 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 reworks, 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.

Conclusion
Firecracker injuries are a common cause of blindness, mainly affecting the pediatric age group. Open globe injuries are associated with poor visual outcomes and can result in blindness (4/15 patients in our study). Timely presentation, early diagnosis, and meticulous management can prevent irreversible ocular sequelae. Simple rules like limiting cracker usage, educating the masses, promotion of rework displays, and precautions like not allowing children to burst crackers individually and protective eyewear can prevent the majority of these injuries. Awareness regarding cracker-related injuries, strict rules regarding safe use, restrictions on the sale of crackers, and promotion of safe reworks is the need of the hour. Figure 1 Bar diagram depicting recracker injury patients in each age group Page 12/13

Figure 2
Image depicting distribution of various injury in adolescent and adult age group