Firework Eye Injuries: Types, Care and Prevention

Firework eye injuries are a seasonal cause of serious ocular trauma, and many victims are children and bystanders.

Also, the injuries combine blast, burn, and chemical damage, and they range from a corneal abrasion to a ruptured globe.

Also, prevention is possible, and early care changes the outcome.

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Who Suffers Firework Eye Injuries?

Reviews of firework trauma show that a large share of victims are bystanders, with children and young men most affected (see the references).

In addition, injuries often occur around festivals, and with illegal or homemade devices.

A significant number, in fact, result in permanent loss of vision.

Mechanisms

• Blast wave: a pressure wave that can also rupture the globe, damage the retina, and cause orbital fractures
• Projectile fragments: metal, plastic, or cardboard that penetrate the eye
• Thermal burn: from the flame and hot particles
• Chemical injury: from the powders, such as alkaline and acidic salts, which stick to the surface (see chemical eye injury)
• Blunt trauma: from the device itself or from fragments

Patterns of Injury

• Burns of the lids and the face
• Corneal and conjunctival abrasions, and embedded particles (see corneal foreign body)
• Hyphema and traumatic iritis (see hyphema)
• Lens injury, with cataract or subluxation
• Open globe injury, with a corneal or scleral laceration, and intraocular foreign body
• Vitreous hemorrhage, retinal tears, retinal detachment, and commotio retinae
• Optic nerve injury and orbital fractures

Emergency Care

• Protect the eye with a rigid shield, and do not press on the globe
• Do not use ointment or remove an embedded object
• Irrigate copiously if there is a chemical component, and the globe is not obviously ruptured
• Keep the patient fasting, in case of surgery, and give analgesics and antiemetics to avoid straining
• Give tetanus prophylaxis, and systemic antibiotics if there is penetration
• Then transfer to an eye emergency department without delay

Evaluation for Firework Eye Injuries

• Record the visual acuity, pupil reactions, and the position of the lids and globe
• Examine gently, with care for an open globe (see ruptured globe)
• CT of the orbit when there is a suspected foreign body or fracture, and avoid MRI when metal is possible
• Ultrasound with caution, but not in a suspected open globe
• Examine the other eye

Treatment for Firework Eye Injuries

• Primary repair of an open globe within hours, with removal of foreign bodies
• Management of hyphema, glaucoma, and cataract
• Vitreoretinal surgery for detachment and retained foreign bodies
• Treatment of corneal burns, with lubricants, antibiotics, and amniotic membrane when indicated
• Reconstruction of the lids and orbit

Visual outcomes also depend on the extent of damage and the speed of treatment.

Prevention

• Attend professional displays, and keep a safe distance
• Use only legal products, and follow the instructions when lighting them
• Wear protective eyewear when handling fireworks
• Do not let children handle them, even sparklers, which burn at high temperatures
• Never relight a device that has failed to ignite

Education campaigns and stricter regulations also lower the number of injuries.

Typical Cases

A boy of ten standing near a neighbor’s celebration is struck in the left eye by a fragment.

He presents with a lid burn, a corneal abrasion, and a hyphema, and the globe is also intact on CT.

He is also treated with a shield, a cycloplegic, topical antibiotics and steroids, and strict rest, and monitored for pressure rise and rebleeding.

In contrast, a man who holds a device that explodes may have a ruptured globe, a retained fragment, and a damaged lens, and he needs urgent surgery.

Firework Eye Injuries: Follow-Up and Long-Term Problems

• Raised pressure and angle recession: can appear months or years later, so lifelong checks are advised (see angle recession glaucoma)
• Cataract and lens subluxation
• Retinal detachment, which can occur late
• Corneal scarring and irregular astigmatism
• Psychological effects, such as anxiety, especially in children

Rehabilitation includes low vision aids, schooling support, and counselling.

Public Health Measures

• Support laws that restrict the sale of dangerous devices
• Promote public displays run by trained staff
• Distribute information to schools and families before festivals
• Report injuries to registries, so that trends can be seen

Eye doctors can take part in campaigns by sharing their cases with permission and by working with local authorities.

Advice for Families After Discharge

• Give the drops as instructed, and also keep the shield on at night
• Keep the child quiet for the first days if there is a hyphema, with the head raised
• Watch for pain, vomiting, or a sudden loss of vision, because they need urgent return
• Attend every follow-up visit, even when the eye looks better
• Explain to the child why safety rules matter, without blame

Support from the family helps recovery and prevents a repeat injury.

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References

1. Wisse RPL, Bijlsma WR, Stilma JS. Ocular firework trauma: a systematic review on incidence, severity, outcome and prevention. Br J Ophthalmol. 2010;94:1586-1591.
2. Kuhn F, Pieramici DJ. Ocular Trauma: Principles and Practice. Thieme; 2002.
3. Mansouri M, Faghihi H, Hajizadeh F, et al. Epidemiology of open-globe injuries in Iran: analysis of 2,340 cases in 5 years (report no. 1). Retina. 2009;29:1141-1149.
4. American Academy of Ophthalmology. Basic and Clinical Science Course, Section 8: External Disease and Cornea. AAO; current edition.