- Email: [email protected]
Incidence of ocular injuries in motor vehicle crash victims with concomitant air bag deployment
Incidence of Ocular Injuries in Motor Vehicle Crash Victims with Concomitant Air Bag Deployment Steven K. Anderson, MD, Uday R. Desai, MD, Sundara V. Raman, MD, FRCS(Glasg) Objective: To report the incidence of ocular and nonocular trauma in patients admitted to the Henry Ford Hospital via the emergency room since 1994 after a motor vehicle crash (MVC) with and without air bag deployment. Design: A retrospective cohort study. Methods: The Henry Ford Hospital Trauma Registry database was reviewed for patients involved in MVCs with and without air bag deployment since 1994. Results: From 1994 to 1999, there were only seven air bag-related ocular injuries, representing 4.4% of all MVC-related ocular injuries. From 1997 to 1999, MVC-related ocular injuries with and without air bags represented 5.0% and 12.7%, respectively, of all MVC-related injuries. For that same period, the death rate and average Injury Severity Score for MVCs with air bag deployment were 3.4% and 10.75, compared with 8% and 14.5, respectively, for MVCs without air bag deployment. Conclusions: MVC-related ocular injuries associated with air bag deployment are rare, and the incidence of ocular injuries associated with MVCs was lower when air bags were deployed. Ophthalmology 2002;109: 2356 –2358 © 2002 by the American Academy of Ophthalmology.
The use of an air bag in vehicles as a safety device became popular in the 1990s. More than 118 million (56.2%) of the 210 million cars and light trucks on U.S. roads have driverside air bags. As of October 2000, air bags had inflated in ⬎3.3 million vehicle crashes.1 The air bag, which is mandatory on all 1998 and later model cars, is a rubber-lined nylon bag folded into the steering column and the dashboard. Sensors located within the vehicle are triggered when a frontal crash occurs at 12 mph or more. The combustion of sodium azide within the bag provides nitrogen gas to fill the 50 liter volume of the air bag in 0.05 seconds. The bag is then propelled toward the occupant at a speed of 100 to 200 mph.2 Deployment of an air bag in a car with a properly belted occupant decreases the mortality rate of motor vehicle crashes (MVCs) by 50% when compared with MCVs with unbelted drivers.3 In fact, the National Highway Traffic Safety Administration estimates that more than 6018 people are alive today because of air bags. Although useful in decreasing the mortality rate of MVCs, the air bag itself was implicated as the cause of death in 169 MVCs as of October 2000.4 In addition, there are numerous reports in the ophthalmic literature in which the air bag is cited as the causOriginally received: October 1, 2001. Accepted: April 22, 2002. Manuscript no. 210831. From the Eye Care Service, Henry Ford Hospital, Detroit, Michigan. Presented at the 5th International Symposium on Ocular Trauma, Montreal, Canada, July, 2000. Reprint requests to Steven K. Anderson, MD, Henry Ford Hospital, 2799 W. Grand Blvd., Detroit, MI 48202. E-mail: [email protected].
2356
© 2002 by the American Academy of Ophthalmology. Published by Elsevier Science Inc.
ative factor of ocular injury ranging from corneal and lid abrasions to retinal detachments and globe rupture.3,5–20 There have been no studies to date comparing ocular injury in MVCs with and without air bag deployment. To determine whether air bags reduce the risk of ocular injury during MVCs, we describe the incidence of ocular and nonocular trauma in patients admitted to the Henry Ford Hospital via the emergency room from 1994 to 1999 after MVCs with and without air bag deployment.
Materials and Methods We retrospectively reviewed the Henry Ford Hospital Trauma Registry database for the years 1994 to 1999. The patients who were entered into the Trauma Registry presented to the emergency room with trauma severe enough to require hospitalization. For this time period, the Trauma Registry was searched for MVCrelated ocular and nonocular injuries with and without air bag deployment. The Trauma Registry provides details regarding the date of the emergency room visit, patient name, an Emergency code that indicates the type of MVC, a description of the injuries that occurred, and patient disposition at discharge, including whether the patient died. Also included is the Abbreviated Injury Scale (AIS) Injury Severity Score (ISS) for the automobile-related injury. According to this scale, a score of 1 to 6 is assigned to each of six different areas of the body on the basis of the severity of injury to that area of the body. The six body regions are head and neck, face, chest, abdominal and pelvic contents, extremities and pelvic girdle, and external injuries. The ISS score is the sum of the squares of the AIS scores for each of the three most severely injured regions. Three AIS 5 injuries or at least one AIS 6 injury results in the maximum score of 75. ISSN 0161-6420/02/$–see front matter PII S0161-6420(02)01289-7
Anderson et al 䡠 Ocular Injuries with Air Bag Deployment Table 1. 1994 –1999 Henry Ford Hospital MVC-associated Ocular Injuries Variable
Table 3. 1997–1999 Henry Ford Hospital Ocular Injuries in MVCs with and without Air Bag Deployment n
Air bag associated Orbital/facial fracture Eyelid laceration Globe laceration Total Without air bag Orbital/facial fracture Eyelid laceration Globe laceration Contrusion of the eye Total
3 3 1 7 69 46 12 24 151
MVC ⫽ motor vehicle crash.
A chi-square test was used to analyze differences between MVC injuries with and without air bag deployment. Differences in ISS scores were compared by using Student’s t test. A P value of 0.05 was considered to be statistically significant.
Variable
Air Bag
Without Air Bag
P Value
Total MVC Ocular injuries
119 6 (5%)
638 81 (12.7%)
0.016
MVC ⫽ motor vehicle crash.
10.85 (standard deviation, 7.44) for MVCs with air bag deployment and 14.5 (standard deviation, 13.76) without air bag deployment. This difference in ISS scores was statistically significant (P ⫽ 0.006). There were 56 MVC-related deaths for this time period, 4 with air bags and 52 without.
Discussion
For the years from 1994 to 1999, there were only seven MVCrelated ocular injuries recorded in the Trauma Registry database in which an air bag was deployed. In that same time period, there were 151 recorded MVC-related eye injuries in which an air bag was not deployed (Table 1). Of all MVC-related eye injuries recorded in the Trauma Registry database during this time period, those in which an air bag was deployed represented 4.4% of the total eye injuries. Because only one MVC-associated ocular injury with air bag deployment was reported in the Trauma Registry before 1997, all comparisons were made of the MVCs occurring from 1997 to 1999. For this time period, 757 MVCs were reported in the Trauma Registry. Of the 757 MVCs, 119 involved air bag deployment. Table 2 summarizes the percentages of MVC-associated injuries by body region. There was a significant difference in the incidence of eye injury in MVCs with (5.0%) and without (12.7%) air bags (P ⫽ 0.016; Table 3). Further comparison was made of the incidence of serious MVC-related injuries by body region with and without air bag deployment (Table 4). Serious injuries were defined as being life threatening, such as thoracic and abdominal aorta injuries, intracranial hemorrhages, vital organ injuries, and significant cervical fractures. The average ISS per patient for this time period was
There are approximately 288,000 cases of ocular injury treated in hospital-based emergency rooms each year. More than 15,000 of these are the result of MVCs, representing 0.44% of the 3.4 million people injured in MVCs each year. The sources of ocular injuries include contact with the windshield (24%), steering wheel rim (10%), and rearview mirror (5%).21 Contact with such surfaces is reduced by the use of air bags. This study indicates that ocular injuries with associated air bag deployment are rare and represent only 4.4% of all MVC-related ocular injuries. Also, only 5.0% of patients involved in MVCs with air bag deployment had ocular injuries, as compared with 12.7% of patients involved in MVCs without air bag deployment. Thus, there are fewer ocular injuries with air bags than without. This finding is consistent with the results of Kuhn et al,2 who reported that the chance of MVC-related ocular injury is increased 2.53 times if the vehicle is not equipped with an air bag. All regions of the body, with the exception of the extremities, had a higher percentage of injury in MVCs when there was no air bag inflation. The higher rate of injury to the extremities in air bag-associated MVCs reflects the greater number of finger and wrist injuries that result from the concussive force of the oncoming air bag on hands that are gripping the steering wheel.22 Additionally, the combustion of sodium azide produces heated gases. These gases are
Table 2. 1997–1999 Henry Ford Hospital MVC-associated Injuries with and without Air Bag Deployment
Table 4. 1997–1999 Henry Ford Hospital Serious Injuries with and without Air Bag Deployment
Results
Injury
Air Bag
Without Air Bag
Variable
Extremities Head Chest Abdomen Face Neck
66% 27% 20% 6% 8% 7%
52% 36% 27% 17% 12% 8.5%
Head Chest Abdomen Neck Average ISS Total deaths
MVC ⫽ motor vehicle crash.
Air Bag 7 (6%) 12 (10%) 2 (1.7%) 7 (6%) 10.85 4 (3.4%)
Without Air Bag
P Value
76 (12%) 87 (14%) 36 (5.6%) 45 (7%) 14.5 52 (8%)
0.053 0.291 0.069 0.643 0.006 0.067
ISS ⫽ Injury Severity Score.
2357
Ophthalmology Volume 109, Number 12, December 2002 rapidly vented away from the occupant as the air bag deflates. The extremities might suffer burns as a result of this venting because they are thrown forward during the crash, whereas the torso and face are kept back by the air bag. The cushioning effect on the torso results in lower rates of serious injuries and death in patients with air bag inflation. A limitation of this study is that the findings are based on a review of the Trauma Registry database. Detailed data regarding the MVCs, such as the height and weight of the patients, long-term follow-up of visual acuity, details regarding the type and speed of the vehicle, and details regarding the mechanism of injury, are lacking. As noted by Kuhn et al,23 however, unless a field investigation evaluating the crash is performed, it is impossible to determine what object in the car caused the injury. In some cases, the air bag was clearly the cause of the ocular injury. In other cases, however, the ocular injury might have been caused by some other projectile in the car. Because other projectiles might have contributed to ocular injury, the air bag alone as a cause of eye trauma might be overrepresented in this article. The Trauma Registry that we reviewed included only patients with injuries severe enough to require hospitalization. We assume that less severe accidents would be less likely to result in ocular injury. Mohamed and Banerjee,24 however, reported that certain minor ocular injuries, such as hyphema and corneal abrasion, might be more prevalent in slower-speed accidents in which the air bag is deployed, and they suggest that these injuries would not have occurred had the air bag not deployed.24 Similarly, Stein et al3 reported a higher rate of severe ocular injury, such as ruptured globes, occurring with air bag deployment in crashes in which the automobile was going at a slower speed (30 mph or slower). These slowerspeed, less severe MVCs might allow for the face and eyes to start coming forward before the air bag inflates, thereby resulting in greater impact to these structures. This study would not identify eye injuries occurring with less severe MVCs. Automobile manufacturers are developing smarter air bags, which would inflate at different speeds according to the severity of the MVC as well as the physical characteristics of the occupants in the driver and passenger seats. These changes should decrease the morbidity associated with air bags, especially when the MVC is not as severe and otherwise less likely to result in bodily injury. Even the use of the current air bags, however, reduces the incidence of both bodily and ocular injury.
References 1. Airbag Statistics. Insurance Institute for Highway Safety, Arlington, VA: Highway Loss Data Institute [rev. April 19,
2358
2. 3. 4.
5. 6. 7. 8. 9. 10. 11.
12.
13.
14. 15. 16.
17.
18.
19.
20. 21. 22.
23. 24.
2002. Available at: http://www.highwaysafety.org/safety_ facts/airbags/stats.htm. Accessed November 18, 2000. Kuhn F, Morris R, Witherspoon CD. Eye injury and the air bag. Curr Opin Ophthalmol 1995;6:38 – 44. Stein JD, Jaeger EA, Jeffers JB. Air bags and ocular injuries. Trans Am Ophthalmol Soc 1999;97:59 – 82; discussion 82– 6. Air Bag Fatal and Serious Injury Summary Report. Washington, DC: National Center for Statistics and Analysis [rev. Oct. 2001. Available at: http://www.nhtsa.dot.gov/people/ncsa/ scireps.html. Accessed November 18, 2000. Duma SM, Kress TA, Porta DJ, et al. Airbag-induced eye injuries: a report of 25 cases. J Trauma 1996;41:114 –9. Larkin GL. Airbag-mediated corneal injury. Am J Emerg Med 1991;9:444 – 6. Mishler KE. Hyphema caused by air bag [letter]. Arch Ophthalmol 1991;109:1635. Rimmer S, Shuler JD. Severe ocular trauma from a driver’sside air bag [letter]. Arch Ophthalmol 1991;109:774. Han DP. Retinal detachment caused by air bag injury [letter]. Arch Ophthalmol 1993;111:1317– 8. Whitacre MM, Pilchard WA. Air bag producing retinal dialysis and detachment [letter]. Arch Ophthalmol 1993;111:1320. Lesher MP, Durrie DS, Stiles MC. Corneal edema, hyphema, and angle recession after air bag inflation [letter]. Arch Ophthalmol 1993;111:1320 –2. Scott IU, John GR, Stark WJ. Air bag-associated ocular injury and periorbital fractures [letter]. Arch Ophthalmol 1993;111: 25. Ghafouri A, Burgess SK, Hrdlicka ZK, Zagelbaum BM. Air bag-related ocular trauma. Am J Emerg Med 1997;15:389 – 92. Manche EE, Goldberg RA, Mondino BJ. Air bag-related ocular injuries. Ophthalmic Surg Lasers 1997;28:246 –50. Braude LS. Passenger side airbag ocular injury while wearing sunglasses [letter]. Br J Ophthalmol 1995;79:391. Scott IU, Greenfield DS, Parrish RK 2nd. Airbag-associated injury producing cyclodialysis cleft and ocular hypotony. Ophthalmic Surg Lasers 1996;27:955–7. Baker RS, Flowers CW Jr, Singh P, et al. Corneoscleral laceration caused by air-bag trauma. Am J Ophthalmol 1996; 121:709 –11. Vichnin MC, Jaeger EA, Gault JA, Jeffers JB. Ocular injuries related to air bag inflation. Ophthalmic Surg Lasers 1995;26: 542– 8. White JE, McClafferty K, Orton RB, et al. Ocular alkali burn associated with automobile air-bag activation. CMAJ 1995; 153:933– 4. Lueder GT. Air bag-associated ocular trauma in children. Ophthalmology 2000;107:1472–5. Young GS. Ocular injuries and motor vehicles. Int Ophthalmol Clin 1988;28:219 –21. Huelke DF, Gilbert R, Schneider LW. Upper Extremity Injuries from Steering Wheel Air Bag Deployment. Detroit, MI: Society of Automotive Engineers, 1997. Paper No. 970493. Kuhn F, Morris R, Witherspoon CD, et al. Air bag: friend or foe. Arch Ophthalmol 1993;111:1333– 4. Mohamed AA, Banerjee A. Patterns of injury associated with automobile air bag usage. Postgrad Med J 1998;74:455– 8.
The use of an air bag in vehicles as a safety device became popular in the 1990s. More than 118 million (56.2%) of the 210 million cars and light trucks on U.S. roads have driverside air bags. As of October 2000, air bags had inflated in ⬎3.3 million vehicle crashes.1 The air bag, which is mandatory on all 1998 and later model cars, is a rubber-lined nylon bag folded into the steering column and the dashboard. Sensors located within the vehicle are triggered when a frontal crash occurs at 12 mph or more. The combustion of sodium azide within the bag provides nitrogen gas to fill the 50 liter volume of the air bag in 0.05 seconds. The bag is then propelled toward the occupant at a speed of 100 to 200 mph.2 Deployment of an air bag in a car with a properly belted occupant decreases the mortality rate of motor vehicle crashes (MVCs) by 50% when compared with MCVs with unbelted drivers.3 In fact, the National Highway Traffic Safety Administration estimates that more than 6018 people are alive today because of air bags. Although useful in decreasing the mortality rate of MVCs, the air bag itself was implicated as the cause of death in 169 MVCs as of October 2000.4 In addition, there are numerous reports in the ophthalmic literature in which the air bag is cited as the causOriginally received: October 1, 2001. Accepted: April 22, 2002. Manuscript no. 210831. From the Eye Care Service, Henry Ford Hospital, Detroit, Michigan. Presented at the 5th International Symposium on Ocular Trauma, Montreal, Canada, July, 2000. Reprint requests to Steven K. Anderson, MD, Henry Ford Hospital, 2799 W. Grand Blvd., Detroit, MI 48202. E-mail: [email protected].
2356
© 2002 by the American Academy of Ophthalmology. Published by Elsevier Science Inc.
ative factor of ocular injury ranging from corneal and lid abrasions to retinal detachments and globe rupture.3,5–20 There have been no studies to date comparing ocular injury in MVCs with and without air bag deployment. To determine whether air bags reduce the risk of ocular injury during MVCs, we describe the incidence of ocular and nonocular trauma in patients admitted to the Henry Ford Hospital via the emergency room from 1994 to 1999 after MVCs with and without air bag deployment.
Materials and Methods We retrospectively reviewed the Henry Ford Hospital Trauma Registry database for the years 1994 to 1999. The patients who were entered into the Trauma Registry presented to the emergency room with trauma severe enough to require hospitalization. For this time period, the Trauma Registry was searched for MVCrelated ocular and nonocular injuries with and without air bag deployment. The Trauma Registry provides details regarding the date of the emergency room visit, patient name, an Emergency code that indicates the type of MVC, a description of the injuries that occurred, and patient disposition at discharge, including whether the patient died. Also included is the Abbreviated Injury Scale (AIS) Injury Severity Score (ISS) for the automobile-related injury. According to this scale, a score of 1 to 6 is assigned to each of six different areas of the body on the basis of the severity of injury to that area of the body. The six body regions are head and neck, face, chest, abdominal and pelvic contents, extremities and pelvic girdle, and external injuries. The ISS score is the sum of the squares of the AIS scores for each of the three most severely injured regions. Three AIS 5 injuries or at least one AIS 6 injury results in the maximum score of 75. ISSN 0161-6420/02/$–see front matter PII S0161-6420(02)01289-7
Anderson et al 䡠 Ocular Injuries with Air Bag Deployment Table 1. 1994 –1999 Henry Ford Hospital MVC-associated Ocular Injuries Variable
Table 3. 1997–1999 Henry Ford Hospital Ocular Injuries in MVCs with and without Air Bag Deployment n
Air bag associated Orbital/facial fracture Eyelid laceration Globe laceration Total Without air bag Orbital/facial fracture Eyelid laceration Globe laceration Contrusion of the eye Total
3 3 1 7 69 46 12 24 151
MVC ⫽ motor vehicle crash.
A chi-square test was used to analyze differences between MVC injuries with and without air bag deployment. Differences in ISS scores were compared by using Student’s t test. A P value of 0.05 was considered to be statistically significant.
Variable
Air Bag
Without Air Bag
P Value
Total MVC Ocular injuries
119 6 (5%)
638 81 (12.7%)
0.016
MVC ⫽ motor vehicle crash.
10.85 (standard deviation, 7.44) for MVCs with air bag deployment and 14.5 (standard deviation, 13.76) without air bag deployment. This difference in ISS scores was statistically significant (P ⫽ 0.006). There were 56 MVC-related deaths for this time period, 4 with air bags and 52 without.
Discussion
For the years from 1994 to 1999, there were only seven MVCrelated ocular injuries recorded in the Trauma Registry database in which an air bag was deployed. In that same time period, there were 151 recorded MVC-related eye injuries in which an air bag was not deployed (Table 1). Of all MVC-related eye injuries recorded in the Trauma Registry database during this time period, those in which an air bag was deployed represented 4.4% of the total eye injuries. Because only one MVC-associated ocular injury with air bag deployment was reported in the Trauma Registry before 1997, all comparisons were made of the MVCs occurring from 1997 to 1999. For this time period, 757 MVCs were reported in the Trauma Registry. Of the 757 MVCs, 119 involved air bag deployment. Table 2 summarizes the percentages of MVC-associated injuries by body region. There was a significant difference in the incidence of eye injury in MVCs with (5.0%) and without (12.7%) air bags (P ⫽ 0.016; Table 3). Further comparison was made of the incidence of serious MVC-related injuries by body region with and without air bag deployment (Table 4). Serious injuries were defined as being life threatening, such as thoracic and abdominal aorta injuries, intracranial hemorrhages, vital organ injuries, and significant cervical fractures. The average ISS per patient for this time period was
There are approximately 288,000 cases of ocular injury treated in hospital-based emergency rooms each year. More than 15,000 of these are the result of MVCs, representing 0.44% of the 3.4 million people injured in MVCs each year. The sources of ocular injuries include contact with the windshield (24%), steering wheel rim (10%), and rearview mirror (5%).21 Contact with such surfaces is reduced by the use of air bags. This study indicates that ocular injuries with associated air bag deployment are rare and represent only 4.4% of all MVC-related ocular injuries. Also, only 5.0% of patients involved in MVCs with air bag deployment had ocular injuries, as compared with 12.7% of patients involved in MVCs without air bag deployment. Thus, there are fewer ocular injuries with air bags than without. This finding is consistent with the results of Kuhn et al,2 who reported that the chance of MVC-related ocular injury is increased 2.53 times if the vehicle is not equipped with an air bag. All regions of the body, with the exception of the extremities, had a higher percentage of injury in MVCs when there was no air bag inflation. The higher rate of injury to the extremities in air bag-associated MVCs reflects the greater number of finger and wrist injuries that result from the concussive force of the oncoming air bag on hands that are gripping the steering wheel.22 Additionally, the combustion of sodium azide produces heated gases. These gases are
Table 2. 1997–1999 Henry Ford Hospital MVC-associated Injuries with and without Air Bag Deployment
Table 4. 1997–1999 Henry Ford Hospital Serious Injuries with and without Air Bag Deployment
Results
Injury
Air Bag
Without Air Bag
Variable
Extremities Head Chest Abdomen Face Neck
66% 27% 20% 6% 8% 7%
52% 36% 27% 17% 12% 8.5%
Head Chest Abdomen Neck Average ISS Total deaths
MVC ⫽ motor vehicle crash.
Air Bag 7 (6%) 12 (10%) 2 (1.7%) 7 (6%) 10.85 4 (3.4%)
Without Air Bag
P Value
76 (12%) 87 (14%) 36 (5.6%) 45 (7%) 14.5 52 (8%)
0.053 0.291 0.069 0.643 0.006 0.067
ISS ⫽ Injury Severity Score.
2357
Ophthalmology Volume 109, Number 12, December 2002 rapidly vented away from the occupant as the air bag deflates. The extremities might suffer burns as a result of this venting because they are thrown forward during the crash, whereas the torso and face are kept back by the air bag. The cushioning effect on the torso results in lower rates of serious injuries and death in patients with air bag inflation. A limitation of this study is that the findings are based on a review of the Trauma Registry database. Detailed data regarding the MVCs, such as the height and weight of the patients, long-term follow-up of visual acuity, details regarding the type and speed of the vehicle, and details regarding the mechanism of injury, are lacking. As noted by Kuhn et al,23 however, unless a field investigation evaluating the crash is performed, it is impossible to determine what object in the car caused the injury. In some cases, the air bag was clearly the cause of the ocular injury. In other cases, however, the ocular injury might have been caused by some other projectile in the car. Because other projectiles might have contributed to ocular injury, the air bag alone as a cause of eye trauma might be overrepresented in this article. The Trauma Registry that we reviewed included only patients with injuries severe enough to require hospitalization. We assume that less severe accidents would be less likely to result in ocular injury. Mohamed and Banerjee,24 however, reported that certain minor ocular injuries, such as hyphema and corneal abrasion, might be more prevalent in slower-speed accidents in which the air bag is deployed, and they suggest that these injuries would not have occurred had the air bag not deployed.24 Similarly, Stein et al3 reported a higher rate of severe ocular injury, such as ruptured globes, occurring with air bag deployment in crashes in which the automobile was going at a slower speed (30 mph or slower). These slowerspeed, less severe MVCs might allow for the face and eyes to start coming forward before the air bag inflates, thereby resulting in greater impact to these structures. This study would not identify eye injuries occurring with less severe MVCs. Automobile manufacturers are developing smarter air bags, which would inflate at different speeds according to the severity of the MVC as well as the physical characteristics of the occupants in the driver and passenger seats. These changes should decrease the morbidity associated with air bags, especially when the MVC is not as severe and otherwise less likely to result in bodily injury. Even the use of the current air bags, however, reduces the incidence of both bodily and ocular injury.
References 1. Airbag Statistics. Insurance Institute for Highway Safety, Arlington, VA: Highway Loss Data Institute [rev. April 19,
2358
2. 3. 4.
5. 6. 7. 8. 9. 10. 11.
12.
13.
14. 15. 16.
17.
18.
19.
20. 21. 22.
23. 24.
2002. Available at: http://www.highwaysafety.org/safety_ facts/airbags/stats.htm. Accessed November 18, 2000. Kuhn F, Morris R, Witherspoon CD. Eye injury and the air bag. Curr Opin Ophthalmol 1995;6:38 – 44. Stein JD, Jaeger EA, Jeffers JB. Air bags and ocular injuries. Trans Am Ophthalmol Soc 1999;97:59 – 82; discussion 82– 6. Air Bag Fatal and Serious Injury Summary Report. Washington, DC: National Center for Statistics and Analysis [rev. Oct. 2001. Available at: http://www.nhtsa.dot.gov/people/ncsa/ scireps.html. Accessed November 18, 2000. Duma SM, Kress TA, Porta DJ, et al. Airbag-induced eye injuries: a report of 25 cases. J Trauma 1996;41:114 –9. Larkin GL. Airbag-mediated corneal injury. Am J Emerg Med 1991;9:444 – 6. Mishler KE. Hyphema caused by air bag [letter]. Arch Ophthalmol 1991;109:1635. Rimmer S, Shuler JD. Severe ocular trauma from a driver’sside air bag [letter]. Arch Ophthalmol 1991;109:774. Han DP. Retinal detachment caused by air bag injury [letter]. Arch Ophthalmol 1993;111:1317– 8. Whitacre MM, Pilchard WA. Air bag producing retinal dialysis and detachment [letter]. Arch Ophthalmol 1993;111:1320. Lesher MP, Durrie DS, Stiles MC. Corneal edema, hyphema, and angle recession after air bag inflation [letter]. Arch Ophthalmol 1993;111:1320 –2. Scott IU, John GR, Stark WJ. Air bag-associated ocular injury and periorbital fractures [letter]. Arch Ophthalmol 1993;111: 25. Ghafouri A, Burgess SK, Hrdlicka ZK, Zagelbaum BM. Air bag-related ocular trauma. Am J Emerg Med 1997;15:389 – 92. Manche EE, Goldberg RA, Mondino BJ. Air bag-related ocular injuries. Ophthalmic Surg Lasers 1997;28:246 –50. Braude LS. Passenger side airbag ocular injury while wearing sunglasses [letter]. Br J Ophthalmol 1995;79:391. Scott IU, Greenfield DS, Parrish RK 2nd. Airbag-associated injury producing cyclodialysis cleft and ocular hypotony. Ophthalmic Surg Lasers 1996;27:955–7. Baker RS, Flowers CW Jr, Singh P, et al. Corneoscleral laceration caused by air-bag trauma. Am J Ophthalmol 1996; 121:709 –11. Vichnin MC, Jaeger EA, Gault JA, Jeffers JB. Ocular injuries related to air bag inflation. Ophthalmic Surg Lasers 1995;26: 542– 8. White JE, McClafferty K, Orton RB, et al. Ocular alkali burn associated with automobile air-bag activation. CMAJ 1995; 153:933– 4. Lueder GT. Air bag-associated ocular trauma in children. Ophthalmology 2000;107:1472–5. Young GS. Ocular injuries and motor vehicles. Int Ophthalmol Clin 1988;28:219 –21. Huelke DF, Gilbert R, Schneider LW. Upper Extremity Injuries from Steering Wheel Air Bag Deployment. Detroit, MI: Society of Automotive Engineers, 1997. Paper No. 970493. Kuhn F, Morris R, Witherspoon CD, et al. Air bag: friend or foe. Arch Ophthalmol 1993;111:1333– 4. Mohamed AA, Banerjee A. Patterns of injury associated with automobile air bag usage. Postgrad Med J 1998;74:455– 8.