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Ocular burns and related injuries due to fireworks during the Aidil Fitri celebration on the East Coast of the Peninsular Malaysia
burns 37 (2011) 170–173
available at www.sciencedirect.com
journal homepage: www.elsevier.com/locate/burns
Ocular burns and related injuries due to fireworks during the Aidil Fitri celebration on the East Coast of the Peninsular Malaysia Rasdi Abd Rashid a, Fatemeh Heidary a, Adil Hussein a, Wan Hazabbah Wan Hitam a, Rohana Abd Rashid b, Zulkifli Abd Ghani b, Nor Anita Che Omar c, Zuraidah Mustari c, Ismail Shatriah a,* a
Department of Ophthalmology, School of Medical Sciences, Universiti Sains Malaysia, 16150 Kubang Kerian, Kelantan, Malaysia Department of Ophthalmology, Hospital Raja Perempuan Zainab II, Kelantan, Malaysia c Department of Ophthalmology, Hospital Sultanah Nur Zahirah, Terengganu, Malaysia b
article info
abstract
Article history:
This study aims to describe the epidemiology of ocular burns and related injuries due to
Accepted 25 May 2010
fireworks during the Aidil Fitri celebration on the East Coast of the Peninsular Malaysia. A prospective analysis of all patients with ocular burns and related injuries due to fireworks
Keywords:
attended three tertiary hospitals in East Coast of Peninsular Malaysia during Aidil Fitri,
Ocular burns
which was from 10 September to 17 October 2008. We observed the demographic and injury
Firecrakers injuries
characteristics, extent of the injuries and presenting visual symptoms. Thirty patients with
Aidil Fitri
34 eyes with ocular burns and related injuries were identified. Patients ranged between 2 and
East Coast of Peninsular Malaysia
43 years of age. 70.00% of the patients were 12 years old and below. Of the 30 patients, 29 (96.67%) were male and the left eye was affected in 14 (46.70%). Thermal injuries accounted for 60.0% of the injuries whereas 40.0% were due to exploding firework. Burns to the eyelid and cornea (35.29%) were the most common injuries noted. Fifteen patients (50%) were bystanders whilst a majority of patients (96.67%) had no eye protection. At presentation, 15 (44.12%) eyes had a visual acuity of 6/6 to 6/9 in the injured eyes, while 3 out of 34 eyes (8.82%) had vision acuity 6/60 or worse. In conclusion, fireworks cause serious preventable ocular burns and related injuries especially in children who are the most affected age group. It affects mainly eyelid and anterior segment structures which result in moderate visual loss on presentation. Health education, public awareness and tighter legislation are essential preventive measures to limit the effect of fireworks to the public. # 2010 Elsevier Ltd and ISBI. All rights reserved.
1.
Introduction
Ocular injuries from fireworks can cause devastating visual and disfiguring effects [1]. The time of year when ocular injuries caused by fireworks occur depends on the traditions in different societies such as New Year’s Eve, Chinese New Year in China, Diwali in India, Aidil Fitri in Muslim countries, the * Corresponding author. Tel.: +6019 9834578. E-mail address: [email protected] (I. Shatriah). 0305-4179/$36.00 # 2010 Elsevier Ltd and ISBI. All rights reserved. doi:10.1016/j.burns.2010.05.019
Fourth of July in the United States, and Last Wednesday of the Persian Year in Iran [2–7]. Malaysia is a multiracial country and almost all of the festivals are celebrated by its people. These include New Year’s Eve, Independence Day, Aidil Fitri, Chinese New Year and Diwali celebrations. Firecrackers are burnt all over the country predominantly during Aidil Fitri and Chinese New
171
burns 37 (2011) 170–173
Year celebrations. Though selling of fireworks in Malaysia was banned many years ago, a minority of the public are still flouting the law and using them illegally. This study prospectively collected all ocular burns and related injuries due to fireworks during Aidil Fitri celebration in East Coast of Peninsular Malaysia. We studied firecrackers related ocular injury with emphasis on patient demographics, injury characteristics, the extent of the injuries and presenting visual acuity.
2.
Patients and methods
We conducted a prospective study of all patients presenting with ocular burns and related injuries due to fireworks during the Aidil Fitri celebration period from 10th September to 17th October 2008. All patients were treated in either one of three tertiary hospitals in East Coast of Peninsular Malaysia, which included Hospital Universiti Sains Malaysia (Kelantan), Hospital Raja Perempuan Zainab II (Kelantan) and Hospital Sultanah Nur Zahirah (Terengganu). The study protocol was approved by the Research and Ethical Committee, School of Medical Sciences, Universiti Sains Malaysia, and written consents were obtained from all the patients. The states along the East Coast of Peninsular Malaysia include Kelantan, Terengganu and Pahang. However, we did not include tertiary hospital in Pahang state in this study. Kelantan and Terengganu have a total estimated population of 3,250,300 people in 2007. Both Kelantan and Terengganu cover an area of about 27,877 km2. About 90% of the population are Malay and the rest being Chinese, Indian and the indigenous Orang Asli. All patients with fireworks ocular injuries during the study period were included in this study. Detailed ocular examination was performed by identified ophthalmologist in the respective centers. This included presenting visual acuity, anterior segment examination by slitlamp biomicroscopy, intraocular pressure measurement by applanation tonometer, gonioscopy, and direct as well indirect ophthalmoscopy were performed in all patients. B-scan ultrasound was performed to assess the status of the posterior segment, particularly in vitreous hemorrhage, retinal detachment and suspicion of intraocular foreign body in eyes with hazy media. Orbital X-ray was performed to rule out retained intraocular foreign body. Detailed questionnaires recorded the demographic information, nature and circumstances of each eye injury resulting from firecrackers during the study period. The completed questionnaires included age, gender, mechanism and nature of injury, laterality, visual acuity and detailed anterior and posterior segment eye examination were sent back to the authors. We had the cooperation from practising ophthalmologists working at the Eye Clinic in the above three tertiary hospitals along the East Coast of Peninsular Malaysia to participate in this study. Patients’ age ranged between 2 and 43 years old. Patients between 2 and 12 years of age were included in the children group. Patients were separated into active users and bystanders. Quantity, type and severity of eye injuries were recorded. Statistical analysis was done with Statistical Package for Social Sciences version 12.0., and presented in both text and table form.
3.
Results
In total, 30 patients with 34 injured eyes were seen with fireworks related eye injuries during the Aidil Fitri celebration festival from 10th September to 17th October 2008. The age range was between 2 and 43 years old. 21 (70.0%) patients were between 2 and 12 years age. Demographic data and injury characteristics are shown in Table 1. From 30 patients, 14 (46.67%) of the injured individuals were those lighting up the firecrackers, 15 (50.00%) were bystanders and 1 (3.33%) where the details were not recorded. We classified the injured structures into single and multiple structures involvement. These are summarized in Table 2. Table 3 illustrates the visual acuity in the injured eyes on the presentation and at 6 weeks after the injury. Three patients were of 5 years of age and below which makes visual acuity testing difficult. Therefore, their visual acuity status is mentioned as unknown in the questionnaire.
4.
Discussion
Aidil Fitri celebrations are related with devastating ocular firecrackers injuries in Malaysia [8]. Our study focuses on Kelantan and Terengganu states, in which the majority of people are Muslims and celebrate Aidil Fitri after a month of fasting each year. The burning of firecrackers to celebrate this
Table 1 – Demographic and injury characteristics. Variable
Number of cases n = 30 (%)
Sex
Male Female
29 (96.67%) 1 (3.33%)
Age (years)
1–10 11–20 21–30 31–40 41–50
19 7 1 1 2
Mechanism of injury
Thermal Exploded
18 (60.00%) 12 (40.00%)
Place of occurrence
Home Recreation and sport Public building Others Unknown
23 3 2 1 1
Type of firecracker
Commercial Combination Home made
29 (96.67%) 1 (3.33%) 0 (0.00%)
Bystander
Yes No Unknown
15 (50.00%) 14 (46.67%) 1 (3.33%)
Eye protection
Yes No Unknown
0 (0.00%) 29 (96.67%) 1 (3.33%)
Laterality
Right eye Left eye Both eyes
12 (40.00%) 14 (46.70%) 4 (13.30%)
(63.33%) (23.33%) (3.33%) (3.33%) (6.68%)
(76.66%) (10.00%) (6.68%) (3.33%) (3.33%)
172
burns 37 (2011) 170–173
Table 2 – Type of ocular injury. Variable
Number of eyes n = 34 (%)
Single structure involvement
Cornea Lid Anterior chamber
9 (26.47%) 2 (5.88%) 1 (2.94%)
Mixed structures involvement
Lid and cornea Cornea and sclera Cornea and anterior chamber Lid and anterior chamber Lid, cornea and anterior chamber Cornea, iris and anterior chamber Lid, cornea, anterior chamber, lens, vitreous, retina, macula and optic nerve
festival is a common phenomenon in both rural and urban areas in Malaysia. Our prospective data analysis showed ocular firecrackers injury occurred predominantly in young male children. 21 (70.00%) of the patients were below 12 years of age, while three of them were below 5 years old. Our finding is consistent with those reported in other countries [2–6,9–12]. The majority (76.67%) of the injuries in our study occurred at home. One eye (3.33%) was injured due to an explosion from a modified commercially available firework. The patient’s eye was injured due to a sudden explosion while he was attempting to lighten a plastic bottle contained an explosive material. The explosive material was derived from a commercially available firecracker. The bystanders accounted for half of the injuries in our study, and this is comparable to other studies that showed a similar pattern [5,6,9]. In contrast, almost half of the injuries occurred among the active users due to sudden explosion of the firecrackers. We observed majority had unilateral eye involvement (86.70%), while the left eye was affected more than the right. Our finding contradicts the existing data that the right eye was the commoner [5,6]. Our study showed that almost two-third (64.71%) of the injured eyes had more than a single structure involvement, while burns to the eyelid and cornea was the most common. Mixed injury of the anterior and posterior segment structures occurred in one eye (2.94%) only. Single structure involvement was seen in 12 (35.29%) of the injured eyes, and this included primarily the eyelid, cornea and the anterior chamber. In our study, 15 (44.12%) of the eyes had visual acuity of 6/9 and better, while 13 (38.24%) had visual acuity worse than 6/9
12 1 3 1 3 1 1
(35.29%) (2.94%) (8.82%) (2.94%) (8.82%) (2.94%) (2.94%)
but better than 6/60. Our result is parallel with Arya et al., as they reported that 69% of their patients had satisfactory visual acuity on presentation [3]. However, there were 3 (8.82%) eyes had visual acuity 6/60 and worse. The remaining 3 (8.82%) eyes were unable to have their visual acuity tested as they were uncooperative during the procedure. In contrast to our finding, Chan et al. reported that 81.8% of their patients had vision of 6/60 or worse [4]. We believe that the severity of ocular injuries is closely related to the type of available firecrackers. At 6 weeks after injury, we observed an improvement of visual acuity 6/12 to 6/60 level to 6/6 to 6/9 level in 6 (20.0%) eyes. Visual acuity of 6/9 and better had been recorded in 11 (68.7%) right and 10 (55.55%) left eyes, respectively. However, the final visual acuity worse than 6/60 remained similar, that were 1 (6.25%) right eye and 2 (11.12%) left eyes. In 1984, the World Health Organisation published strategies for the prevention of blindness and called out for a worldwide ban on manufacturing fireworks with the aim to reduce visual loss [13]. Countries with laws for firework control have shown 50 times fewer injuries than those without the laws [9]. Our study suggests the level of awareness regarding the importance in prevention of blindness due to firecrackers is relatively low in our community. This has been reflected that almost all of injured patients had no eye protection. There are other studies highlighted the similar problem that warrant a serious implementation of the law to prevent devastating eye and adnexal injuries [3,4,9]. In conclusion, our study supports the existing reports of ocular firecrackers injuries during festival season worldwide. Burns to the eyelid and cornea are the common injury, and
Table 3 – Visual acuity of the affected eye(s) at presentation and 6 weeks after trauma. Variable
VA on presentation
VA 6 weeks post-trauma
OD n = 16 (%)
OS n = 18 (%)
OD n = 16 (%)
6/6 to 6/9 6/12 to 6/60
8 (50.00%) 6 (37.50%)
7 (38.89%) 7 (38.89%)
11 (68.75%) 3 (18.75%)
Worse than 6/60 Counting fingers Hand movement Perception of light No perception of light Not tested
0 1 0 0 1
0 0 2 0 2
(0.00%) (6.25%) (0.00%) (0.00%) (6.25%)
(0.00%) (0.00%) (11.11%) (0.00%) (11.11%)
1 0 0 0 1
(6.25%) (0.00%) (0.00%) (0.00%) (6.25%)
OS n = 18 (%) 10 (55.55%) 4 (22.22%)
1 0 1 0 2
(5.56%) (0.00%) (5.56%) (0.00%) (11.11%)
burns 37 (2011) 170–173
majority had moderate visual disturbance on presentation. Most of the ocular firecrackers injuries during Aidil Fitri celebration in our country which affect mainly the young boys are essentially preventable. An active and continuous national restriction of firecrackers should be emphasized and implemented to reduce the ocular morbidity in the country.
Conflict of interest statement The authors report no conflicts of interest.
Acknowledgements This study was supported by an Incentive Grant of Universiti Sains Malaysia. The authors thank all the ophthalmologists and staffs in the involved centres for their useful contributions to this study. This paper had been presented as oral presentation at the 25th Malaysia-Singapore Joint Ophthalmic Meeting in Kuala Lumpur, Malaysia on 25th November 2009.
references
[1] Knox FA, Chan WC, Jackson AJ, Foot B, Sharkey JA, McGinnity FG. A British Ophthalmological Surveilance Unit study on serious ocular injuries from fireworks in the UK. Eye 2008;22:944–7.
173
[2] Sundelin K, Norrsell K. Eye injuries from fireworks in Western Sweden. Acta Ophthalmol Scand 2000;78:61–4. [3] Arya SK, Malhotra S, Dhir SP, Sood S. Ocular fireworks injuries. Clinical features and visual outcomes. Ind J Ophthalmol 2001;49:189–90. [4] Chan WC, Knox FA, McGinnity G, Sharkey JA. Serious eye and adnexal injuries from fireworks in Northern Ireland— an Ophthalmology unit’s experience. Int Ophthalmol 2004;25:167–9. [5] Sacu S, Segur-Eltz N, Stenng K, Zehetmayer M. Ocular fireworks injuries at New Year’s Eve. Ophthalmologica 2002;216:55–9. [6] Lee RT. Fire-cracker injury to the eyes in Hong Kong. Br J Ophthalmol 1966;50:666–9. [7] Saadat S, Naseripour M, Rahimi B. Safety preparedness of urban community for New Year fireworks in Tehran. J Burns 2009;35(5):719–22. [8] Rohana AR, Azlyn AJ, Ibrahim M, Shatriah I, Wan-Hazabbah WH. Case series and variants of ocular injury secondary to firecrackers. Int J Ophthalmol 2008;8(3):467–9. [9] Vernon SA. Fireworks and the eye. J R Soc Med 1988;81: 569–71. [10] Kuhn FC, Morris RC, Witherspoon DC, Mann L, Mester V, Modis L, et al. Serious fireworks-related eye injuries. Ophthalmic Epidemiol 2000;7(2):85–6. [11] Singh DV, Sharma YR, Azad RV. Visual outcome after fireworks injuries. J Trauma Inj Infect Crit Care 2005;59:09– 111. [12] Wisse RPL, Bijlsma WR, Stilma JS. Br J Ophthalmol 2009. published online October 20, 2009 doi:10.1136/bjo.2009. 168419.. [13] World Health Organization. Strategies for the prevention of blindness in National Programs. Geneva: WHO; 1984. pp. 73–79.
available at www.sciencedirect.com
journal homepage: www.elsevier.com/locate/burns
Ocular burns and related injuries due to fireworks during the Aidil Fitri celebration on the East Coast of the Peninsular Malaysia Rasdi Abd Rashid a, Fatemeh Heidary a, Adil Hussein a, Wan Hazabbah Wan Hitam a, Rohana Abd Rashid b, Zulkifli Abd Ghani b, Nor Anita Che Omar c, Zuraidah Mustari c, Ismail Shatriah a,* a
Department of Ophthalmology, School of Medical Sciences, Universiti Sains Malaysia, 16150 Kubang Kerian, Kelantan, Malaysia Department of Ophthalmology, Hospital Raja Perempuan Zainab II, Kelantan, Malaysia c Department of Ophthalmology, Hospital Sultanah Nur Zahirah, Terengganu, Malaysia b
article info
abstract
Article history:
This study aims to describe the epidemiology of ocular burns and related injuries due to
Accepted 25 May 2010
fireworks during the Aidil Fitri celebration on the East Coast of the Peninsular Malaysia. A prospective analysis of all patients with ocular burns and related injuries due to fireworks
Keywords:
attended three tertiary hospitals in East Coast of Peninsular Malaysia during Aidil Fitri,
Ocular burns
which was from 10 September to 17 October 2008. We observed the demographic and injury
Firecrakers injuries
characteristics, extent of the injuries and presenting visual symptoms. Thirty patients with
Aidil Fitri
34 eyes with ocular burns and related injuries were identified. Patients ranged between 2 and
East Coast of Peninsular Malaysia
43 years of age. 70.00% of the patients were 12 years old and below. Of the 30 patients, 29 (96.67%) were male and the left eye was affected in 14 (46.70%). Thermal injuries accounted for 60.0% of the injuries whereas 40.0% were due to exploding firework. Burns to the eyelid and cornea (35.29%) were the most common injuries noted. Fifteen patients (50%) were bystanders whilst a majority of patients (96.67%) had no eye protection. At presentation, 15 (44.12%) eyes had a visual acuity of 6/6 to 6/9 in the injured eyes, while 3 out of 34 eyes (8.82%) had vision acuity 6/60 or worse. In conclusion, fireworks cause serious preventable ocular burns and related injuries especially in children who are the most affected age group. It affects mainly eyelid and anterior segment structures which result in moderate visual loss on presentation. Health education, public awareness and tighter legislation are essential preventive measures to limit the effect of fireworks to the public. # 2010 Elsevier Ltd and ISBI. All rights reserved.
1.
Introduction
Ocular injuries from fireworks can cause devastating visual and disfiguring effects [1]. The time of year when ocular injuries caused by fireworks occur depends on the traditions in different societies such as New Year’s Eve, Chinese New Year in China, Diwali in India, Aidil Fitri in Muslim countries, the * Corresponding author. Tel.: +6019 9834578. E-mail address: [email protected] (I. Shatriah). 0305-4179/$36.00 # 2010 Elsevier Ltd and ISBI. All rights reserved. doi:10.1016/j.burns.2010.05.019
Fourth of July in the United States, and Last Wednesday of the Persian Year in Iran [2–7]. Malaysia is a multiracial country and almost all of the festivals are celebrated by its people. These include New Year’s Eve, Independence Day, Aidil Fitri, Chinese New Year and Diwali celebrations. Firecrackers are burnt all over the country predominantly during Aidil Fitri and Chinese New
171
burns 37 (2011) 170–173
Year celebrations. Though selling of fireworks in Malaysia was banned many years ago, a minority of the public are still flouting the law and using them illegally. This study prospectively collected all ocular burns and related injuries due to fireworks during Aidil Fitri celebration in East Coast of Peninsular Malaysia. We studied firecrackers related ocular injury with emphasis on patient demographics, injury characteristics, the extent of the injuries and presenting visual acuity.
2.
Patients and methods
We conducted a prospective study of all patients presenting with ocular burns and related injuries due to fireworks during the Aidil Fitri celebration period from 10th September to 17th October 2008. All patients were treated in either one of three tertiary hospitals in East Coast of Peninsular Malaysia, which included Hospital Universiti Sains Malaysia (Kelantan), Hospital Raja Perempuan Zainab II (Kelantan) and Hospital Sultanah Nur Zahirah (Terengganu). The study protocol was approved by the Research and Ethical Committee, School of Medical Sciences, Universiti Sains Malaysia, and written consents were obtained from all the patients. The states along the East Coast of Peninsular Malaysia include Kelantan, Terengganu and Pahang. However, we did not include tertiary hospital in Pahang state in this study. Kelantan and Terengganu have a total estimated population of 3,250,300 people in 2007. Both Kelantan and Terengganu cover an area of about 27,877 km2. About 90% of the population are Malay and the rest being Chinese, Indian and the indigenous Orang Asli. All patients with fireworks ocular injuries during the study period were included in this study. Detailed ocular examination was performed by identified ophthalmologist in the respective centers. This included presenting visual acuity, anterior segment examination by slitlamp biomicroscopy, intraocular pressure measurement by applanation tonometer, gonioscopy, and direct as well indirect ophthalmoscopy were performed in all patients. B-scan ultrasound was performed to assess the status of the posterior segment, particularly in vitreous hemorrhage, retinal detachment and suspicion of intraocular foreign body in eyes with hazy media. Orbital X-ray was performed to rule out retained intraocular foreign body. Detailed questionnaires recorded the demographic information, nature and circumstances of each eye injury resulting from firecrackers during the study period. The completed questionnaires included age, gender, mechanism and nature of injury, laterality, visual acuity and detailed anterior and posterior segment eye examination were sent back to the authors. We had the cooperation from practising ophthalmologists working at the Eye Clinic in the above three tertiary hospitals along the East Coast of Peninsular Malaysia to participate in this study. Patients’ age ranged between 2 and 43 years old. Patients between 2 and 12 years of age were included in the children group. Patients were separated into active users and bystanders. Quantity, type and severity of eye injuries were recorded. Statistical analysis was done with Statistical Package for Social Sciences version 12.0., and presented in both text and table form.
3.
Results
In total, 30 patients with 34 injured eyes were seen with fireworks related eye injuries during the Aidil Fitri celebration festival from 10th September to 17th October 2008. The age range was between 2 and 43 years old. 21 (70.0%) patients were between 2 and 12 years age. Demographic data and injury characteristics are shown in Table 1. From 30 patients, 14 (46.67%) of the injured individuals were those lighting up the firecrackers, 15 (50.00%) were bystanders and 1 (3.33%) where the details were not recorded. We classified the injured structures into single and multiple structures involvement. These are summarized in Table 2. Table 3 illustrates the visual acuity in the injured eyes on the presentation and at 6 weeks after the injury. Three patients were of 5 years of age and below which makes visual acuity testing difficult. Therefore, their visual acuity status is mentioned as unknown in the questionnaire.
4.
Discussion
Aidil Fitri celebrations are related with devastating ocular firecrackers injuries in Malaysia [8]. Our study focuses on Kelantan and Terengganu states, in which the majority of people are Muslims and celebrate Aidil Fitri after a month of fasting each year. The burning of firecrackers to celebrate this
Table 1 – Demographic and injury characteristics. Variable
Number of cases n = 30 (%)
Sex
Male Female
29 (96.67%) 1 (3.33%)
Age (years)
1–10 11–20 21–30 31–40 41–50
19 7 1 1 2
Mechanism of injury
Thermal Exploded
18 (60.00%) 12 (40.00%)
Place of occurrence
Home Recreation and sport Public building Others Unknown
23 3 2 1 1
Type of firecracker
Commercial Combination Home made
29 (96.67%) 1 (3.33%) 0 (0.00%)
Bystander
Yes No Unknown
15 (50.00%) 14 (46.67%) 1 (3.33%)
Eye protection
Yes No Unknown
0 (0.00%) 29 (96.67%) 1 (3.33%)
Laterality
Right eye Left eye Both eyes
12 (40.00%) 14 (46.70%) 4 (13.30%)
(63.33%) (23.33%) (3.33%) (3.33%) (6.68%)
(76.66%) (10.00%) (6.68%) (3.33%) (3.33%)
172
burns 37 (2011) 170–173
Table 2 – Type of ocular injury. Variable
Number of eyes n = 34 (%)
Single structure involvement
Cornea Lid Anterior chamber
9 (26.47%) 2 (5.88%) 1 (2.94%)
Mixed structures involvement
Lid and cornea Cornea and sclera Cornea and anterior chamber Lid and anterior chamber Lid, cornea and anterior chamber Cornea, iris and anterior chamber Lid, cornea, anterior chamber, lens, vitreous, retina, macula and optic nerve
festival is a common phenomenon in both rural and urban areas in Malaysia. Our prospective data analysis showed ocular firecrackers injury occurred predominantly in young male children. 21 (70.00%) of the patients were below 12 years of age, while three of them were below 5 years old. Our finding is consistent with those reported in other countries [2–6,9–12]. The majority (76.67%) of the injuries in our study occurred at home. One eye (3.33%) was injured due to an explosion from a modified commercially available firework. The patient’s eye was injured due to a sudden explosion while he was attempting to lighten a plastic bottle contained an explosive material. The explosive material was derived from a commercially available firecracker. The bystanders accounted for half of the injuries in our study, and this is comparable to other studies that showed a similar pattern [5,6,9]. In contrast, almost half of the injuries occurred among the active users due to sudden explosion of the firecrackers. We observed majority had unilateral eye involvement (86.70%), while the left eye was affected more than the right. Our finding contradicts the existing data that the right eye was the commoner [5,6]. Our study showed that almost two-third (64.71%) of the injured eyes had more than a single structure involvement, while burns to the eyelid and cornea was the most common. Mixed injury of the anterior and posterior segment structures occurred in one eye (2.94%) only. Single structure involvement was seen in 12 (35.29%) of the injured eyes, and this included primarily the eyelid, cornea and the anterior chamber. In our study, 15 (44.12%) of the eyes had visual acuity of 6/9 and better, while 13 (38.24%) had visual acuity worse than 6/9
12 1 3 1 3 1 1
(35.29%) (2.94%) (8.82%) (2.94%) (8.82%) (2.94%) (2.94%)
but better than 6/60. Our result is parallel with Arya et al., as they reported that 69% of their patients had satisfactory visual acuity on presentation [3]. However, there were 3 (8.82%) eyes had visual acuity 6/60 and worse. The remaining 3 (8.82%) eyes were unable to have their visual acuity tested as they were uncooperative during the procedure. In contrast to our finding, Chan et al. reported that 81.8% of their patients had vision of 6/60 or worse [4]. We believe that the severity of ocular injuries is closely related to the type of available firecrackers. At 6 weeks after injury, we observed an improvement of visual acuity 6/12 to 6/60 level to 6/6 to 6/9 level in 6 (20.0%) eyes. Visual acuity of 6/9 and better had been recorded in 11 (68.7%) right and 10 (55.55%) left eyes, respectively. However, the final visual acuity worse than 6/60 remained similar, that were 1 (6.25%) right eye and 2 (11.12%) left eyes. In 1984, the World Health Organisation published strategies for the prevention of blindness and called out for a worldwide ban on manufacturing fireworks with the aim to reduce visual loss [13]. Countries with laws for firework control have shown 50 times fewer injuries than those without the laws [9]. Our study suggests the level of awareness regarding the importance in prevention of blindness due to firecrackers is relatively low in our community. This has been reflected that almost all of injured patients had no eye protection. There are other studies highlighted the similar problem that warrant a serious implementation of the law to prevent devastating eye and adnexal injuries [3,4,9]. In conclusion, our study supports the existing reports of ocular firecrackers injuries during festival season worldwide. Burns to the eyelid and cornea are the common injury, and
Table 3 – Visual acuity of the affected eye(s) at presentation and 6 weeks after trauma. Variable
VA on presentation
VA 6 weeks post-trauma
OD n = 16 (%)
OS n = 18 (%)
OD n = 16 (%)
6/6 to 6/9 6/12 to 6/60
8 (50.00%) 6 (37.50%)
7 (38.89%) 7 (38.89%)
11 (68.75%) 3 (18.75%)
Worse than 6/60 Counting fingers Hand movement Perception of light No perception of light Not tested
0 1 0 0 1
0 0 2 0 2
(0.00%) (6.25%) (0.00%) (0.00%) (6.25%)
(0.00%) (0.00%) (11.11%) (0.00%) (11.11%)
1 0 0 0 1
(6.25%) (0.00%) (0.00%) (0.00%) (6.25%)
OS n = 18 (%) 10 (55.55%) 4 (22.22%)
1 0 1 0 2
(5.56%) (0.00%) (5.56%) (0.00%) (11.11%)
burns 37 (2011) 170–173
majority had moderate visual disturbance on presentation. Most of the ocular firecrackers injuries during Aidil Fitri celebration in our country which affect mainly the young boys are essentially preventable. An active and continuous national restriction of firecrackers should be emphasized and implemented to reduce the ocular morbidity in the country.
Conflict of interest statement The authors report no conflicts of interest.
Acknowledgements This study was supported by an Incentive Grant of Universiti Sains Malaysia. The authors thank all the ophthalmologists and staffs in the involved centres for their useful contributions to this study. This paper had been presented as oral presentation at the 25th Malaysia-Singapore Joint Ophthalmic Meeting in Kuala Lumpur, Malaysia on 25th November 2009.
references
[1] Knox FA, Chan WC, Jackson AJ, Foot B, Sharkey JA, McGinnity FG. A British Ophthalmological Surveilance Unit study on serious ocular injuries from fireworks in the UK. Eye 2008;22:944–7.
173
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