Pediatric eye injuries due to nonpowder guns in the United States, 2002-2012 Rachel Lee, BS, and Douglas Fredrick, MD, FAAP, FACS PURPOSE METHODS
RESULTS
CONCLUSIONS
To identify epidemiologic trends in nonpowder gun-related pediatric eye injuries and to determine factors associated with severe injury requiring hospital admission. US emergency department data on pediatric eye injuries between 2002 and 2012 were reviewed using the National Electronic Injury Surveillance System. Literature review was conducted to determine trends in visual outcomes after treatment and use of eye protection. In 2012 roughly 3,161 children were treated in US emergency departments for nonpowder gun-related eye injuries. Since 2010 rates of severe nonpowder gun pediatric eye injury have increased by over 500% (P 5 0.039). Specifically, while rates of hospital admission due to paintball gun eye injury have dropped precipitously (P 5 0.0077), rates of admissions for air gun eye injuries have increased by over 600% since 2010 (P 5 0.033). Children sustaining eye injury due to air guns are more likely to be diagnosed and admitted with foreign body or ocular puncture injury. Roughly 28% of documented cases of airsoft or BB gun–related injury had visual acuity worse than 20/50 after initial treatment. Over 98% of injuries occurred without eye protection. Air guns are rising in popularity and now account for the majority of pediatric eye injuries requiring hospital admissions. These eye injuries occur without ocular protection and may lead to permanent eye injury. Increasing regulations for eye protection, sales, and usage of air guns are needed to prevent serious pediatric eye injuries. ( J AAPOS 2015;19: 163-168)
P
opular nonpowder firearms include paintball guns, airsoft guns, BB guns, and pellet guns. Paintball guns fire 17 mm diameter gelatin capsules filled with nontoxic paint, designed to “mark” targets.1 By contrast, airsoft guns are 1:1 scale replicas of powder guns that release lightweight, 6 mm plastic bullets.2 BB guns discharge 4.5 mm round lead or steel bullets, and pellet guns fire 4.5 mm metal, nonspherical pellets with thin waists and distinctive tips.3 These differences in pellet design, combined with different power sources—spring, CO2, and air pump—afford varying velocities and flight ranges. For instance, while paintballs reach up to 90 m/s, BB gun pellets can reach maximum velocities of 380 m/s if powered by a spring.3,4 Previous literature indicates a steady rise in the number of pediatric ocular injuries due to nonpowder firearms.5-9 Multiple prior studies have documented severe repercussions of ocular trauma secondary to nonpowder
Author affiliations: Stanford University School of Medicine, Palo Alto, California Submitted July 17, 2014. Revision accepted January 26, 2015. Published online March 26, 2015. Correspondence: Rachel Lee, BS, Stanford Byers Eye Institute, Stanford University School of Medicine, 2452 Watson Court, Palo Alto, CA 94303 (email: [email protected]). Copyright Ó 2015 by the American Association for Pediatric Ophthalmology and Strabismus. 1091-8531/$36.00 http://dx.doi.org/10.1016/j.jaapos.2015.01.010
Journal of AAPOS
gun injury. Commonly reported injuries include hyphema, lens dislocation, and corneal abrasion; more severe injuries include retinal detachment and global rupture.10-34 However, these studies largely examine time frames prior to 20015,7-9 or nonpowder gun injuries as a whole, without differentiating the various types of nonpowder guns.6 To our knowledge, this is the first study to closely examine trends and risk factors for paintball and airsoft pediatric ocular injuries using a nationally representative sample. Improved understanding of these trends may allow for a more targeted approach to identifying and preventing nonpowder gun injuries in pediatric patients.
Methods The US Consumer Product Safety Commission (CPSC) documents US emergency department visits for injuries secondary to a various consumer products through the National Electronic Injury Surveillance System (NEISS). The NEISS draws from a stratified probability sample of roughly 100 hospital emergency departments of varying sizes, selected to reflect the current distribution of hospitals in the US. All selected hospital emergency departments provided service 24 hours a day, with at least 6 hospital beds. Trained NEISS coordinators transcribe data regarding all consumer product–associated injuries, including date of treatment, patient demographic information (age, sex, and ethnicity), initial injury diagnosis, affected body part, disposition, involved
163
164
Lee and Fredrick
consumer products, and a short case narrative. Data are weighted to enable national estimates of consumer product–related injuries. All data obtained from the CPSC involved pediatric (2-18 years old) cases with documented ocular injuries due to nonpowder firearms (NEISS product codes 1237, 1936, 5016, 1200). Cases were further examined and separated based on the type of firearm implicated in the narrative. Nonpowder guns encompass a wide range of gun types, including pellet guns, BB guns, airsoft guns, and paintball guns, among others. Although there is a clear distinction between paintball guns and other nonpowder gun types, the differences between other nonpowder guns (BB gun vs pellet gun vs airsoft guns) may not be readily identified by the layperson. To account for inaccuracies in reporting, BB, pellet, and airsoft guns were grouped together for the purposes of analysis.
Statistical Analysis All data were analyzed using STATA 13 for Macintosh (College Station, TX). All data reported are national estimates based on the cases and their corresponding weighting factors, as reported by the CPSC. Population data provided by the US Census Bureau was used to calculate rates of pediatric ocular injuries. All 95% confidence intervals were calculated based on the CPSC estimates of coefficient of variance. P values for the trends in pediatric ocular injuries were calculated using linear regression for the data points within the indicated time frames. Differences in sample averages were calculated by t test, as indicated.
Volume 19 Number 2 / April 2015
FIG 1. Rates of pediatric eye injuries requiring hospital admission, 2002-2012. Hospital admission rates for children sustaining ocular injury due to recreational activities after initial evaluation in emergency departments were calculated. Each data point represents number of pediatric hospital admissions adjusted for changes in US population. Data obtained from US Census Bureau.
Literature Search Data were extracted from all English language published reports of ocular injuries related to airsoft guns and BB guns, including age, sex, eye protection status, treatments, and presenting and final best-corrected visual acuities.
Results In 2012 approximately 12,773 children 2-18 years of age were treated in US emergency departments for eye injuries due to nonpowder firearms, fireworks, and ball sports. Roughly 3,161 of these injuries (49.5 per 1 million children) were secondary to nonpowder gun use (95% CI, 27.3-62.5 per 1 million children). Trends in US emergency department visits for recreational activities between 2002 and 2012 are listed in Table A1 (Appendix). Nonpowder guns were a leading cause of pediatric eye injury requiring hospital admission following evaluation in US emergency departments, with roughly 10 children per million admitted between 2002 to 2006 (Figure 1). By contrast, less than 2 of every 1 million children were admitted annually for ocular injuries due to other recreational injuries during the same time frame. Between 2006 and 2010 the rate of pediatric US hospital admissions and observations for nonpowder gun eye injuries decreased by 722% (P 5 0.007 for linear trend). However, from 2010 to 2012 the rates of nonpowder gun eye injury admissions rebounded by 511% (2010: 1.5 per million; 2012: 7.9 per million; P 5 0.039 for linear trend).
FIG 2. Trends in ocular injury due to paintball versus air guns. Hospital admission rates of children sustaining nonpowder gun–related ocular injury were calculated. Nonpowder gun injuries were further divided into paintball gun versus air gun injuries. Each data point represents the number of US emergency department visits, adjusted for changes in US population US population. Data obtained from US Census Bureau.
Notably, average hospital admissions rates for paintball gun eye injuries after 2006 is roughly 10% of the average admissions rates prior to 2006 (2002-2006: 4.1 1.6 per million children; 2006–2012: 0.4 0.3 per million children; P 5 0.007; Figure 2). By contrast, air guns are now the major cause of pediatric nonpowder gun–related eye injury. Rates of hospital admissions for severe pediatric air gun–related ocular injuries fell from 2005 to 2010 (2005: 9.3 per million; 2010: 1.3 per 1 million; P 5 0.003 for linear trend) but have been followed by a drastic rise in hospital admissions since 2010 (2012: 8.4 per million; P 5 0.033 for linear trend). Nonpowder gun-related ocular injuries most commonly resulted in contusions and abrasions, and conjunctival hemorrhage and hyphemas (Table 1). Comparison of the paintball- and air gun–induced pediatric injuries
Journal of AAPOS
Volume 19 Number 2 / April 2015
Lee and Fredrick
Table 1. Types of nonpowder gun injuries and incidence frequencies between 2002—2012 All nonpowder gunsa 47.5 8.1 12.1 4.3 2.4 1.5
Contusion/abrasion Foreign body Hemorrhage Iritis Puncture Global rupture
165
Table 3. Final visual acuity after treatment in 169 total cases
Paintballa
Air gunsa
P valueb
40.4 2.5 16.8 3.7 0.7 3.4
46.7 11.5 12.9 4.1 2.6 1.0
0.252 0.017 0.456 0.829 0.046 0.287
BCVA after treatmenta 20/40 or better 20/50 to 20/150 20/200 or worse
Airsoft guns (n 5 144), no. (%)
BB guns (n 5 53), no. (%)
123 (85.4) 16 (11.1) 5 (3.5)
18 (34.0) 6 (11.3) 29 (54.7)
BCVA, best-corrected visual acuity. a Follow-up time after initial presentation ranged from 1 week to 21 months.
a
Average numbers of injury types between 2002-2012 listed for each gun type. b P values listed comparing paintball and air gun injuries; values calculated using 2-sample z test. Table 2. Parameters associated with hospital admission in 20022012 Parameter
OR (95% CI)a
Age 2-9 years Male White Paintball Admitting diagnoses Contusion/ abrasion Foreign body Hematoma Laceration Puncture Strain/sprain Hemorrhage Global rupture
0.837 (0.774-0.905) 1.079 (0.981-1.187) 0.838 (0.781-0.899) 1.542 (1.443-1.647) 0.117 (0.108-0.126) 5.419 (4.978-5.898) 0.984 (0.775-1.249) 4.119 (3.205-5.294) 5.541 (4.705-6.524) 0.310 (0.134-0.719) 9.90 (9.73-10.07) 53.427 (38.246-74.632)
OR, odds ratio. a OR for likelihood of hospital admission compared to treatment in emergency department alone calculated for each predictive factor. OR .1 indicates increased odds of hospital admissions. Cases in which patient left against medical advice are excluded from analysis. ORs for other admitting diagnoses—nerve damage, conjunctivitis, and traumatic iritis—could not be calculated because emergency department admissions for these diagnoses had either 100% hospital admission rates (nerve damage) or 0% hospital admission rates (conjunctivitis and traumatic iritis).
demonstrated that a child sustaining an air gun injury was over 4 times more likely to be treated in the emergency department for a foreign body injury (air gun: 11.5% of all reported eye injuries; paintball: 2.5%; P 5 0.017). Furthermore, a child sustaining an air gun eye injury was over 3 times more likely to be seen in the emergency department for ocular puncture injury (air gun: 2.6%; paintball: 0.7%; P 5 0.046). To identify the characteristics that were associated with eye injury severe enough to require hospital admission or observation, odds ratios for demographic profiles, type of nonpowder gun involved, and admitting diagnoses were calculated. The odds of hospital admission for children under the age of 10 and white children were slightly lower than children over the age of 10 and non-white children (0.837 [95% CI, 0.774-0.905] and 0.838 [95% CI, 0.781–0.899],
Journal of AAPOS
resp.; see Table 2). There was no statistically significant difference in the odds of hospital admission between males and females. Children who had sustained an ocular injury from a paintball gun had a 50% increased odds of hospital admission compared to those who had been injured by an air gun (95% CI, 1.44-1.65). Admitting diagnoses of foreign body, laceration, puncture, and hemorrhage were associated with up to a 4-5 times increased odds of admission. An initial diagnosis of global rupture was associated with over a 50 times increased odds of hospital admission (53.43 [95% CI, 38.25-74.63]; see Table 2). A total of 399 cases of airsoft and BB gun eye injuries have been published since the 1950s.10-34 Age was reported in 181 of the cases; sex, in 144 cases. The average age of patients was 11.0 5.6 years, and 85.7% of the patients were male. Eye protection status was reported in only 71 cases. Of these 71, 1 patient was purportedly wearing sunglasses, and 70 were not wearing eye protection—including goggles or facemasks—at the time of injury.8 In line with NEISS data, corneal abrasions and hyphemas were the most common injuries. Low rates of global rupture were documented, with 3 total cases out of 286 (1%) in the literature. A complete list of injury types and frequencies described in published cases is provided in Table A2. Best-corrected visual acuity of patients after treatment was reported in 197 cases, with follow-up times ranging from 7 days to 21 months. A total of 21 cases (15%) with airsoft gun injury and 35 cases (66%) with BB gun injury had visual acuity worse than 20/50 at last followup (Table 3).
Discussion This study demonstrates that nonpowder gun eye injuries are a leading cause of serious pediatric eye injuries that require hospital admission. Our data show that the two major types of nonpowder guns—paintball guns and air guns—demonstrated different trends in injury rates over the last decade. Whereas national rates of hospital admissions for pediatric air gun eye injuries have climbed since 2010, paintball eye injuries have steeply declined over the last decade. Paintball gun eye injuries were more likely to require subsequent hospitalization; however, air guns were also found to inflict high rates of serious injury with lasting impact on visual outcome even with treatment. Children sustaining air gun injuries were more likely to
166
Lee and Fredrick
Volume 19 Number 2 / April 2015
FIG 3. Map of states with nonpowder gun control laws. A total of 22 states regulate use and possession of nonpowder guns. States that define some or all nonpowder guns as firearms: IL, MI, NJ, RI. States that identify nonpowder guns as dangerous weapons: CT, DE, ND. States that impose age restrictions on possession and use of nonpowder guns: CA, DE, FL, IL, MA, ME, MN, NY, NC, PA, VA. States that regulate possession of nonpowder guns on school grounds: CA, CO, DE, MN, MI, NC, NH, SD, VA, WA, WI. The District of Columbia also imposes age restrictions on nonpowder gun use.40
be diagnosed with eye puncture and foreign body injuries, each of which was associated with increased odds of hospital admission. Increased promotion of nonpowder gun safety in the early 2000s likely contributed to the drop in pediatric eye injuries until 2010. During this time, BB gun manufacturing companies established internal restrictions on sales and marketing to minors,35 and the American Academy of Pediatrics and American Academy of Ophthalmology released a joint policy statement to promote eye protection for high-risk recreational activities.36 The sharp rise in pediatric eye injury due to air guns since 2010 parallels the recent growth in popularity of airsoft guns, shifts in state legislature, and continued difficulties with promoting eye protection among minors. There are no national studies on the trends in memberships and sales of air guns versus paintball guns. However, multiple sources have noted drastic increase in sales of air guns, but not paintball guns, since around 2004.37-40 Air guns are often marketed to teenagers, likely accounting for increased odds of injury as compared to younger children. While there are few studies regarding association between differences in serious nonpowder gun injury and ethnicity, it is possible that the increased likelihood of serious injury non-white children may be due to differences in health care access or use of protective equipment. This increase in air gun use has not been met with increased regulation or safety awareness, thus culminating in a rise in pediatric eye injury by air guns since 2010.
There are currently no federal laws regulating nonpowder guns, and only 22 US states regulate the transfer, possession, and use of nonpowder guns to varying degrees (Figure 3). The majority of states allow minors to purchase and possess nonpowder guns.41 Additionally, our study suggests that these injuries occur when children do not wear protective eyewear. In line with prior studies,42,43 we report that only 1 of 71 children had some form of eye protection at the time of injury. Prior studies indicate that polycarbonate lenses greater than 3 mm thickness are shatter resistant even at maximum pellet or BB gun velocities.44,45 Increased legislation regarding air gun possession, usage, and marketing, as well as renewed eye protection policies, and efforts to increase awareness of air gun safety may be necessary to prevent accidental injury in children. Overall, the rates of injuries attributable to nonpowder firearms calculated in this study are consistent with those reported in prior studies.6,7 In line with case reports, the types of presenting injuries are similar in both the NEISS data. However, for two reasons this study tends to underestimate the fraction of patients with common signs, such as hemorrhage and hyphema, compared to prior studies. First, prior case series and retrospective chart reviews were likely subject to sampling variability. Second, while each case likely presents with multiple signs and symptoms following ocular trauma, each of which is taken into account by prior studies, the CPSC reports a single “diagnosis” per case. There are several limitations to this study. First, the study likely underestimates rates of pediatric ocular injury.
Journal of AAPOS
Volume 19 Number 2 / April 2015 As the NEISS dataset only captures patients who were eventually treated in the emergency department, the rates calculated here do not account for children who sustained ocular injuries but were seen in alternative health care settings or were not seen by a health care provider at all. Along the same lines, injury rates were calculated based on the total population of pediatric patients provided by the US Census Bureau. Therefore, rates of ocular injury with active participation in the recreational activities examined are likely higher than what is reported here. In conclusion, this is the first study to document the recent rise in incidence of air gun, but not paintball, pediatric ocular injuries requiring hospitalization in the US. Air guns are more likely to be associated with introduction of a foreign body to the eye as well as puncture wounds, each of which is associated with significantly increased odds of eye injury requiring hospital admission. These injuries lead to lasting changes in visual acuity, and the majority of these injuries occur when children are not wearing proper eye protection. Taken together, these results demonstrate that air guns can cause severe, yet preventable, eye injury among the pediatric population. To reduce rates of pediatric eye injury, both practitioners and air gun companies should first promote and lobby for eye safety mandates among all air gun users. Furthermore, changes in state policy to regulate possession and usage of air guns among minors may be warranted to reduce rates of accidental injury.
Literature Search PubMed searches were conducted in July 2014 to retrieve articles related to BB gun and airsoft gun injuries. Search terms included airsoft gun, air gun, BB gun, AND eye OR ocular injury. The reference lists of each article were reviewed in detail. Epidemiologic studies based on regional or national databases, as well as studies involving guns other than air or BB guns were excluded from analysis. Each article in full text (n 5 25 articles) was read and cases were evaluated for age, sex, presenting diagnoses, bestcorrected visual acuity at presentation and after treatment, time to last follow-up, status of eye protection, and details on treatment and surgical management.
Acknowledgments US CPSC, US Consumer Product Safety Commission; NEISS, National Electronic Injury Surveillance System. References 1. All about paintball. World and Regional Paintball Information Guide. 2012. http://www.warpig.com/paintball/newbie/aboutpb. shtml. Accessed April 21, 2014. 2. What is airsoft. RaidenTech. 2011. http://www.raidentech.com/faq. html. Accessed April 21, 2014. 3. Air guns: BB guns vs. pellet guns. Air Gun Warehouse. 2014. http://www.airgunwarehouseinc.com/bbguns.html. Accessed April 21, 2014. 4. Diana RWS 350 P Magnum. Air Gun Warehouse. 2014. http://www. airgunwarehouseinc.com/py-1835-3706.html. Accessed April 21, 2014.
Journal of AAPOS
Lee and Fredrick
167
5. Conn JM, Annest JL, Gilchrist J, Ryan GW. Injuries from paintball game related activities in the United States, 1997-2001. Inj Prev 2003;10:139-43. 6. Pollard KA, Xiang H, Smith GA. Pediatric eye injuries treated in US emergency departments, 1990-2009. Clin Pediatr (Phila) 2012;51: 374-81. 7. Listman DA. Paintball injuries in children: more than meets the eye. Pediatrics 2004;113:e15-18. 8. Fineman MS. Ocular paintball injuries. Curr Opin Ophthalmol 2001; 12:186-90. 9. Annest JL, Mercy JA, Gibson DR, Ryan GW. National estimates of nonfatal firearm-related injuries. JAMA 1996;273:1749-54. 10. Ahmadabadi MN, Karkhaneh R, Valeshabad AK, Tabatabai A, Jager MJ, Ahmadabadi EN. Clinical presentation and outcome of perforating ocular injuries due to BB guns: a case series. Injury 2011;42:492-5. 11. Shazly TA, Al-Hussaini AK. Pediatric ocular injuries from airsoft toy guns. J Pediatr Ophthalmol Strabismus 2012;49:54-7. 12. Saunte JP, Saunte ME. 33 cases of airsoft gun pellet ocular injuries in Copenhagen, Denmark, 1998-2002. Acta Ophthalmol Scand 2006; 84:755-8. 13. Endo S, Ishida N, Yamaguchi T. Tear in the trabecular meshwork caused by an airsoft gun. Am J Ophthalmol 2001;131:656-7. 14. Ramstead C, Ng MC, Rudnisky CJ. Ocular injuries associated with Airsoft guns: a case series. Can J Ophthalmol 2008;45:584-7. 15. Jovanovic M, Bobic-Radovanovic A, Vukovic D, Knezevic M, Risovic D. Ocular injuries caused by airsoft guns—ten-year experience. Acta Chir Iugosl 2012;59:73-6. 16. Adyanthaya R, Chou T, Parhiz AT. Penetrating ocular trauma from airsoft gun. Arch Ophthalmol 2012;130:944-5. 17. Gilmour DF, Ramaesh K, Fleck BW. Trans-orbital intra-cranial air gun injury. Eur J Ophthalmol 2003;13:320-23. 18. Iqbal S, Muqit MM, Mathews BJ, Bishop F. Trans-oculofacial injury from airgun pellet. Emerg Med J 2007;24:370. 19. Shanon A, Feldman W. Serious childhood injuries caused by air guns. CMAJ 1991;144:723-5. 20. Rambaud C, Tabary A, Contraires G, El Hassan F, Labalette P. Contextual study of Airsoft gun related ocular injuries. J Fr Ophtalmol 2013;36:236-41. 21. Gelston CD, Mandava N, Durairaj VD. Orbital foreign body masquerading as conjunctival melanoma 60 years after injury. Clin Experiment Ophthalmol 2005;33:661-3. 22. Patel BC. Penetrating eye injuries. Arch Dis Child 1989;64:317-20. 23. Jacobs NA, Morgan LH. On the management of retained airgun pellets: a survey of 11 orbital cases. Br J Ophthalmol 1988;72:97-100. 24. Tomar VP. Intra-ocular magnetic airgun shot. Br J Ophthalmol 1955; 39:50-51. 25. Reddy AK, Ray R, Yen KG. Surgical intervention for traumatic cataracts in children: epidemiology, complications, and outcomes. J AAPOS 2009;13:170-74. 26. Mohammadpour M, Soheilian M. Concomitant optic nerve transection and chorioretinitis sclopetaria. BMC Ophthalmology 2005;5:29. 27. Newman TL, Russo PA. Ocular sequelae of BB injuries to the eye and surrounding adnexa. J Am Optom Assoc 1998;69:583-90. 28. Ho VH, Wilson MW, Fleming JC, Haik BG. Retained intraorbital metallic foreign bodies. Ophthal Plast Reconstr Surg 2004;20:232-6. 29. Pulido JS, Gupta S, Folk JC, Ossoiny KC. Perforating BB gun injuries of the globe. Ophthalmic Surg Laser 1997;28:625-32. 30. Finkelstein M, Legmann A, Rubin PA. Projectile metallic foreign bodies in the orbit: a retrospective study of epidemiologic factors, management, and outcomes. Ophthalmology 1997;104:96-103. 31. Rudd JC, Jaeger EA, Freitag SK, Jeffers JB. Traumatically ruptured globes in children. J Pediatr Ophthalmol Strabismus 1994;31:307-11. 32. LaRoche GR, Mcintyre L, Schertzer RM. Epidemiology of severe eye injuries in childhood. Ophthalmology 1988;95:1603-7. 33. Brown GC, Tasman WS, Benson WE. BB-gun injuries to the eye. Ophthalmic Surg 1985;16:505-8.
168
Lee and Fredrick
34. O’Neill PJ, Lumpkin MF, Clapp B, et al. Significant pediatric morbidity and mortality from intracranial ballistic injuries caused by nonpowder gunshot wounds. Pediatr Neurosurg 2009;45:205-9. 35. Presnell SK. Comment: Federal regulation of BB guns: aiming to protect our children. North Carolina Law Review 2002;80:1001. 36. American Academy of Pediatrics CoSMaF, American Academy of Ophthalmology EHaPITF. Joint policy statement: protective eyewear for young athletes. Ophthalmology 2004;111:600-603. 37. Smith E. Airsoft locks in rapid fire mode. Chatanooga Times Free Press. 2010. http://www.timesfreepress.com/news/2010/dec/ 25/airsoft-locks-rapid-fire-mode/?business. Accessed June 25, 2014. 38. Nakaso D. Replica guns gaining popularity in Hawai’i. Honolulu advertiser. 2003. http://the.honoluluadvertiser.com/article/2003/ Jul/21/bz/bz01a.html. Accessed June 25, 2014. 39. Velsey K. “War Games”: Airsoft growing in popularity. The Courant. 2011. http://articles.courant.com/2011-10-09/community/hc-ctairsoft-1002-20111009_1_paintball-replica-firearms-war-games. Accessed June 25, 2014.
Volume 19 Number 2 / April 2015 40. Fox RS. Airsoft guns: Parents on the front line of a risky hobby. Parenthood.com. 2004. http://www.parenthood.com/article/ airsoft_guns_parents_on_the_front_line_of_a_risky_hobby.html#. U7xcJo1dVcI. Accessed June 25, 2014. 41. Non-powder guns policy summary. 2012; http://smartgunlaws.org. Accessed July 7, 2014. 42. Matter KC, Sinclair SA, Xiang H. Use of protective eyewear in US children: results from the National Health Interview Survey. Ophthalmic Epidemiology 2007;14:37-43. 43. Alliman KJ, Smiddy WE, Banta J, Qureshi Y, Miller DM, Schiffman JC. Ocular trauma and visual outcome secondary to paintball projectiles. Am J Ophthalmol 2009;147:239-42. 44. Vinger PF, Parver L, Alfaro DV, Woods T, Abrams BS. Shatter resistance of spectacle lenses. JAMA 1997;277:142-4. 45. Rychwalski PJ, Packwood EA, Cruz OA, Holds JB. Impact resistance of common spectacle and safety lenses to airgun and rimfire projectiles. J AAPOS 2003;7:268-73.
I don’t know how to suppress an immediate reflex reaction to eyedrops—such as a kick (I try to work from the side or behind the child’s head—not much he/she can do to me there!), but I have found two strategies that work pretty well: (1) start with anesthetic drops (“magic drops—so the other’s won’t sting”); (2) invite the child to let out his/her anger by offering my forefingers and asking him/her to squeeze them (one in each fist) as hard as he/she can until the drops don’t hurt any more. Sometimes I even encourage them to squeeze harder! Works as a good distraction and provides an acceptable way to channel the resentment! So far, my fingers have been no worse for wear! Contributed by Scott Brodie, MD, PhD, New York City
Journal of AAPOS
Volume 19 Number 2 / April 2015
Lee and Fredrick
168.e1
Appendix. Overall injury rates and types of injuries Table A1. Rates of pediatric (2-18 years of age) eye injuries (per 1 million children in population)a Number children seen in emergency departments (95% CI) Year
Nonpowder gun injuries
Fireworks injuries
Baseball injuries
Large ball sports injuries
Tennis sports injuries
Hockey injuries
2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012
36.36 (20.95-43.79) 30.54 (16.82-38.51) 39.18 (24.23-50.65) 40.00 (25.75-49.27) 62.84 (43.29-76.03) 44.09 (27.79-53.18) 50.67 (31.13-57.05) 36.83 (23.62-47.22) 30.43 (19.33-38.65) 43.75 (28.77-55.06) 44.90 (27.30-62.50)
15.29 (n/a) 17.78 (n/a) 21.65 (12.74-30.55) 24.03 (16.03-32.04) 16.95 (n/a) 15.88 (n/a) 12.45 (n/a) 18.83 (10.34-27.32) 11.36 (n/a) 10.14 (n/a) 5.45 (n/a)
37.37 (27.85-46.89) 45.25 (32.83-57.67) 41.60 (30.19-53.02) 38.96 (21.39-52.90) 28.11 (18.74-37.47) 25.93 (17.29-34.57) 25.11 (17.29-34.57) 32.97 (15.76-34.57) 24.64 (20.04-45.89) 21.51 (15.95-33.33) 36.39 (23.55-49.23)
73.72 (54.94-92.51) 89.96 (70.57-109.36) 77.39 (57.67-97.10) 68.93 (55.42-82.43) 86.25 (64.28-108.23) 67.27 (48.81-85.73) 58.32 (42.32-74.32) 66.22 (50.64-81.79) 81.95 (65.88-98.01) 72.67 (55.58-89.76) 82.60 (59.93-105.26)
11.17 (n/a) 8.29 (n/a) 11.05 (n/a) 7.78 (n/a) 10.49 (n/a) 10.02 (n/a) 6.07 (n/a) 7.38 (n/a) 4.72 (n/a) 6.67 (n/a) 10.83 (n/a)
1.41 (n/a) 0.35 (n/a) 0.93 (n/a) 0.30 (n/a) 0.00 (n/a) 0.00 (n/a) 1.45 (n/a) 0.31 (n/a) 0.62 (n/a) 1.04 (n/a) 1.29 (n/a)
CI, confidence interval. All population data obtained from US Census Bureau.
a
Table A2. Specific injuries reported in 286 published casesa Injury
Airsoft guns, no. (%)
BB guns, no. (%)
Corneal abrasion/edema Hyphema Cataract Traumatic mydriasis Vitreous hemorrhage Commotio retinae Retinal detachment/tear Choroidal rupture Ruptured globe
112 (49.1) 193 (84.7) 11 (4.8) 35 (15.4) 9 (4.0) 6 (2.6) 2 (0.9) 2 (0.9) 1 (0.4)
22 (37.9) 10 (17.2) 5 (8.6) 0 (0.0) 23 (39.7) 8 (13.8) 21 (36.2) 7 (12.1) 2 (3.5)
a
Documented injuries at the time of initial presentation were described in a total of 228 total airsoft gun cases and 58 total BB gun cases in the literature.
Journal of AAPOS
RESULTS
CONCLUSIONS
To identify epidemiologic trends in nonpowder gun-related pediatric eye injuries and to determine factors associated with severe injury requiring hospital admission. US emergency department data on pediatric eye injuries between 2002 and 2012 were reviewed using the National Electronic Injury Surveillance System. Literature review was conducted to determine trends in visual outcomes after treatment and use of eye protection. In 2012 roughly 3,161 children were treated in US emergency departments for nonpowder gun-related eye injuries. Since 2010 rates of severe nonpowder gun pediatric eye injury have increased by over 500% (P 5 0.039). Specifically, while rates of hospital admission due to paintball gun eye injury have dropped precipitously (P 5 0.0077), rates of admissions for air gun eye injuries have increased by over 600% since 2010 (P 5 0.033). Children sustaining eye injury due to air guns are more likely to be diagnosed and admitted with foreign body or ocular puncture injury. Roughly 28% of documented cases of airsoft or BB gun–related injury had visual acuity worse than 20/50 after initial treatment. Over 98% of injuries occurred without eye protection. Air guns are rising in popularity and now account for the majority of pediatric eye injuries requiring hospital admissions. These eye injuries occur without ocular protection and may lead to permanent eye injury. Increasing regulations for eye protection, sales, and usage of air guns are needed to prevent serious pediatric eye injuries. ( J AAPOS 2015;19: 163-168)
P
opular nonpowder firearms include paintball guns, airsoft guns, BB guns, and pellet guns. Paintball guns fire 17 mm diameter gelatin capsules filled with nontoxic paint, designed to “mark” targets.1 By contrast, airsoft guns are 1:1 scale replicas of powder guns that release lightweight, 6 mm plastic bullets.2 BB guns discharge 4.5 mm round lead or steel bullets, and pellet guns fire 4.5 mm metal, nonspherical pellets with thin waists and distinctive tips.3 These differences in pellet design, combined with different power sources—spring, CO2, and air pump—afford varying velocities and flight ranges. For instance, while paintballs reach up to 90 m/s, BB gun pellets can reach maximum velocities of 380 m/s if powered by a spring.3,4 Previous literature indicates a steady rise in the number of pediatric ocular injuries due to nonpowder firearms.5-9 Multiple prior studies have documented severe repercussions of ocular trauma secondary to nonpowder
Author affiliations: Stanford University School of Medicine, Palo Alto, California Submitted July 17, 2014. Revision accepted January 26, 2015. Published online March 26, 2015. Correspondence: Rachel Lee, BS, Stanford Byers Eye Institute, Stanford University School of Medicine, 2452 Watson Court, Palo Alto, CA 94303 (email: [email protected]). Copyright Ó 2015 by the American Association for Pediatric Ophthalmology and Strabismus. 1091-8531/$36.00 http://dx.doi.org/10.1016/j.jaapos.2015.01.010
Journal of AAPOS
gun injury. Commonly reported injuries include hyphema, lens dislocation, and corneal abrasion; more severe injuries include retinal detachment and global rupture.10-34 However, these studies largely examine time frames prior to 20015,7-9 or nonpowder gun injuries as a whole, without differentiating the various types of nonpowder guns.6 To our knowledge, this is the first study to closely examine trends and risk factors for paintball and airsoft pediatric ocular injuries using a nationally representative sample. Improved understanding of these trends may allow for a more targeted approach to identifying and preventing nonpowder gun injuries in pediatric patients.
Methods The US Consumer Product Safety Commission (CPSC) documents US emergency department visits for injuries secondary to a various consumer products through the National Electronic Injury Surveillance System (NEISS). The NEISS draws from a stratified probability sample of roughly 100 hospital emergency departments of varying sizes, selected to reflect the current distribution of hospitals in the US. All selected hospital emergency departments provided service 24 hours a day, with at least 6 hospital beds. Trained NEISS coordinators transcribe data regarding all consumer product–associated injuries, including date of treatment, patient demographic information (age, sex, and ethnicity), initial injury diagnosis, affected body part, disposition, involved
163
164
Lee and Fredrick
consumer products, and a short case narrative. Data are weighted to enable national estimates of consumer product–related injuries. All data obtained from the CPSC involved pediatric (2-18 years old) cases with documented ocular injuries due to nonpowder firearms (NEISS product codes 1237, 1936, 5016, 1200). Cases were further examined and separated based on the type of firearm implicated in the narrative. Nonpowder guns encompass a wide range of gun types, including pellet guns, BB guns, airsoft guns, and paintball guns, among others. Although there is a clear distinction between paintball guns and other nonpowder gun types, the differences between other nonpowder guns (BB gun vs pellet gun vs airsoft guns) may not be readily identified by the layperson. To account for inaccuracies in reporting, BB, pellet, and airsoft guns were grouped together for the purposes of analysis.
Statistical Analysis All data were analyzed using STATA 13 for Macintosh (College Station, TX). All data reported are national estimates based on the cases and their corresponding weighting factors, as reported by the CPSC. Population data provided by the US Census Bureau was used to calculate rates of pediatric ocular injuries. All 95% confidence intervals were calculated based on the CPSC estimates of coefficient of variance. P values for the trends in pediatric ocular injuries were calculated using linear regression for the data points within the indicated time frames. Differences in sample averages were calculated by t test, as indicated.
Volume 19 Number 2 / April 2015
FIG 1. Rates of pediatric eye injuries requiring hospital admission, 2002-2012. Hospital admission rates for children sustaining ocular injury due to recreational activities after initial evaluation in emergency departments were calculated. Each data point represents number of pediatric hospital admissions adjusted for changes in US population. Data obtained from US Census Bureau.
Literature Search Data were extracted from all English language published reports of ocular injuries related to airsoft guns and BB guns, including age, sex, eye protection status, treatments, and presenting and final best-corrected visual acuities.
Results In 2012 approximately 12,773 children 2-18 years of age were treated in US emergency departments for eye injuries due to nonpowder firearms, fireworks, and ball sports. Roughly 3,161 of these injuries (49.5 per 1 million children) were secondary to nonpowder gun use (95% CI, 27.3-62.5 per 1 million children). Trends in US emergency department visits for recreational activities between 2002 and 2012 are listed in Table A1 (Appendix). Nonpowder guns were a leading cause of pediatric eye injury requiring hospital admission following evaluation in US emergency departments, with roughly 10 children per million admitted between 2002 to 2006 (Figure 1). By contrast, less than 2 of every 1 million children were admitted annually for ocular injuries due to other recreational injuries during the same time frame. Between 2006 and 2010 the rate of pediatric US hospital admissions and observations for nonpowder gun eye injuries decreased by 722% (P 5 0.007 for linear trend). However, from 2010 to 2012 the rates of nonpowder gun eye injury admissions rebounded by 511% (2010: 1.5 per million; 2012: 7.9 per million; P 5 0.039 for linear trend).
FIG 2. Trends in ocular injury due to paintball versus air guns. Hospital admission rates of children sustaining nonpowder gun–related ocular injury were calculated. Nonpowder gun injuries were further divided into paintball gun versus air gun injuries. Each data point represents the number of US emergency department visits, adjusted for changes in US population US population. Data obtained from US Census Bureau.
Notably, average hospital admissions rates for paintball gun eye injuries after 2006 is roughly 10% of the average admissions rates prior to 2006 (2002-2006: 4.1 1.6 per million children; 2006–2012: 0.4 0.3 per million children; P 5 0.007; Figure 2). By contrast, air guns are now the major cause of pediatric nonpowder gun–related eye injury. Rates of hospital admissions for severe pediatric air gun–related ocular injuries fell from 2005 to 2010 (2005: 9.3 per million; 2010: 1.3 per 1 million; P 5 0.003 for linear trend) but have been followed by a drastic rise in hospital admissions since 2010 (2012: 8.4 per million; P 5 0.033 for linear trend). Nonpowder gun-related ocular injuries most commonly resulted in contusions and abrasions, and conjunctival hemorrhage and hyphemas (Table 1). Comparison of the paintball- and air gun–induced pediatric injuries
Journal of AAPOS
Volume 19 Number 2 / April 2015
Lee and Fredrick
Table 1. Types of nonpowder gun injuries and incidence frequencies between 2002—2012 All nonpowder gunsa 47.5 8.1 12.1 4.3 2.4 1.5
Contusion/abrasion Foreign body Hemorrhage Iritis Puncture Global rupture
165
Table 3. Final visual acuity after treatment in 169 total cases
Paintballa
Air gunsa
P valueb
40.4 2.5 16.8 3.7 0.7 3.4
46.7 11.5 12.9 4.1 2.6 1.0
0.252 0.017 0.456 0.829 0.046 0.287
BCVA after treatmenta 20/40 or better 20/50 to 20/150 20/200 or worse
Airsoft guns (n 5 144), no. (%)
BB guns (n 5 53), no. (%)
123 (85.4) 16 (11.1) 5 (3.5)
18 (34.0) 6 (11.3) 29 (54.7)
BCVA, best-corrected visual acuity. a Follow-up time after initial presentation ranged from 1 week to 21 months.
a
Average numbers of injury types between 2002-2012 listed for each gun type. b P values listed comparing paintball and air gun injuries; values calculated using 2-sample z test. Table 2. Parameters associated with hospital admission in 20022012 Parameter
OR (95% CI)a
Age 2-9 years Male White Paintball Admitting diagnoses Contusion/ abrasion Foreign body Hematoma Laceration Puncture Strain/sprain Hemorrhage Global rupture
0.837 (0.774-0.905) 1.079 (0.981-1.187) 0.838 (0.781-0.899) 1.542 (1.443-1.647) 0.117 (0.108-0.126) 5.419 (4.978-5.898) 0.984 (0.775-1.249) 4.119 (3.205-5.294) 5.541 (4.705-6.524) 0.310 (0.134-0.719) 9.90 (9.73-10.07) 53.427 (38.246-74.632)
OR, odds ratio. a OR for likelihood of hospital admission compared to treatment in emergency department alone calculated for each predictive factor. OR .1 indicates increased odds of hospital admissions. Cases in which patient left against medical advice are excluded from analysis. ORs for other admitting diagnoses—nerve damage, conjunctivitis, and traumatic iritis—could not be calculated because emergency department admissions for these diagnoses had either 100% hospital admission rates (nerve damage) or 0% hospital admission rates (conjunctivitis and traumatic iritis).
demonstrated that a child sustaining an air gun injury was over 4 times more likely to be treated in the emergency department for a foreign body injury (air gun: 11.5% of all reported eye injuries; paintball: 2.5%; P 5 0.017). Furthermore, a child sustaining an air gun eye injury was over 3 times more likely to be seen in the emergency department for ocular puncture injury (air gun: 2.6%; paintball: 0.7%; P 5 0.046). To identify the characteristics that were associated with eye injury severe enough to require hospital admission or observation, odds ratios for demographic profiles, type of nonpowder gun involved, and admitting diagnoses were calculated. The odds of hospital admission for children under the age of 10 and white children were slightly lower than children over the age of 10 and non-white children (0.837 [95% CI, 0.774-0.905] and 0.838 [95% CI, 0.781–0.899],
Journal of AAPOS
resp.; see Table 2). There was no statistically significant difference in the odds of hospital admission between males and females. Children who had sustained an ocular injury from a paintball gun had a 50% increased odds of hospital admission compared to those who had been injured by an air gun (95% CI, 1.44-1.65). Admitting diagnoses of foreign body, laceration, puncture, and hemorrhage were associated with up to a 4-5 times increased odds of admission. An initial diagnosis of global rupture was associated with over a 50 times increased odds of hospital admission (53.43 [95% CI, 38.25-74.63]; see Table 2). A total of 399 cases of airsoft and BB gun eye injuries have been published since the 1950s.10-34 Age was reported in 181 of the cases; sex, in 144 cases. The average age of patients was 11.0 5.6 years, and 85.7% of the patients were male. Eye protection status was reported in only 71 cases. Of these 71, 1 patient was purportedly wearing sunglasses, and 70 were not wearing eye protection—including goggles or facemasks—at the time of injury.8 In line with NEISS data, corneal abrasions and hyphemas were the most common injuries. Low rates of global rupture were documented, with 3 total cases out of 286 (1%) in the literature. A complete list of injury types and frequencies described in published cases is provided in Table A2. Best-corrected visual acuity of patients after treatment was reported in 197 cases, with follow-up times ranging from 7 days to 21 months. A total of 21 cases (15%) with airsoft gun injury and 35 cases (66%) with BB gun injury had visual acuity worse than 20/50 at last followup (Table 3).
Discussion This study demonstrates that nonpowder gun eye injuries are a leading cause of serious pediatric eye injuries that require hospital admission. Our data show that the two major types of nonpowder guns—paintball guns and air guns—demonstrated different trends in injury rates over the last decade. Whereas national rates of hospital admissions for pediatric air gun eye injuries have climbed since 2010, paintball eye injuries have steeply declined over the last decade. Paintball gun eye injuries were more likely to require subsequent hospitalization; however, air guns were also found to inflict high rates of serious injury with lasting impact on visual outcome even with treatment. Children sustaining air gun injuries were more likely to
166
Lee and Fredrick
Volume 19 Number 2 / April 2015
FIG 3. Map of states with nonpowder gun control laws. A total of 22 states regulate use and possession of nonpowder guns. States that define some or all nonpowder guns as firearms: IL, MI, NJ, RI. States that identify nonpowder guns as dangerous weapons: CT, DE, ND. States that impose age restrictions on possession and use of nonpowder guns: CA, DE, FL, IL, MA, ME, MN, NY, NC, PA, VA. States that regulate possession of nonpowder guns on school grounds: CA, CO, DE, MN, MI, NC, NH, SD, VA, WA, WI. The District of Columbia also imposes age restrictions on nonpowder gun use.40
be diagnosed with eye puncture and foreign body injuries, each of which was associated with increased odds of hospital admission. Increased promotion of nonpowder gun safety in the early 2000s likely contributed to the drop in pediatric eye injuries until 2010. During this time, BB gun manufacturing companies established internal restrictions on sales and marketing to minors,35 and the American Academy of Pediatrics and American Academy of Ophthalmology released a joint policy statement to promote eye protection for high-risk recreational activities.36 The sharp rise in pediatric eye injury due to air guns since 2010 parallels the recent growth in popularity of airsoft guns, shifts in state legislature, and continued difficulties with promoting eye protection among minors. There are no national studies on the trends in memberships and sales of air guns versus paintball guns. However, multiple sources have noted drastic increase in sales of air guns, but not paintball guns, since around 2004.37-40 Air guns are often marketed to teenagers, likely accounting for increased odds of injury as compared to younger children. While there are few studies regarding association between differences in serious nonpowder gun injury and ethnicity, it is possible that the increased likelihood of serious injury non-white children may be due to differences in health care access or use of protective equipment. This increase in air gun use has not been met with increased regulation or safety awareness, thus culminating in a rise in pediatric eye injury by air guns since 2010.
There are currently no federal laws regulating nonpowder guns, and only 22 US states regulate the transfer, possession, and use of nonpowder guns to varying degrees (Figure 3). The majority of states allow minors to purchase and possess nonpowder guns.41 Additionally, our study suggests that these injuries occur when children do not wear protective eyewear. In line with prior studies,42,43 we report that only 1 of 71 children had some form of eye protection at the time of injury. Prior studies indicate that polycarbonate lenses greater than 3 mm thickness are shatter resistant even at maximum pellet or BB gun velocities.44,45 Increased legislation regarding air gun possession, usage, and marketing, as well as renewed eye protection policies, and efforts to increase awareness of air gun safety may be necessary to prevent accidental injury in children. Overall, the rates of injuries attributable to nonpowder firearms calculated in this study are consistent with those reported in prior studies.6,7 In line with case reports, the types of presenting injuries are similar in both the NEISS data. However, for two reasons this study tends to underestimate the fraction of patients with common signs, such as hemorrhage and hyphema, compared to prior studies. First, prior case series and retrospective chart reviews were likely subject to sampling variability. Second, while each case likely presents with multiple signs and symptoms following ocular trauma, each of which is taken into account by prior studies, the CPSC reports a single “diagnosis” per case. There are several limitations to this study. First, the study likely underestimates rates of pediatric ocular injury.
Journal of AAPOS
Volume 19 Number 2 / April 2015 As the NEISS dataset only captures patients who were eventually treated in the emergency department, the rates calculated here do not account for children who sustained ocular injuries but were seen in alternative health care settings or were not seen by a health care provider at all. Along the same lines, injury rates were calculated based on the total population of pediatric patients provided by the US Census Bureau. Therefore, rates of ocular injury with active participation in the recreational activities examined are likely higher than what is reported here. In conclusion, this is the first study to document the recent rise in incidence of air gun, but not paintball, pediatric ocular injuries requiring hospitalization in the US. Air guns are more likely to be associated with introduction of a foreign body to the eye as well as puncture wounds, each of which is associated with significantly increased odds of eye injury requiring hospital admission. These injuries lead to lasting changes in visual acuity, and the majority of these injuries occur when children are not wearing proper eye protection. Taken together, these results demonstrate that air guns can cause severe, yet preventable, eye injury among the pediatric population. To reduce rates of pediatric eye injury, both practitioners and air gun companies should first promote and lobby for eye safety mandates among all air gun users. Furthermore, changes in state policy to regulate possession and usage of air guns among minors may be warranted to reduce rates of accidental injury.
Literature Search PubMed searches were conducted in July 2014 to retrieve articles related to BB gun and airsoft gun injuries. Search terms included airsoft gun, air gun, BB gun, AND eye OR ocular injury. The reference lists of each article were reviewed in detail. Epidemiologic studies based on regional or national databases, as well as studies involving guns other than air or BB guns were excluded from analysis. Each article in full text (n 5 25 articles) was read and cases were evaluated for age, sex, presenting diagnoses, bestcorrected visual acuity at presentation and after treatment, time to last follow-up, status of eye protection, and details on treatment and surgical management.
Acknowledgments US CPSC, US Consumer Product Safety Commission; NEISS, National Electronic Injury Surveillance System. References 1. All about paintball. World and Regional Paintball Information Guide. 2012. http://www.warpig.com/paintball/newbie/aboutpb. shtml. Accessed April 21, 2014. 2. What is airsoft. RaidenTech. 2011. http://www.raidentech.com/faq. html. Accessed April 21, 2014. 3. Air guns: BB guns vs. pellet guns. Air Gun Warehouse. 2014. http://www.airgunwarehouseinc.com/bbguns.html. Accessed April 21, 2014. 4. Diana RWS 350 P Magnum. Air Gun Warehouse. 2014. http://www. airgunwarehouseinc.com/py-1835-3706.html. Accessed April 21, 2014.
Journal of AAPOS
Lee and Fredrick
167
5. Conn JM, Annest JL, Gilchrist J, Ryan GW. Injuries from paintball game related activities in the United States, 1997-2001. Inj Prev 2003;10:139-43. 6. Pollard KA, Xiang H, Smith GA. Pediatric eye injuries treated in US emergency departments, 1990-2009. Clin Pediatr (Phila) 2012;51: 374-81. 7. Listman DA. Paintball injuries in children: more than meets the eye. Pediatrics 2004;113:e15-18. 8. Fineman MS. Ocular paintball injuries. Curr Opin Ophthalmol 2001; 12:186-90. 9. Annest JL, Mercy JA, Gibson DR, Ryan GW. National estimates of nonfatal firearm-related injuries. JAMA 1996;273:1749-54. 10. Ahmadabadi MN, Karkhaneh R, Valeshabad AK, Tabatabai A, Jager MJ, Ahmadabadi EN. Clinical presentation and outcome of perforating ocular injuries due to BB guns: a case series. Injury 2011;42:492-5. 11. Shazly TA, Al-Hussaini AK. Pediatric ocular injuries from airsoft toy guns. J Pediatr Ophthalmol Strabismus 2012;49:54-7. 12. Saunte JP, Saunte ME. 33 cases of airsoft gun pellet ocular injuries in Copenhagen, Denmark, 1998-2002. Acta Ophthalmol Scand 2006; 84:755-8. 13. Endo S, Ishida N, Yamaguchi T. Tear in the trabecular meshwork caused by an airsoft gun. Am J Ophthalmol 2001;131:656-7. 14. Ramstead C, Ng MC, Rudnisky CJ. Ocular injuries associated with Airsoft guns: a case series. Can J Ophthalmol 2008;45:584-7. 15. Jovanovic M, Bobic-Radovanovic A, Vukovic D, Knezevic M, Risovic D. Ocular injuries caused by airsoft guns—ten-year experience. Acta Chir Iugosl 2012;59:73-6. 16. Adyanthaya R, Chou T, Parhiz AT. Penetrating ocular trauma from airsoft gun. Arch Ophthalmol 2012;130:944-5. 17. Gilmour DF, Ramaesh K, Fleck BW. Trans-orbital intra-cranial air gun injury. Eur J Ophthalmol 2003;13:320-23. 18. Iqbal S, Muqit MM, Mathews BJ, Bishop F. Trans-oculofacial injury from airgun pellet. Emerg Med J 2007;24:370. 19. Shanon A, Feldman W. Serious childhood injuries caused by air guns. CMAJ 1991;144:723-5. 20. Rambaud C, Tabary A, Contraires G, El Hassan F, Labalette P. Contextual study of Airsoft gun related ocular injuries. J Fr Ophtalmol 2013;36:236-41. 21. Gelston CD, Mandava N, Durairaj VD. Orbital foreign body masquerading as conjunctival melanoma 60 years after injury. Clin Experiment Ophthalmol 2005;33:661-3. 22. Patel BC. Penetrating eye injuries. Arch Dis Child 1989;64:317-20. 23. Jacobs NA, Morgan LH. On the management of retained airgun pellets: a survey of 11 orbital cases. Br J Ophthalmol 1988;72:97-100. 24. Tomar VP. Intra-ocular magnetic airgun shot. Br J Ophthalmol 1955; 39:50-51. 25. Reddy AK, Ray R, Yen KG. Surgical intervention for traumatic cataracts in children: epidemiology, complications, and outcomes. J AAPOS 2009;13:170-74. 26. Mohammadpour M, Soheilian M. Concomitant optic nerve transection and chorioretinitis sclopetaria. BMC Ophthalmology 2005;5:29. 27. Newman TL, Russo PA. Ocular sequelae of BB injuries to the eye and surrounding adnexa. J Am Optom Assoc 1998;69:583-90. 28. Ho VH, Wilson MW, Fleming JC, Haik BG. Retained intraorbital metallic foreign bodies. Ophthal Plast Reconstr Surg 2004;20:232-6. 29. Pulido JS, Gupta S, Folk JC, Ossoiny KC. Perforating BB gun injuries of the globe. Ophthalmic Surg Laser 1997;28:625-32. 30. Finkelstein M, Legmann A, Rubin PA. Projectile metallic foreign bodies in the orbit: a retrospective study of epidemiologic factors, management, and outcomes. Ophthalmology 1997;104:96-103. 31. Rudd JC, Jaeger EA, Freitag SK, Jeffers JB. Traumatically ruptured globes in children. J Pediatr Ophthalmol Strabismus 1994;31:307-11. 32. LaRoche GR, Mcintyre L, Schertzer RM. Epidemiology of severe eye injuries in childhood. Ophthalmology 1988;95:1603-7. 33. Brown GC, Tasman WS, Benson WE. BB-gun injuries to the eye. Ophthalmic Surg 1985;16:505-8.
168
Lee and Fredrick
34. O’Neill PJ, Lumpkin MF, Clapp B, et al. Significant pediatric morbidity and mortality from intracranial ballistic injuries caused by nonpowder gunshot wounds. Pediatr Neurosurg 2009;45:205-9. 35. Presnell SK. Comment: Federal regulation of BB guns: aiming to protect our children. North Carolina Law Review 2002;80:1001. 36. American Academy of Pediatrics CoSMaF, American Academy of Ophthalmology EHaPITF. Joint policy statement: protective eyewear for young athletes. Ophthalmology 2004;111:600-603. 37. Smith E. Airsoft locks in rapid fire mode. Chatanooga Times Free Press. 2010. http://www.timesfreepress.com/news/2010/dec/ 25/airsoft-locks-rapid-fire-mode/?business. Accessed June 25, 2014. 38. Nakaso D. Replica guns gaining popularity in Hawai’i. Honolulu advertiser. 2003. http://the.honoluluadvertiser.com/article/2003/ Jul/21/bz/bz01a.html. Accessed June 25, 2014. 39. Velsey K. “War Games”: Airsoft growing in popularity. The Courant. 2011. http://articles.courant.com/2011-10-09/community/hc-ctairsoft-1002-20111009_1_paintball-replica-firearms-war-games. Accessed June 25, 2014.
Volume 19 Number 2 / April 2015 40. Fox RS. Airsoft guns: Parents on the front line of a risky hobby. Parenthood.com. 2004. http://www.parenthood.com/article/ airsoft_guns_parents_on_the_front_line_of_a_risky_hobby.html#. U7xcJo1dVcI. Accessed June 25, 2014. 41. Non-powder guns policy summary. 2012; http://smartgunlaws.org. Accessed July 7, 2014. 42. Matter KC, Sinclair SA, Xiang H. Use of protective eyewear in US children: results from the National Health Interview Survey. Ophthalmic Epidemiology 2007;14:37-43. 43. Alliman KJ, Smiddy WE, Banta J, Qureshi Y, Miller DM, Schiffman JC. Ocular trauma and visual outcome secondary to paintball projectiles. Am J Ophthalmol 2009;147:239-42. 44. Vinger PF, Parver L, Alfaro DV, Woods T, Abrams BS. Shatter resistance of spectacle lenses. JAMA 1997;277:142-4. 45. Rychwalski PJ, Packwood EA, Cruz OA, Holds JB. Impact resistance of common spectacle and safety lenses to airgun and rimfire projectiles. J AAPOS 2003;7:268-73.
I don’t know how to suppress an immediate reflex reaction to eyedrops—such as a kick (I try to work from the side or behind the child’s head—not much he/she can do to me there!), but I have found two strategies that work pretty well: (1) start with anesthetic drops (“magic drops—so the other’s won’t sting”); (2) invite the child to let out his/her anger by offering my forefingers and asking him/her to squeeze them (one in each fist) as hard as he/she can until the drops don’t hurt any more. Sometimes I even encourage them to squeeze harder! Works as a good distraction and provides an acceptable way to channel the resentment! So far, my fingers have been no worse for wear! Contributed by Scott Brodie, MD, PhD, New York City
Journal of AAPOS
Volume 19 Number 2 / April 2015
Lee and Fredrick
168.e1
Appendix. Overall injury rates and types of injuries Table A1. Rates of pediatric (2-18 years of age) eye injuries (per 1 million children in population)a Number children seen in emergency departments (95% CI) Year
Nonpowder gun injuries
Fireworks injuries
Baseball injuries
Large ball sports injuries
Tennis sports injuries
Hockey injuries
2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012
36.36 (20.95-43.79) 30.54 (16.82-38.51) 39.18 (24.23-50.65) 40.00 (25.75-49.27) 62.84 (43.29-76.03) 44.09 (27.79-53.18) 50.67 (31.13-57.05) 36.83 (23.62-47.22) 30.43 (19.33-38.65) 43.75 (28.77-55.06) 44.90 (27.30-62.50)
15.29 (n/a) 17.78 (n/a) 21.65 (12.74-30.55) 24.03 (16.03-32.04) 16.95 (n/a) 15.88 (n/a) 12.45 (n/a) 18.83 (10.34-27.32) 11.36 (n/a) 10.14 (n/a) 5.45 (n/a)
37.37 (27.85-46.89) 45.25 (32.83-57.67) 41.60 (30.19-53.02) 38.96 (21.39-52.90) 28.11 (18.74-37.47) 25.93 (17.29-34.57) 25.11 (17.29-34.57) 32.97 (15.76-34.57) 24.64 (20.04-45.89) 21.51 (15.95-33.33) 36.39 (23.55-49.23)
73.72 (54.94-92.51) 89.96 (70.57-109.36) 77.39 (57.67-97.10) 68.93 (55.42-82.43) 86.25 (64.28-108.23) 67.27 (48.81-85.73) 58.32 (42.32-74.32) 66.22 (50.64-81.79) 81.95 (65.88-98.01) 72.67 (55.58-89.76) 82.60 (59.93-105.26)
11.17 (n/a) 8.29 (n/a) 11.05 (n/a) 7.78 (n/a) 10.49 (n/a) 10.02 (n/a) 6.07 (n/a) 7.38 (n/a) 4.72 (n/a) 6.67 (n/a) 10.83 (n/a)
1.41 (n/a) 0.35 (n/a) 0.93 (n/a) 0.30 (n/a) 0.00 (n/a) 0.00 (n/a) 1.45 (n/a) 0.31 (n/a) 0.62 (n/a) 1.04 (n/a) 1.29 (n/a)
CI, confidence interval. All population data obtained from US Census Bureau.
a
Table A2. Specific injuries reported in 286 published casesa Injury
Airsoft guns, no. (%)
BB guns, no. (%)
Corneal abrasion/edema Hyphema Cataract Traumatic mydriasis Vitreous hemorrhage Commotio retinae Retinal detachment/tear Choroidal rupture Ruptured globe
112 (49.1) 193 (84.7) 11 (4.8) 35 (15.4) 9 (4.0) 6 (2.6) 2 (0.9) 2 (0.9) 1 (0.4)
22 (37.9) 10 (17.2) 5 (8.6) 0 (0.0) 23 (39.7) 8 (13.8) 21 (36.2) 7 (12.1) 2 (3.5)
a
Documented injuries at the time of initial presentation were described in a total of 228 total airsoft gun cases and 58 total BB gun cases in the literature.
Journal of AAPOS
