Fireworks are often associated with severe ocular injury. In India, fireworks are an important cause of ocular injury during Deepavali festival. We present the spectrum of fire-cracker related ocular injuries on the day of Deepavali and their associated risk factors. All patients with cracker related ocular injuries on Deepavali day, seen at a tertiary care eye hospital, are included in this case series. This case series evaluates the type of ocular injury, type of firecracker involved and the associated risk factors leading to the casualtie

Lodhi, Sikander A K

Mukkavalli, Nalinikanth

Saudhamini, S.

Shreya, Thandra Sai

English

Atharva Scientific Publications (E-Jounals)

Lodhi et al                                Fireworks related ocular injuries 
Vol 3 Issue 1 Jan – Mar 2017                                                          Indian J Case Reports / 1 
Case Series 
Spectrum of fireworks related ocular injuries on the day of Deepavali 
Sikander A K Lodhi, S. Saudhamini, Thandra Sai Shreya, Nalinikanth Mukkavalli 
From the Department of Ophthalmology, Osmania Medical College / Sarojini Devi Eye Hospital, Hyderabad, Telangana India 
Correspondence to: Dr Sikander AK Lodhi, ‘Hill View’, 10-3-300/3, Humayun Nagar, Masab Tank, Hyderabad - 500028, 
Telangana, India. Email: sikanderlodhi@gmail.com 
Received: 01 Dec 2016    Initial Review: 21 Dec 2016    Accepted: 30 Dec 2016      Published Online: 09 Jan 2017 
ABSTRACT 
Fireworks are often associated with severe ocular injury. In India, fireworks are an important cause of ocular injury during 
Deepavali festival. We present the spectrum of fire-cracker related ocular injuries on the day of Deepavali and their associated 
risk factors. All patients with cracker related ocular injuries on Deepavali day, seen at a tertiary care eye hospital, are included 
in this case series. This case series evaluates the type of ocular injury, type of firecracker involved and the associated risk 
factors leading to the casualties 
Keywords: Fireworks, ocular injury, corneal abrasions, hyphema 
 
eepavali is an important Indian festival that is 
celebrated on a mass scale, not only in India but 
also in other countries wherever Indians are 
settled. Traditionally firecrackers are an essential part of 
Deepavali celebrations, “The Festival of Lights”. 
Fireworks are also part of The Hari Raya Festival in 
Malaysia, Independence Day in the United States and the 
Chaharshanbe Soori in Iran. 
We do not have population-based studies to show the 
real magnitude of fire-cracker related eye injuries in India, 
but hospital-based studies show that it causes significant 
ocular morbidity in our country [1, 2]. We report a series 
of cases of cracker-related ocular injuries seen on the day 
of Deepavali, to highlight the importance of fireworks 
being an important cause of ocular injury in India and to 
study their associated risk factors. 
MATERIAL AND METHODS 
All the patients with cracker-related eye injuries attending 
the Emergency department of a tertiary care government  
 
eye hospital on the day of Deepavali, from noon to 6 AM 
next morning, were included in this case series. All the 
patients were attended immediately. A comprehensive eye 
examination was done and the necessary treatment was 
given immediately. The injuries were classified according 
to Birmingham eye trauma terminology system (BETTS) 
[3]. 
Patients with minor injuries were given treatment and 
sent home and those with ocular injuries of more serious 
magnitude were admitted either for observation or for any 
surgical treatment. Superficial skin burns, abrasions, 
foreign bodies on the cornea and corneal epithelial 
abrasions were given outpatient treatment. Those with 
closed globe injuries, causing hyphema, iridodialysis, lens 
subluxation and vitreous hemorrhage; and open globe 
injuries were admitted for further management.  
RESULTS 
Twenty-three patients (with the involvement of 28 eyes) 
were seen on the day of Deepavali, twenty were males and 
D 
Lodhi et al                                Fireworks related ocular injuries 
Vol 3 Issue 1 Jan – Mar 2017                                                          Indian J Case Reports / 2 
three were female patients. The age range was four to fifty 
years, seventeen of whom were less than 25 years. 
Different types of crackers - flower pots, rockets, 
sparklers, bombs, to name a few were involved in causing 
the ocular injuries. The most common type of cracker 
causing injury was a bomb. 
Table 1 - Cases admitted for inpatient management 
               Cases                                                       Initial VA        Visual outcome 
1. Blunt trauma with total hyphema and vitreous 
hemorrhage 
PL+ CF ½ 
meter 
Hyphema cleared with persisting VH 
2. Blunt trauma with hyphema CF 2 meter 6/9 Hyphema cleared and normal fundus 
3. Hyphema, dislocated cataractous lens,VH +RD PL ± PL ± PPL+PPV+EL +SOI 
4. Open globe laceration PL- PL- Wound repair 
5. Hyphema  6/60p 6/9 Hyphema cleared with medical 
management 
The number of cases that were actively involved in 
burning crackers and getting injured was 10 and the 
remaining 13 were comprised of onlookers, passersby or 
accidentally getting injured due to a flying cracker from a 
distance. None of the cracker injury patients gave a history 
of using any protective eyewear. The right eye was 
involved in 12 cases and both eyes in 6 cases. Strangely, 
all these 12 cases of RE involvement belong to those cases 
who were actively involved in burning the crackers. 
On initial assessment, nine patients had a vision of 6/60 
or less, with three patients having a vision of only light 
perception (PL). All three patients with PL only vision 
were less than five years of age. The distribution of cases 
with a vision of 6/60 or less was equal between those who 
were actively involved and those who were 
passersby/onlookers. Three patients less than 5 years of 
age did not cooperate for vision recording. 
0
5
10
15
20
25
OCULAR INJURY
No of eyes
 
Figure 1 - The spectrum of cracker related ocular injuries
According to BETTS, 22 eyes had closed globe 
injuries and only one eye had open globe injury (Fig. 1, 2, 
& 3). Among the closed globe injuries, the common 
features were skin burns, corneal epithelial defects and 
corneal foreign bodies (soot particles). The most common 
serious manifestation was hyphema, seen in 11 eyes. All 
cases with eyelid skin burn; conjunctival and corneal 
foreign bodies were treated on an outpatient basis. The 
cases were treated as per the standard protocol for the 
management of ocular burns and chemical injuries. All 
Lodhi et al                                Fireworks related ocular injuries 
Vol 3 Issue 1 Jan – Mar 2017                                                          Indian J Case Reports / 3 
external injuries were treated with a thorough wash with 
an irrigating saline solution. Soot particles and foreign 
bodies were removed under local anesthesia. Patients were 
prescribed antibiotic drops, lubricating solutions, and 
cycloplegic drops. All the cases with visual acuity 6/60 or 
less were admitted for further evaluation and management. 
 
Figure 2 a) shows hyphaema. b) Soot particles on external 
surface with limbal ischemia. c) Charred eyelashes and 
multiple foreign bodies on the cornea. d) Flourescein 
staining showing extensive epithelial defects on the cornea. 
 
Figure 3 a) Edematous lids with superficial skin burns 
and abrasions. b) corneoscleral laceration. c) Ultrasound 
showing vitreous hemorrhage in a case with total 
hyphema. 
Of the five admitted patients (Table 1), two patients 
with hyphema had a good visual outcome of 6/9 after total 
clearing of blood from the anterior chamber on medical 
management. One other patient had total clearing of 
hyphaema but with persisting vitreous hemorrhage; had a 
vision of ½ meter. Two patients required surgical 
intervention. One patient with blunt trauma, subluxated 
lens, vitreous hemorrhage and RD had a pars plana 
lensectomy and vitrectomy with silicone oil injection had a 
poor outcome due to decompensated cornea. He had just a 
perception of light. The patient with open globe injury, 
with a corneoscleral laceration, had primary wound repair. 
The eyeball was soft and ultrasound showed multiple 
hemorrhagic choroidal detachments. Perception of light 
was doubtful. 
DISCUSSION 
Cracker related body injuries in general and ocular 
injuries, in particular, are common during festivals and 
national celebrations like Deepavali in India, the spring 
festival in China, Independence Day in the United States 
and the Chaharshanbe Soori in Iran. Considering their 
explosive nature, the use of firecrackers causes serious 
injury and cost to the family and society. This injury and 
cost to the society are quite substantial considering the 
disproportionately higher involvement of younger 
individuals, as can be seen in the present study. 
This is a hospital based single center prospective case 
series of firecracker-related ocular injuries seen on the day 
of Deepavali this year. The majority of patients were 
below the age of 25 years, and a majority of them were 
males. The number of onlookers or those getting 
accidentally injured was more than the cases who were 
actively involved in lighting crackers. This is different 
from a systematic review by Wisse RP et al, where the 
victims among bystanders were less than 50% [4]. There 
were instances where individuals walking on the road, 
sitting in their shop or house were hit by a flying cracker. 
The most common type of cracker causing ocular injury in 
this study was a bomb, small or big. This was similar to a 
study by Kumar R, et al from South India [1]. Right eye 
involvement was the common factor among all those who 
were actively involved. The reasons could be the dominant 
nature of right eye and the victim approaching closer to the 
firecracker to check the status of ignition. 
The most common injuries were hyphaemas, corneal 
abrasions, corneal foreign bodies and lid injuries. Chang et 
al report similar manifestations in their study from “The 
Lodhi et al                                Fireworks related ocular injuries 
Vol 3 Issue 1 Jan – Mar 2017                                                          Indian J Case Reports / 4 
11-Year Experience of a US Level I Trauma Center” [5]. 
Wisse et al, in their systematic review, report 
Corneal/adnexal burn, Contusion and Corneal abrasion as 
the most common ocular injuries from crackers [4]. The 
poor visual outcome in three eyes out of the total of 28 
eyes (11%) affected in our study was due to corneoscleral 
laceration and posterior segment damage. 
One important observation in this study is the high 
number of onlookers and passersby who are affected. They 
comprise 56.5%, compared to 43.5% of those who were 
actively involved in lighting the crackers. This is similar to 
other studies where in addition to users, a significant 
number of passersby and onlookers sustained ocular 
injuries due to fireworks. This is in contrast to a 
professional firework display, where ocular injuries are 
relatively rare. In the study by Chang et al [5], only one 
patient had sustained an ocular injury during a public 
firework display and that patient was the one who was 
handling the fireworks. Countries using restrictive 
firework legislation have a lower incidence of firework 
related ocular injuries [4]. Another important observation 
is the lack of usage of any protective eyewear in all those 
who were actively involved in lighting the crackers. 
We make few recommendations to curtail the 
incidence of cracker related ocular injuries. The authorities 
should not allow the use of firecrackers at public places, 
thoroughfares, communities, settlements, and rooftops. 
Public fireworks can be arranged in open places during 
festival times. There should be a recommendation for 
safety and preventive measures like maintaining a safe 
distance and use of protective eyewear on warning labels 
for fireworks. Concurrent sale of protective eyewear with 
the sale of crackers should be made compulsory. The role 
of ophthalmologists in the media campaign and use of 
social networking highlighting the risks of cracker related 
ocular injuries and triage in the management is important. 
 
 
 
 
 
 
CONCLUSION 
Injuries to the eye from fireworks are quite common and 
visually devastating. Though the majority of the cases in 
this case series did improve on immediate management, 
but a sizeable number resulted in a significant visual loss. 
Public education and preventive measures should reduce 
the incidence of fireworks-related ocular injuries in future.  
REFERENCES 
1. Kumar R, Puttanna M, Sriprakash K S, Sujatha Rathod B 
L, Prabhakaran VC. Firecracker eye injuries during 
Deepavali festival: A case series. Indian J Ophthalmol. 
2010; 58: 157-9 
2. Tandon R, Agrawal K, Narayan RP, Tiwari VK, Prakash 
V, Kumar S, et al. Firecracker injuries during Diwali 
festival: The epidemiology and impact of legislation in 
Delhi. Indian J Plast Surg. 2012;45: 97-101. 
3. Kuhn F, Morris R, Witherspoon CD. Birmingham Eye 
Trauma Terminology (BETT): terminology and 
classification of mechanical eye injuries. Ophthalmol Clin 
North Am. 2002; 15(2): 139-43. 
4. Wisse RP, Bijlsma WR, Stilma JS. Ocular firework trauma: 
A systematic review on incidence, severity, outcome and 
prevention. Br J Ophthalmol. 2010; 94: 1586-91 
5. Chang IT, Prendes MA, Tarbet KJ, Amadi AJ, Chang SH, 
Shaftel SS. Ocular Injuries from Fireworks: The 11-Year 
Experience of a US Level I Trauma Center. Eye (Lond). 
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How to cite this article: Lodhi SAK, Saudhamini S, 
Shreya TS, Mukkavalli N. Spectrum of fireworks 
related ocular injuries on the day of Deepavali. Indian J 
Case Reports. 2017; 3(1): 1-4. 
Conflict of interest: None stated, Funding: Nil 


Spectrum of fireworks related ocular injuries on the day of Deepavali

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Spectrum of fireworks related ocular injuries on the day of Deepavali

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