Pediatric Ocular Injuries from Airsoft Toy Guns
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Pediatric Ocular Injuries From Airsoft Toy Guns Tarek A. Shazly, MD; A. K. Al-Hussaini, MD ABSTRACT Purpose: To report ocular injuries caused by airsoft in 7 cases. Seven patients presented with traumatic guns in children. cataract, and two had iridodialysis. Immediate surgical intervention was performed in 7 patients and 7 pa- Methods: A retrospective chart review of pediatric tients were scheduled for elective surgery. The patients patients who sustained ocular injuries related to airsoft presented after an average of 1.9 ± 1.9 days (range: 4 guns between November 2005 and December 2007. hours to 6 days) after the injury. Average follow-up was Place of trauma, presenting symptoms and signs, surgi- 18 days (range: 7 days to 5 months). Final visual acuity cal interventions performed, and final visual outcome was 20/200 or worse in 5 patients, 20/40 or better in 23 were reviewed. patients, and could not be assessed in 2 cases. Results: Thirty-two patients with a mean age of 8.8 Conclusion: Airsoft guns can cause a variety of serious ± 4.0 years (range: 1.5 to 18 years) were examined; 28 injuries, sometimes necessitating operative interven- were boys (87.5%). Presenting visual acuity ranged from tion. The long-term morbidity from some of these in- hand motions to 20/20 and could not be assessed in juries is significant. Airsoft guns are capable of inflicting 2 patients. Hyphema was a common finding that was serious and permanent ocular damage. present in 24 cases, corneal abrasions were present in 10 cases, and raised intraocular pressure was present [J Pediatr Ophthalmol Strabismus 2012;49:54-57.] INTRODUCTION guns. The study reviews a series of 32 children who Ocular trauma is one of the significant causes of sustained ocular injuries from airsoft guns. visual disability in children.1 Airsoft guns are non- powder firearms in which a plastic pellet is propelled PATIENTS AND METHODS by compressed gas. The gas may be compressed by The hospital medical records were reviewed for a powerful spring or by the repetitive pumping of all patients who presented to the ophthalmology air into a gas chamber.1-3 Physicians usually have a department of Assiut University Hospital between tendency to underestimate the injuries caused by November 2005 and December 2007 following in- airsoft guns.4-5 During the past two decades, air- juries sustained from airsoft guns. Assiut University soft gun weapons capable of penetrating the human Hospital is a tertiary care medical center, located in body were manufactured.6-9 This work aims to draw Assiut, Egypt. It serves more than 5 million Egyp- attention to this emerging problem and to prevent tians from all over the northern part of Upper Egypt. serious eye injuries in children resulting from airsoft Demographic information (age, sex, and geographi- From the Ophthalmology (TAS), Massachusetts Eye and Ear Infirmary/Harvard Medical School, Boston, Massachusetts; and the Department of Ophthal- mology (TAS, AKA-H), Assiut University Hospital, Assiut, Egypt. Originally submitted September 24, 2010. Accepted for publication November 23, 2010. Posted online January 25, 2011. The authors have no financial or proprietary interest in the materials presented herein. Address correspondence to Tarek A. Shazly, MD, 20 Pondmeadow Dr., Ste. 203, Reading, MA 01867. E-mail: [email protected] doi: 10.3928/01913913-20110118-05 54 Copyright © SLACK Incorporated TABLE Spectrum of Ocular Injuries by Airsoft Guns in 32 Children Effect of Injury No. of Patients No. of Surgical Interventions Visual Disabilities Hyphema (24) I/A of hyphema (7) 2 cases of blood staining of the Mild (1/3 of AC height) 16 1 hemophiliac patient (3) cornea, both hemophiliacs Moderate (2/3 of AC height) 3 1 hemophiliac patient (2) Total hyphema 5 2 cases (2) Cataract (7) 4 cases of unilateral aphakia Ruptured cataractous lens 3 Urgent I/A without IOL + 3 cases of pseudophakia implantation (3) With intact capsule 3 I/A + PC-IOL 3 weeks later (3) Subluxated lens 1 ICCE without IOL implantation (1) Corneal abrasions 10 – – Iridodialysis 2 – – Vitreous hemorrhage 1 – Resolved in 1 month on conservative treatment I/A = irrigation/aspiration; AC = anterior chamber; IOL = intraocular lens; PC-IOL = posterior chamber intraocular lens; ICCE = intracapsular cataract extraction. cal location of accident), extent of injury, details of chamber; (2) mild: blood filling one-third to one- the accident, operative procedure, complications, half of the anterior chamber; (3) moderate: layered and long-term morbidity were reviewed. blood filling one-half to less than total of the an- terior chamber; and (4) severe: total clotted blood, RESULTS often referred to as blackball or 8-ball hyphema. The clinical records of 403 patients evaluated by Traumatic hyphema was the presenting feature the ophthalmology emergency department of Assiut of 24 patients (16 had mild, 3 had moderate, and University Hospital for ocular trauma between No- 5 had total hyphema). Four cases required urgent vember 2005 and December 2007 were reviewed. drainage of hyphema, in 3 cases the indication was During this period, 32 cases of ocular trauma by total hyphema with persistent rise of intraocular airsoft guns were encountered, accounting for 8% pressure above 50 mm Hg, and in one case the in- of all cases of ocular trauma. Nineteen of the cases dication was persistence of total hyphema and com- (59.4%) were admitted to the inpatient floor and mencement of microscopic blood staining of the the remainder were treated as outpatients. The cornea (Table). The remaining 20 cases of hyphema mean hospital stay for the hospitalized patients was were managed conservatively with a topical cyclo- 4 days (range: 1 to 32 days). None of the 32 children plegic, topical steroid, eye shield, and elevation of had means for ocular protection at the time of the the head of the bed. ocular injury. The follow-up schedule frequency was Corneal abrasions occurred in 10 cases and all dependent on the severity of the injury. recovered in less than 48 hours. The observed abra- The mean age of those patients was 8.8 ± 4.0 sions were either circular or oval shaped at the site years (range: 1.5 to 18 years) and 28 were boys of impact. (87.5%). The assailant was a family member or a Intraocular pressure was elevated initially in 7 friend in 24 cases (75%) and unknown to the victim cases; in 3 it persisted and warranted evacuation of in 8 cases. All of the traumatic events occurred in hyphema, whereas in the remaining 4 cases, intra- or around the child’s home. Presenting visual acuity ocular pressure was controlled medically until reso- ranged from 20/20 to hand motions and could not lution of hyphema. By the end of our follow-up, we be assessed in 2 patients. did not detect any case of angle recession. Hyphema was classified as (1) trace: layered Seven (21.9%) of the patients required 10 ur- blood occupying less than one-third of the anterior gent surgical interventions during their initial hos- Journal of Pediatric Ophthalmology & Strabismus • Vol. 49, No. 1, 2012 55 Figure 2. (A) A group of copper-plated BBs, 4.5-mm steel balls. (B) Airsoft gun pellets measuring 6 mm in diameter. (C) Paintball gela- Figure 1. (A) Traumatic cataract, inferonasal iridodialysis, and su- tin balls, measuring 11 mm in diameter and filled with paint. perficial corneal opacity of the left eye of an 8-year-old boy. (B) Corneal abrasion (black arrow) with diffuse corneal edema and mild hyphema (white arrow) of the right eye of a 12-year-old boy. departments in the United States.11 Therefore, non- powder firearms pose a significant public health haz- pitalization. Of those, one patient with hemophilia ard to children and untrained adults who use them required three successive surgeries to evacuate hy- for play.12,13 phema and another child with hemophilia required In our study, patients presented after an average two evacuation procedures despite receiving inten- of 1.9 days (range: 4 hours to 6 days). This may in- sive factor VIII therapy. Two children had a hy- dicate the lack of parental awareness of the serious- phema drainage surgery and 3 children underwent ness of trauma with airsoft guns. In some instances, urgent cataract extractions for ruptured crystalline children presented as late as 6 days after being treat- lenses. ed with decongestant eye drops by general practi- Seven children had visually significant traumat- tioners. This may reflect the false sense of security ic cataracts. Three of them had urgent irrigation/as- among physicians facing such a trauma. piration of the ruptured lens without intraocular When compared to ocular injuries caused by lens (IOL) implantation. The surgical plan was to paintball pistols, our series did not include any perform delayed secondary posterior chamber intra- cases with corneal/corneoscleral ruptures or retinal ocular lens (PC-IOL) implantation, which was not breaks.14 Although airsoft guns are similar in opera- done originally due to lack of adequate capsular sup- tion and muzzle velocity (300 to 400 feet/second) port. Three patients underwent irrigation/aspiration to paintball guns, airsoft guns use lighter weight of cataract with PC-IOL implantation 3 weeks after projectiles (Fig. 2). The difference in momentum of the initial trauma. One patient had cataractous sub- the projectiles may explain the more severe ocular luxated lens and underwent intracapsular cataract morbidities caused by paintball guns. extraction without IOL implantation. One patient To this end, recommendations based on this and had traumatic cataract and iridodialysis (Fig. 1). other reports in the literature may be made regard- Average follow-up was 18 days (range: 7 days ing the management of airsoft gun injuries4,15-18: to 5 months).