FACULTY OF MEDICINE UNIVERSITY OF HELSINKI FINLAND EYE INJURIES IN CHILDHOOD AND THOSE CAUSED BY TOY GUNS, SPORT AND WOODEN PROJECTILES Anna-Kaisa Haavisto ACADEMIC DISSERTATION To be presented for public discussion with the permission of the Faculty of Medicine, University of Helsinki, in Lecture Hall 1 of Biomedicum, Haartmaninkatu 8, Helsinki on 21st of October, 2020, at 16 o’clock. Helsinki 2020 SUPERVISORS PhD, MD Tiina Leivo Department of Ophthalmology University of Helsinki and Helsinki University Hospital Helsinki, Finland Docent Päivi Puska Department of Ophthalmology Helsinki University Hospital Helsinki, Finland Professor Juha Holopainen Department of Ophthalmology University of Helsinki and Helsinki University Hospital Helsinki, Finland REVIEWERS Associate Professor Enping Chen St. Eriks Eye Hospital Stockholm, Sweden Professor Nina Hautala Department of Ophthalmology University of Oulu and Oulu University Hospital Oulu, Finland OPPONENT Associate Professor Ferenc Kuhn University of Alabama at Birmingham Birmingham, USA ISBN 978-951-51-5886-4 (nid.) ISBN 978-951-51-5887-1 (PDF) The Faculty of Medicine uses the Urkund system (plagiarism recognition) to examine all doctoral dissertations. Cover: Sakari Saukkonen Layout: Pirta Mikkola Illustrations: Figures 1, 2 and 6 Sakari Saukkonen. Figures 4 and 5 Vuokko Haavisto. Press: Picaset 2 3 To Antti, Otso and Vuokko 3 ABSTRACT ABSTRACT Eye injuries cause inconvenience at least and permanent disability at worst. Yet most of the injuries are preventable. Therefore, it is essential to have updated information on the circumstances leading to eye injuries. By reporting on the causes and contexts, we can pro- mote proper eye protection and safe behaviour to reduce the number of accidents. In this thesis, the focus of analysis was leisure-time eye injuries; injuries in children and those caused by toy guns, sports and wooden projectiles in Southern Finland. Patients were gathered from all new eye trauma patients (n = 1151) taken into care at the Helsinki Univer- sity Eye Hospital during a one-year period in 2011-2012. The background information was received via a questionnaire, and hospital records were accessed in order to gain complete information on status findings, treatments and resource use. The follow-up time was three months and patients injured by toy guns were examined also five years after the eye injury. Children comprised 18 % (n = 202/1151) of all patients. Eye injury was most likely at the age of 13-16, and the leading causes were a hit of a sporting equipment (15 %), contact with the human body (12 %) and superficial foreign body (11 %). The main diagnosis was mild ocular or periorbital trauma (50 %). Six open globe traumas were caused by fireworks, tools, ski pole and a gun. Permanent disability was estimated for 9 % (n = 19) of children. Toy guns caused 1 % (n = 15/1151) of all eye injuries, consisting of 12 airsoft guns, 2 peashooters and 1 paintball gun. The main diagnosis was contusion (87 %). At the five-year follow-up, 47 % (n = 7) had subjective impairment, and 53 % had (n = 8) abnormal clinical findings. Sports caused 13 % (n = 149/1151) of all eye injuries. Floorball, football and tennis were the main sports to come up in the study. Floorball eye injuries decreased from 45 to 32 % of all sports-eye injuries from the season 2002-2003. The main diagnosis was contusion (77 %). Re- garding participants, rink bandy had the highest risk. Permanent disability was diagnosed in 11 % of patients and was more common (p = 0.033) in ice hockey than in other sports in the number of injuries. Wooden projectiles caused 6 % (n = 67/1151) of all eye injuries. Males aged 51-67 were at the highest risk. The most common activity during the accidents was playing (27 %), gar- dening (18 %) and forest work (16 %). In relation to time spent in the activity, the risk of eye injury was the highest in gardening, forest work and woodwork. Permanent disability was diagnosed for 10 % due to various activities. Children should be guided safe play with sticks, and fireworks and tools should be avoided among children. The sale of toy guns should be more restricted and put under the Firearms Act to increase awareness of the risk. The use of eye protection in floorball is rec- ommended for all age groups, and in ice hockey, the use of visors should be emphasised. In gardening, forest work and woodwork, the use of protective eyewear should be enhanced. 3 LIST OF ORIGINAL PUBLICATIONS LIST OF ORIGINAL PUBLICATIONS This thesis is based on the following publications: I Leivo T, Haavisto AK, Sahraravand A. Sports-related eye injuries: the current picture. Acta Ophthalmologica 2015; 93 (3): 224-231. II Haavisto AK, Sahraravand A, Holopainen J, Leivo, T. Paediatric eye injuries in Finland. Helsinki eye trauma study. Acta Ophthalmologica 2017; 95 (4): 392-399. III Haavisto AK, Sahraravand A, Puska P, Leivo T. Toy gun eye injuries -eye protection needed. Helsinki Ocular Trauma Study. Acta Ophthalmologica 2019; 2019; 97 (4): 430-434. IV Haavisto AK, Sahraravand A, Holopainen J, Puska P, Leivo T: Eye injuries caused by wooden projectiles in Finland. Helsinki Ocular Trauma Study. Submitted. The publications are referred to in the text by their roman numerals. 4 5 ABBREVIATIONS ABBREVIATIONS AS/NZM Standards Australia and Standards New Zealand ASTM American Society of Testing and Materials BCVA Best corrected visual acuity BETTS Birmingham eye trauma terminology system FB Foreign body CSA Canadian Standards Association CT Computer tomography Dg Diagnosis EN European Standard HM Hand movement HUEH Helsinki University Eye Hospital ICD-10 International classification of diagnosis, tenth revision IOFB Intraocular foreign body IOL Intraocular lens IOP Intraocular pressure ISO International Organization for Standardization JIS Japanese Industrial Standards LP Light perception LVA Lowered visual acuity mm millimetre MRI Magnetic resonance imaging NA Data not available NF Need for follow-up NFL Nerve fibre layer NLP No light perception NOCSAE National Operating Committee on Standards for Athletic Equipment OGT Open globe trauma Orbital fr Orbital fracture OTS Ocular trauma score PCO Posterior capsule opacity PD Permanent disability POTS Paediatric ocular trauma score RAPD Relative afferent pupillary defect TA Applanation tonometry Tot Total number of patients VA Visual acuity WHO World Health Organisation 5 CONTENTS CONTENTS 1 INTRODUCTION ..............................................................................................................................8 2 BACKGROUND ................................................................................................................................9 2.1 EPIDEMIOLOGY OF EYE INJURIES ..................................................................................................9 2.1.1 EYE INJURIES IN CHILDREN ...................................................................................................9 2.1.2 EYE INJURIES CAUSED BY TOY GUNS ................................................................................11 2.1.2.1 Airsoft guns .............................................................................................................11 2.1.2.2 Paintball ...................................................................................................................12 2.1.2.3 Other toy guns ........................................................................................................14 2.1.3 EYE INJURIES CAUSED BY SPORTS ....................................................................................14 2.1.4 EYE INJURIES CAUSED BY WOODEN ITEMS .....................................................................17 2.2 CLASSIFICATION AND DEFINITION OF EYE INJURIES ............................................................................ 19 2.2.1 BIRMINGHAM EYE TRAUMA TERMINOLOGY (BETT) ........................................................19 2.2.1.1 Closed globe trauma .............................................................................................20 2.2.1.2 Open globe trauma ................................................................................................21 2.2.2 OTHER TRAUMA –TYPES (NOT CATEGORIZED IN BETT) .................................................23 2.2.2.1 Minor corneal and conjunctival injuries ...............................................................23 2.2.2.2 Trauma in the periocular area ...............................................................................23 2.2.2.3 Traumatic optic neuropathy ...................................................................................25 2.2.2.4 Orbital fracture .......................................................................................................25 2.3 SEVERITY OF THE EYE TRAUMA ....................................................................................................25 2.3.1 OCULAR TRAUMA SCORE ...................................................................................................25 2.3.1.1 Ocular Trauma Score in paediatric patients .........................................................27 2.3.2 ZONES OF INJURY ................................................................................................................27 2.3.3 TRAUMATIC GLAUCOMA .....................................................................................................28 2.4 RESOURCE USE ...............................................................................................................................30