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| ORIGINAL ARTICLE |
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| Year : 2022 | Volume
: 15
| Issue : 1 | Page : 61-68 |
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Effect of legislation and changing trends of Diwali ocular firecracker injuries in Northern India
Rebika Dhiman, Karthikeyan Mahalingam, Neelima Balakrishnan, Atul Kumar, Rohit Saxena, Ramanjit Sihota
Department of Ophthalmology, Dr. R. P. Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India
| Date of Submission | 19-Oct-2021 |
| Date of Decision | 22-Nov-2021 |
| Date of Acceptance | 17-Dec-2021 |
| Date of Web Publication | 02-Mar-2022 |
Correspondence Address:
Dr. Karthikeyan Mahalingam
Department of Ophthalmology, Dr. R. P. Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, Ansari Nagar, New Delhi
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/ojo.ojo_303_21
 Abstract | | |
OBJECTIVE: The objective of this study is to study the impact of temporary legislation implemented during Diwali on ocular firecracker injuries in Delhi-National Capital Region (NCR) region.
MATERIALS AND METHODS: In this retrospective study, records of the patients presenting with ocular firecracker injury during 10 days of Diwali (prediwali, Diwali and 8 days postdiwali) from 2014 to 2019 were retreived from the medical record section. Clinico-demographic profile, relevant history pertaining to the use of firecracker, and details of eye examination, namely presenting visual acuity (VA), laterality and classification of injury based on Birmingham Eye Trauma Terminology System were noted.
RESULTS: Six hundred and sixty-seven eyes of 646 patients were recruited. The median age of patients was 14 years (R = 3–65 years) and male: Female ratio was 4.9:1. Majority of patients (57.7%; n = 373) were from outside Delhi. Most of them were open globe injuries (66.8%). In 55.4% (n = 356) eyes, presenting VA was perception of light to finger counting close to face and 28% (n = 180) eyes could not perceive any light. A significant reduction was noted in the number of ocular firecrcaker injuries after regulation (preregulation [2014–2016] n = 456; postregulation [2017–2019] n = 211; [P = 0.01, t-test]). During preregulation period, presenting VA was worse than 1/60 in significantly higher number of eyes (85.5%; n = 376) than post regulation (78.8%, n = 160) (P = 0.03, Chi-square test).
CONCLUSION: Although temporary legislation seems to be effective in reducing ocular firecracker injuries (52.7% reduction) in NCR, uniform implementation of stricter laws nationwide is essential to further minimize the problem.
Keywords: Diwali, firecracker injury, firecrackers, ocular trauma, trauma
How to cite this article:
Dhiman R, Mahalingam K, Balakrishnan N, Kumar A, Saxena R, Sihota R. Effect of legislation and changing trends of Diwali ocular firecracker injuries in Northern India. Oman J Ophthalmol 2022;15:61-8 |
How to cite this URL:
Dhiman R, Mahalingam K, Balakrishnan N, Kumar A, Saxena R, Sihota R. Effect of legislation and changing trends of Diwali ocular firecracker injuries in Northern India. Oman J Ophthalmol [serial online] 2022 [cited 2023 Mar 27];15:61-8. Available from: https://www.ojoonline.org/text.asp?2022/15/1/61/338884 |
| Introduction | |  |
The words firecracker and festivities go hand in hand. However, the impact of bursting firecrackers on the environment and the health of the people is worrisome. A surge in the number of firecracker-related injuries during these celebrations is a common plight worldwide.[1],[2],[3],[4] In India, similar spike is noted during Diwali which is a week-long festival celebrated between mid-October to mid-November in the Hindu Lunisolar month of “Kartik.” Eye is the common site of involvement in firecracker injuries with the incidence ranging from 18% to 45%[5],[6],[7] that often result in permanent blindness.[8],[9],[10] [Table 1] summarizes the results of various studies reporting ocular firecrcacker injuries.[1],[2],[11],[12],[13],[14],[15],[16],[17],[18],[19],[20],[21],[22],[23],[24],[25],[26],[27],[28] | Table 1: Summary of results of various studies reporting ocular firecracker injuries
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As firecracker injuries are largely avoidable, legislation restricting its sale or use may help mitigate its occurrence. Several countries such as United States, United Kingdom, and Norway have seen drastic reduction in the incidence of firecracker-related injuries following the implementation of strict laws prohibiting the sale or use of firecrackers.[19],[20],[21],[22],[23],[24],[25],[26],[27],[28],[29],[30],[31] In India, as per the ruling of the apex Court of the country, a temporary ban is observed during Diwali on the sale of firecrackers since 2017 in National Capital Region (NCR) comprising of Delhi and the adjoining districts from neighbouring states.
Ours is a tertiary eye care referral center located in Delhi that receives the large number of firecracker-related eye injuries from within and the adjoining states every year, especially during Diwali. While there are several studies related to firecracker injuries, none have evaluated the change in trend before and after the enactment of above law forbidding the sale of firecrackers in the state. The purpose of the current study was to analyze the impact of legislation on the clinicodemographic profile of patients presenting to our center with ocular firecracker injury during Diwali.
| Materials and Methods | | |
This was a retrospective, single center, hospital record-based study conducted at a tertiary care hospital in Northern India. The institute ethical committee approval was sought and the study followed the tenets of Declaration of Helsinki. Records of patients presenting with firecracker injury to the emergency and out-patient eye care services during 10 days of Diwali (prediwali, Diwali and 8 days postdiwali) from 2014 to 2019 were retreived from the medical record section and compiled in an excel sheet.
Clinicodemographic profile of the patients such as age, gender, and geographical location were documented. Important history pertaining to the type of firecracker, whether the patient was a user or a by-stander, use of protective gear and adult supervision in minors while bursting the cracker and duration of injury were noted. Details of eye examination namely presenting visual acuity (VA) on Snellen's test type, laterality, and classification of injury based on Birmingham Eye Trauma Terminology System were registered. Details of ocular structures involved and type of treatment administered wherever available were gathered.
Statistical analysis was performed with IBM SPSS software version 23 (IBM, Armonk, NY, USA). The Chi-square test and Mann–Whitney U were used for nonparametric data and t-test was used for parametric data. P ≤ 0.05 was considered statistically significant.
| Results | | |
In total, 667 eyes of 646 patients sustained ocular firecracker injury during the study period of 6 years (2014–2019). Bilateral involvement was seen in 3.2% (n = 21) cases. [Table 2] summarizes the clinicodemographic profile of these patients. The median age of patients was 14 years (mean = 18.3 years, R = 3–65 years) and male: female ratio was 4.9:1 (P < 0.001, Chi-square test). Majority of the cases (65%, n = 420) were bursting firecracker at the time of injury [Table 2]. None of them were wearing any protective eye-gear and 94.5% of the children were not supervised by any adult at the time of the injury. The most common type of firecracker causing eye trauma was bombs/string bombs (64%) followed by flare/fountain (23%), bottle rockets (7%), and sparklers (6%) in decreasing frequency. | Table 2: Clinicodemographic characteristics of all patients and comparison of these characteristics before and after regulation
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Presenting VA could be assessed in 643 eyes (96.4%) [Figure 1]. Vision evaluation could not be done in 24 eyes as the patient was unable to open the eyes due to extensive trauma or were uncooperative. In 2.3% (n = 15) cases vision was <6/60 bilaterally. Majority of patients (69%) who had presenting VA of no perception of light presented after 24 h of injury. The spectrum of ocular damage ranged from superficial foreign body to deformed globe. Details of type of ocular injury are provided in [Table 2]. In-patient care was needed in 474 patients (73.4%) that were mostly open globe injuries requiring immediate surgical intervention or certain cases of closed globe injuries. Patients actively involved in bursting firecrackers (70.5%; n = 304) had significantly higher percentage of open globe injury compared to bystanders (60.2%; n = 142) (P = 0.007, Chi-square test). | Figure 1: Bar diagram showing the presenting visual acuity in 646 eyes and comparison between pre and post-regulation data
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The details of various ocular structures involved and type of treatment given were available for the year 2019. In this year, 65 eyes of 63 patients sustained firecracker injury with the following characteristics: vitreous hemorrhage (n = 50, 76.9%), hyphema (n = 45, 69.2%), uveal prolapse (n = 24, 36.9%), retinal detachment (n = 22, 33.85%), cataract (n = 20, 30.8%), anterior capsular rupture (n = 12, 18.5%), lid injury (n = 10, 15.4%), superficial foreign body (n = 7, 10.8%), secondary glaucoma (n = 5, 7.7%), thermochemical injury (n = 4, 6.1%), and endophthalmitis (n = 3, 4.6%) [Figure 2]. Eighty-nine percentage (n = 56) cases required in-patient management and surgical intervention was warranted in 85.7% (n = 56 eyes of 54 cases). In 52 eyes (80%) corneal tear repair, scleral tear repair or both was performed. Other types of surgical intervention needed were lid laceration repair in 10 eyes (15.4%), lens aspiration in 7 eyes (10.8%), trabeculectomy in 2 eyes (3%), and endophthalmitis vitrectomy in 2 eyes (3%), respectively. | Figure 2: Clinical pictures of various types of ocular injury seen in 2019
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The data were compared between the pre- and postregulation period [Table 2] and [Figure 3]. The number of patients presenting with ocular firecracker injuries before regulation (2014-2016) (n = 456) was significantly higher than after regulation (2017–2019) (n = 211) (P = 0.01, t-test).{Figure31}
| Discussion | | |
Ocular firecracker injuries are an important preventable cause of visual morbidity and blindness worldwide.[11] In India, this takes the shape of a major public health problem during Diwali when tremendous increase in the number of cases is documented. This study evaluates the clinicodemographic profile of patients presenting with firecracker-related ocular injuries in our center over the past 6 years and documents a reassuring trend of decreasing number of cases after the implementation of ban on the Diwali firecracker sale in the Delhi-NCR region.
The most susceptible group to firecracker injuries is the adolescent males. This has been corroborated in most studies from the various parts of the world including ours.[1],[11],[12],[13],[14],[15],[16],[17],[18],[19],[20],[21],[32],[33],[34],[35], It is due to unsupervised practices and unsafe use of firecrackers by children and young adults. As per the American Academy of Pediatrics, nearly 45% cases treated for firecracker injury in US hospital emergency services in 1999 were <15 years. They reported permanent blindness occurring in around one-third cases with eye injury and rarely death.[32] According to a systematic review in 2009, one in six ocular fireworks trauma occurring in young males suffer from severe visual loss.[9] In our study, 28% eyes could not perceive light and 2.3% cases had a vision of <6/60 bilaterally at presentation. Considering that the baseline VA is a strong predictor for the final visual outcome,[34] it would be expected that large number of our patients would eventually become blind. Therefore, ocular firecracker injuries do constitute a significant cause of blindness especially in children.
Although most patients in this study acquired trauma while bursting the cracker and were also the ones who sustained severe trauma (open globe injury), 35% cases were bystanders. In fact, some studies have reported a greater occurrence of ocular injuries in the innocent bystanders.[11],[12],[14],[16],[21],[24] This emphasizes that bursting of firecrackers should be permitted only in predesignated open spaces rather than anywhere on streets and housing societies. Bombs/string bombs are especially popular among children as it makes more noise unlike other variants and therefore the most common ones associated with ocular injury as also seen in some other Indian studies.[12],[14]
Overall, three-fourth (72%) patients in this study presented to the hospital after 24 h of occurrence of injury. This could be because most patients were from outside Delhi. This is also a reflection that there is a need to improve the eye care services at primary and secondary level to deal with severe traumatic cases in every state and to impart basic level of training related to trauma management at resident level. The significance of early presentation can be understood by the fact that majority of patients (69%) who could not perceive any light presented after 24 h of injury. However, a significant improvement was noted in the number of patients presenting within 24 h postregulation (33%) compared to preregulation period (25%). This can be attributed to improved awareness regarding the seriousness of firecracker injuries among people after the ban, thereby encouraging them to seek early treatment.
Majority of patients in our study required in-patient management due to greater trauma severity with nearly two-third cases (67%) having open globe injury. There are only few studies where >50% patients had open globe injury.[2],[12],[20] Being the apex government tertiary referral center, higher number of severe cases are expected. This also explains poor presenting VA in most of our cases (VA <1/60 in more than 80%).
Nearly 52.7% reduction in the number of ocular firecracker injuries (from 2014 to 2019) was noted after the implementation of regulation in 2017 during Diwali. Tandon et al. had reported an increase in the number of firecracker-related injuries in the Delhi-NCR region from 2002 to 2010.[36] India was lacking any stringent law restricting the sale or use of firecrackers until in 2017 a temporary ban was imposed on the Diwali fire cracker sale in the Delhi-NCR region after it surfaced as the most polluted city in the world. While online sale was banned, the ruling allowed the use of environmentally safe “green” firecrackers for a restricted time from 8pm to 10pm on Diwali. We report an encouraging trend in the number ocular firecracker injuries after the implementation of this temporary ban. Furthermore, the presenting VA in postregulation period was significantly better than the preregulation period highlighting the effectiveness of this regulation. The implementation of strict laws has shown encouraging trend in various other countries such as Denmark, Norway, Unites States, and United Kingdom.[19],[20],[21],[22],[23],[24],[25],[26],[27],[28],[29],[30],[31],[37] A systematic review by Wisse et al. reports 87% decline in the incidence of ocular trauma with restrictive laws in place.[9] In fact, World Health Organization has urged for a worldwide ban on the manufacture of fireworks.[38] However, complete ban is not the solution as many livelihoods are associated with the fireworks industry.
The limitation of this study is that being retrospective in nature, details of follow-up and visual outcomes could not be obtained and many patients who were treated on outpatient basis may have been missed. Being a tertiary center, we do have the referral bias with only severe cases being referred. The bulk of cases are managed at the primary and secondary level. This also implies that the number of cases we are reporting is like touching the tip of the iceberg.
| Conclusion | | |
While the temporary legislation seems to be effective in reducing ocular firecracker injuries in NCR, uniform implementation of stricter laws nationwide and promotion of safe use of firecrackers, especially in school children is essential to further minimize the problem. Considering the fairly heavy severe ocular trauma case referrals during Diwali to a tertiary center, this study also highlights the inadequacy of primary and secondary eye care centers to manage trauma in our country. While keeping the spirit of the festival alive, efforts must be made to make such occasions safe for all.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
| 1. | Rashid RA, Heidary F, Hussein A, Hitam WHW, Rashid RA, Ghani ZA, et al. Ocular burns and related injuries due to fireworks during the Aidil Fitri celebration on the East Coast of the Peninsular Malaysia. Burns J Int Soc Burn Inj 2011;37:170-3.  |
| 2. | Jing Y, Yi-qiao X, Yan-ning Y, Ming A, An-huai Y, Lian-hong Z. Clinical analysis of firework-related ocular injuries during Spring Festival 2009. Graefes Arch Clin Exp Ophthalmol Albrecht Von Graefes Arch Klin Exp Ophthalmol 2010;248:333-8. |
| 3. | Hatamabadi HR, Tabatabaey A, Heidari K, Khoramian MK. Firecracker Injuries During Chaharshanbeh Soori Festival In Iran: a Case Series Study. Arch Trauma Res 2013;2:46-9. |
| 4. | Rosenthal AR, Oakley G. Firework related ocular injury. J R Soc Med 1988;81:559-60. |
| 5. | Greene MA, Race PM. 1999 Fireworks Annual Report: Fireworks-Related Deaths, Emergency Department Treated Injuries, and Enforcement Activities During 1999. Washington, DC: US Consumer Product Safety Commission; 2000:25. |
| 6. | Kon M. Firework injuries to the hand. Ann Chir Main Memb Superieur Organe Off Soc Chir Main Ann Hand Up Limb Surg 1991;10:443-77. |
| 7. | |
| 8. | Wilson RS. Ocular fireworks injuries and blindness. An analysis of 154 cases and a three-state survey comparing the effectiveness of model law regulation. Ophthalmology 1982;89:291-7. |
| 9. | Wisse RPL, Bijlsma WR, Stilma JS. Ocular firework trauma: a systematic review on incidence, severity, outcome and prevention. Br J Ophthalmol BMJ Publishing Group Ltd; 2010;94:1586-91. |
| 10. | |
| 11. | Chakraborti C, Majumdar S, Gayen S. Profile of firecracker injuries of the eye during Diwali: A tertiary eye-care center study. Med J Dr Patil Vidyapeeth 2019;12:415. |
| 12. | Pujari A, Kumar A, Chawla R, Khokhar S, Agarwal D, Gagrani M, et al. Impact on the pattern of ocular injuries and awareness following a ban on firecrackers in New Delhi: A tertiary eye hospital-based study. Indian J Ophthalmol 2018; 66 : 837–40. [ PUBMED] [Full text] |
| 13. | Adenuga OO, Kannan NB, Ahuja AA, Ramasamy K. Ocular trauma from fireworks during diwali festival. Niger J Ophthalmol 2018;26:51. [Full text] |
| 14. | Venkatesh R, Gurav P, Tibrewal S, Agarwal M, Dubey S, Mathur U, et al. Appraising the spectrum of firework trauma and the related laws during Diwali in North India. Indian J Ophthalmol 2017;65:140. [ PUBMED] [Full text] |
| 15. | Chang IT, Prendes MA, Tarbet KJ, Amadi AJ, Chang S-H, Shaftel SS. Ocular injuries from fireworks: the 11-year experience of a US level I trauma center. Eye 2016;30:1324-30. |
| 16. | Elangovan S, Rajalakshmi AR, Velayutham V, Prabhu DR. An analysis of ocular firecracker injuries in five consecutive years during a festive season in a tertiary eye care hospital in South India. Expert Rev Ophthalmol Taylor & Francis; 2016;11:235-40. |
| 17. | Patel R, Mukherjee B. Crash and Burn: Ocular Injuries due to Fireworks. Semin Ophthalmol 2016;31:243-8. |
| 18. | John D, Philip SS, Mittal R, John SS, Paul P. Spectrum of ocular firework injuries in children: A 5-year retrospective study during a festive season in Southern India. Indian J Ophthalmol 2015;63: 843. [ PUBMED] [Full text] |
| 19. | Malik A, Bhala S, Arya SK, Sood S, Narang S. Five-year study of ocular injuries due to fireworks in India. Int Ophthalmol 2013;33:381-5. |
| 20. | Lin Y, Liang X, Liu X, Qu B, Ni Y, Jiang S, et al. Prognostic factors and visual outcome for fireworks-related burns during spring festival in South China. J Burn Care Res Off Publ Am Burn Assoc 2012;33:e108-113. |
| 21. | Kumar R, Puttanna M, Sriprakash KS, Sujatha Rathod BL, Prabhakaran VC. Firecracker eye injuries during Deepavali festival: a case series. Indian J Ophthalmol 2010;58:157-9. [ PUBMED] [Full text] |
| 22. | De Faber JTHN. [Fireworks injuries treated by Dutch ophthalmologists New Year 2008/'09]. Ned Tijdschr Geneeskd 2009;153:A507. |
| 23. | Knox FA, Chan WC, Jackson AJ, Foot B, Sharkey JA, McGinnity FG. A British Ophthalmological Surveillance Unit study on serious ocular injuries from fireworks in the UK. Eye Lond Engl 2008;22:944-7. |
| 24. | Mansouri M-R, Mohammadi S-F, Hatef E, Rahbari H, Khazanehdari M-S, Zandi P, et al. The Persian Wednesday Eve Festival “Charshanbe-Soori” fireworks eye injuries: a case series. Ophthalmic Epidemiol 2007;14:17-24. |
| 25. | Barhanpurkar S, Kumar P, Kapadia P. Profile of Fireworks Related Ocular Injuries (FROI) from Western India. Indian J Community Med 2005;30:98. [Full text] |
| 26. | Singh DV, Sharma YR, Azad RV. Visual outcome after fireworks injuries. J Trauma 2005;59:109-11. |
| 27. | Chan WC, Knox FA, McGinnity FG, Sharkey JA. Serious eye and adnexal injuries from fireworks in Northern Ireland before and after lifting of the firework ban--an ophthalmology unit's experience. Int Ophthalmol 2004;25:167-9. |
| 28. | Arya SK, Malhotra S, Dhir SP, Sood S. Ocular fireworks injuries. clinical features and visual outcome. Indian J Ophthalmol 2001;49:189. [ PUBMED] [Full text] |
| 29. | Berger LR, Kalishman S, Rivara FP. Injuries from fireworks. Pediatrics 1985;75:877-82. |
| 30. | Edwin AFL, Cubison TCS, Pape SA. The impact of recent legislation on paediatric fireworks injuries in the Newcastle upon Tyne region. Burns J Int Soc Burn Inj 2008;34:953-64. |
| 31. | Bull N. Legislation as a tool to prevent firework-related eye injuries. Acta Ophthalmol (Copenh) 2011;89:e654-655. |
| 32. | Witsaman RJ, Comstock RD, Smith GA. Pediatric fireworks-related injuries in the United States: 1990-2003. Pediatrics 2006;118:296-303. |
| 33. | Puri V, Mahendru S, Rana R, Deshpande M. Firework injuries: a ten-year study. J Plast Reconstr Aesthetic Surg JPRAS 2009;62:1103-11. |
| 34. | Kurien NA, Peter J, Jacob P. Spectrum of Ocular Injuries and Visual Outcome Following Firework Injury to the Eye. J Emerg Trauma Shock 2020;13:39-44. [Full text] |
| 35. | |
| 36. | 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 Off Publ Assoc Plast Surg India 2012;45:97-101. |
| 37. | Sheller JP, Muchardt O, Jønsson B, Mikkelsen MB. Burn injuries caused by fireworks: effect of prophylaxis. Burns J Int Soc Burn Inj 1995;21:50–3. |
| 38. | |
[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2]
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