Effect of legislation and changing trends of Diwali ocular firecracker injuries in Northern India.

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. Copyright:

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.[1234] 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%[567] that often result in permanent blindness.[8910] Table 1 summarizes the results of various studies reporting ocular firecrcacker injuries.[12111213141516171819202122232425262728]

Table 1

Summary of results of various studies reporting ocular firecracker injuries

Article	Country (region)	Occasion	Number of years (days)	Number of cases (eyes)	Age (years), range	Male (%)	Bystanders (%)	VA	Injury classification (%)	Bilateral involvement (%)
Present study	North India (Delhi-NCR)	Diwali	6 (10)	646 (667)	14 (3-65) 62% <18 years	82.9	35	<1/60-83.4%	Open=66.8 Closed=33.2 VH=76.9 Hyphema=69.2 RD=33.8 Cataract=30.8	3.2
Chakraborti et al., 2019[11]	West India	Diwali	2 (7)	30	97% <15 years	76.7	63.3	<6/60=23.2	Open=13.3 Closed=86.7	NA
Pujari et al. 2018[12]	North India (Delhi-NCR)	Diwali	1 (10)	68 (70)	16 (6-60) 62% <18 years	73.5	64.7	HMCF-6/60=38.2% PL-HMCF=29.4% No Pl=4.4% ≤6/60=70%	Open=82.3 Closed=17.7	2.9
Adenuga et al., 2018[13]	South India	Diwali	3 (10)	110 (114)	21.9 (1-74) 56% <18 years	81	NA	≤3/60=37.7%	Open=12.3 Closed=87.7 Hyphema=42.1 VH=28.9 Cataract=24.6	3.6
Venkatesh et al., 2017[14]	North India	Diwali	5 (5)	45 (53)	20.5 (3-53) 76% <30 years	87	55.5	<6/60=36.4	Open=9.4 Closed=90.6 Hyphema=19 VH=9	17.8
Chang et al., 2016[15]	USA	New Year’s Eve and 4th July	11	100	24 (41% <18 years)	89	26	Mean LogMAR=1.7	Hyphema=42 Eyelid=39 VH=19 Glaucoma=15 Cataract=13	NA
Elangovan et al., 2016[16]	South India	Diwali	5	541	12 (1-60) 64.7% <15 years	76	71.7	<6/60=21.8	Open-8.3 Lid injury-24.7 Lens involved-6.5 VH/RD-4.2	9
Patel et al., 2016[17]	South India	Diwali	1 (30)	49	17	81	48.9	NA	Open=26.5 Closed=67.3	NA
John et al., 2015[18]	South India	Diwali	5 (3)	84	Boys: 9.8 Girls: 8.4 100% <18 years	80	31	<6/60=24.7	Open=6% Closed=94 Hyphema=28.6 Cataract=11.9 VH=9.5	31
Malik et al., 2013[19]	India	Diwali	5	101	17.6±11.9	77.7	NA	Mean logMAR Open globe=1.22 Closed globe=0.64	Open=16.8 Closed=83.2	NA
Lin et al., 2012[20]	China	Spring festival	1	46 (53)	14.3 (3-62) 63% <15 years	89.1	6.5	<6/60=68	Open=79.2 Cataract=34 VH=17 RD=15.1	15.2
Rashid et al., 2011[1]	Malaysia	Aidil fitri	1(2mos)	30 (34)	2-43 70% <12 years	96.7	50	≤6/60=8.8		13.3
Kumar et al., 2010[21]	South India	Diwali	1 (7)	51 (58)	19 (3-70)	78.5	58.7	≤6/60=50%	Open=15.5 Closed=84.5	13.7
Jing et al., 2010[2]	China	Spring festival	1 (22)	24 (25)	41.7% were children	79.2	NA	NA	Open=62.5 Cataract=56 VH=28 RD=28	4.2
De Faber et al., 2009[22]	Netherland	New year	1 (9)	268 (315)	NA	NA	56	No PL=8.6%	NA	17.5
Knox et al., 2007[23]	UK	Guy fawkes night	2	47	NA	NA	NA	<6/60=53	Open=35	NA
Mansouri et al., 2007[24]	Iran	Charshanbe-soori	3 (3)	437	17 (2-74)	84.6	79.9	NA	Open=12.3 Hyphema=48.1	18.6
Barhanpurkar et al., 2005[25]	West India	Diwali	2	44 (59)	55% <12 years	86.4	45.5	NA	NA	34.1
Singh et al., 2005[26]	North India	Diwali	1	26	NA	96	NA	NA	NA	NA
Chan et al., 2004[27]	Ireland	Halloween	12	23	18	73.9	NA	NA	NA	NA
Arya et al., 2001[28]	North India	Diwali	3	42 (47)	15.5 (3-33)	83.3	NA	6/6-6/9=69% ≤6/60=9.4%	Open=7.1% Hyphema=33.35 VH=9.5	11.9

VA: Visual acuity, NA: Not available, VH: Vitreous hemorrhage, RD: Retinal detachment

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.[19202122232425262728293031] 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

	Number (n=646; 667 eyes), n (%)	Preregulation (n=442; 456 eyes), n (%)	Postregulation (n=204; 211 eyes), n (%)	P (pre- and post- regulation); test used
Median age (years), range	14 (3-65)	15 (3-65)	13 (3-65)	0.3; Man-Whitney U
Male: female ratio	4.9:1	4.5:1	6.2:1
Male	536 (83)	361 (81.7)	176 (86.3)	0.13; Chi-square test
Female	110 (17)	81 (18.3)	28 (13.7)
Place
Delhi	273 (42.3)	175 (39.6)	98 (48)	0.12; Chi-square test
Outside Delhi	373 (57.7)	267 (60.4)	106 (52)
UP	204 (31.6)	142 (32.1)	62 (30.4)
Haryana	113 (17.5)	85 (19.2)	28 (13.7)
MP	29 (4.5)	18 (4.1)	11 (5.4)
Bihar	20 (3.1)	17 (3.8)	3 (1.5)
Rajasthan	7 (1)	5 (1.1)	2 (1)
Patients were
Bursting crackers	420 (65)	290 (65.6)	130 (63.7)	0.19; Chi-square test
Bystanders	226 (35)	152 (34.4)	74 (36.3)
Duration of presentation (h)				0.02; Chi-square test
<24	182 (28.2)	114 (25.8)	68 (33.3)
24-48	327 (50.6)	223 (50.4)	104 (51)
>48	137 (21.2)	105 (23.8)	32 (15.7)
Laterality				0.35; Chi-square test
Right eye	301 (46.6)	205 (46.4)	96 (47.1)
Left eye	324 (50.2)	223 (50.4)	101 (49.5)
Bilateral	21 (3.2)	14 (3.2)	7 (3.4)
Visual acuity	n=643 eyes	n=440 eyes	n=203 eyes	0.007; Chi-square test
No perception of light	180 (28)	113 (25.7)	67 (33)
Perception of light to FCCF	356 (55.4)	263 (59.8)	93 (45.8)
1/60-6/60	30 (4.7)	22 (5)	10 (4.9)
6/36-6/18	21 (3.2)	12 (2.7)	6 (3)
≥6/12	55 (8.7)	30 (6.8)	27 (13.3)
Day of presentation
One day before diwali	71 (11)	53 (12)	17 (8.5)	<0.001; Chi-square test
On diwali	122 (18.9)	91 (20.6)	31 (15.2)
1st day postdiwali	143 (22.1)	104 (23.5)	37 (18.1)
2nd day postdiwali	82 (12.7)	38 (8.6)	43 (21.1)
3rd-8th day postdiwali	228 (35.3)	156 (35.3)	76 (37.1)
Classification
Closed globe	221 (33.1)	149 (33.7)	72 (35.3)	0.29; Chi-square test
Contusions/superficial foreign body	200 (30)	140 (31.7)	60 (29.4)
Lamellar laceration	21 (3.1)	9 (2)	12 (5.9)
Open globe	446 (66.8)	307 (69.5)	139 (68.1)
Penetrating/perforating injury	427 (64)	296 (67)	131 (64.2)
Intraocular foreign body	19 (2.8)	11 (2.5)	8 (3.9)

UP: Uttar Pradesh, MP: Madhya Pradesh, FCCF: Finger Counting Close to Face

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

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

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).

Figure 3

Line diagram showing the year-wise trend of total cases presenting from 2014 to 2019

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.[1111213141516171819202132333435] 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.[111214162124] 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.[1214]

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.[21220] 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.[1920212223242526272829303137] 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.