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There have been many calls for preventive action against injuries caused by air-guns. Eye injuries are particularly serious, and we conducted a retrospective study to review their characteristics. Ophthalmic consultants in the south-west region of England and South Wales were asked to recollect any injuries that had resulted from air weapons. Information was recorded on the nature and circumstances of the injury, subsequent management, and long-term effects.
19 cases of ocular injury were identified, sustained at mean age 19.7 years, all in the past decade. 15 of the victims were male. At least 12 shootings were accidental but 2 were deliberate. The injury was self-inflicted in 5 cases, and in 6 the assailant was known to the victim. 9 sustained ruptured globes and 8 had severe contusions. Ultimately 4 individuals required enucleation and 2 evisceration. At last review, visual acuity was no perception of light in 10 (53%) and ‘counting fingers’ or worse in 16. Victims spent an average of nearly 10 days as an inpatient.
The characteristics of the incidents that lead to ocular air-weapon injuries are unchanged. Reform of the firearms laws is probably the best way to prevention.
Injuries and fatalities resulting from air weapons have been widely reported1,2 and numerous investigators in different countries have called for measures to raise public awareness or for legislative changes. But the law in England and Wales has changed little in the past 30 years. We have reviewed air-gun injuries to the eye in south-west England to examine the circumstances, the characteristics of the individuals, the damage caused and the functional effects.
A letter was circulated to 50 ophthalmic consultants in the south-west region (including South Wales). The letter asked the consultants to supply the following information about any individual that they could recall who had sustained an ocular air-weapon injury, past or present: type of incident that resulted in the injury; characteristics of the individual(s); damage sustained; medical interventions performed as a result of the injury; and effects of injury. The letter did not request a response if no such injury could be recalled.
Where any of the above information was missing, a proforma was sent to the reporting ophthalmologist for completion from the case records. The data collected were entered into a database for simple descriptive analysis.
Verbal or written replies were received from 20 of the 50 consultants contacted. 19 cases of ocular injury were identified and no case was reported by more than one ophthalmologist. The earliest case was seen in 1988 and the latest in 1998. The demographic characteristics of the victims are recorded in Table 1 and the details of the incident that led to the injury in Table 2.
Where not stated, it is reasonable to assume that the injuries were inflicted by 0.177 or 0.22 air weapons. However, 3 BB gun injuries were readily identified (in the USA BB means a ball-bearing gun; in the UK plastic pellets are the usual projectiles). All victims, except one with a BB gun injury, presented immediately to the emergency department. In the 15 cases investigated radiologically, a total of 11 series of plain X-rays, 7 computed tomographic scans and one magnetic resonance (MRI) scan were performed. The MRI was done only after an identical air-gun pellet had been found to be non-magnetic; it revealed a pellet embedded in the occipital cortex (having transversed the orbit and the cranium) and the patient had a resultant defect in the visual field of the undamaged fellow eye.
9 injuries were penetrating or perforating globe ruptures, 8 were severe contusions and 2 were minor contusions. Within the first 2 days, 7 patients underwent a primary repair of the eye, 1 eye was eviscerated and one victim required intracranial surgery. The remaining 10 patients were initially managed conservatively, including one with a ruptured globe which was enucleated on day 6.
The site of the pellet was recorded as intraocular in 4 cases, intraorbital in 7, in the orbital wall/cranium in 2, and in the maxillary sinus in another. No pellet was evident in 4 cases and details were not available in 1. In all, 21 operations were performed as a result of these injuries. Eventually 6 eyes were either enucleated or eviscerated and 7 required ocular prostheses. On average, victims spent 9.7 days as inpatients (range 0-23) and visited as outpatients on 10.3 occasions (range 1-56). Several are still under ophthalmic review.
The visual acuities at presentation and at the last visit are illustrated in Figure 1. Visual acuity deteriorated in 9, was unchanged in 5 and improved in only 3 (2 not determined). Of note is that BB weapon injuries were associated with a better outcome than conventional 0.177 and 0.22 air-weapon injuries with a last recorded visual acuity of 6/7.5 Snellen or better in all 3 cases. Of the 9 victims with penetrating/perforating injuries 8 were eventually recorded as having no perception of light and the other as light perception only.
First we must address the weaknesses of this study. Since the patients were ascertained retrospectively by questionnaire, with ophthalmologists having to recall cases from memory, the data are likely to be incomplete and biased towards severe cases. Our aim is to show that these devastating injuries still occur in sizeable numbers and to reinforce the case for preventive action.
Every year more than 1000 incidents involving air weapons are recorded in the UK3 and at least 1 person is killed4. Since 1994 at least 3 children have been shot dead whilst numerous other irresponsible, depraved and illegal acts have been reported by the media. In the USA the number of reported incidents is twenty-five times higher and 7 deaths are recorded annually5,6. Despite having some of the strictest gun control laws in the world, the UK still allows children under 14 to use an air weapon if supervised by a person over 217. There may be as many as 4 million air weapons in the UK8, and most do not require certification. The laws relating to such weapons in England and Wales have changed little in 30 years. The ophthalmologist, perhaps better than most, appreciates the devastating effects and lasting morbidity that air weapon injuries inflict (Table 3).
The findings of our study are in close accord with previous reports9,10. Typically the victim is a juvenile male9,10,11 injured accidentally and nearly always in the absence of adult supervision10,11,12. A friend, relative or the victim himself or herself, is usually responsible for discharging the weapon directly into the eye at close range, but ricochets and accidents whilst cleaning weapons also occur. A few shootings are deliberate acts of violence19.
The presence of a penetrating injury or an intraocular pellet carries a grave prognosis10,20 and the advent of routine vitrectomy surgery has not improved outcomes21,22. The long-term visual outlook is poor, with 10-60% of all injured eyes becoming phthisical or requiring evisceration or enucleation.
It is of concern that the characteristics of the incidents leading to air-gun injuries, and those of the victims, have not altered despite numerous calls for stricter licensing or prohibition of such weapons9,23,24. Either the threat posed by these weapons is not taken seriously or politicians and public remain unaware of these devasting injuries which can blight lives25.
Since many injuries already occur outside of the existing laws, some researchers favour measures to raise public awareness26,27,28. However, previous lessons do not seem to have been learned, and we suggest that the only answer lies in restricting access and ownership of such weapons.