Eye Injuries From Fireworks Greater in Areas Where They Are Legal

The chances of eye injuries from fireworks were slightly higher among residents of areas where fireworks were legal compared with residents of areas where fireworks were banned, a single-center case-control study showed.

At a level 1 trauma center in Seattle, the odds of firework-related ocular trauma were higher among those living in an area where fireworks were legal compared with those living in an area where fireworks were banned (OR 2.0, 95% CI 1.2-3.5, P=0.01), reported Shu Feng, MD, of the University of Washington School of Medicine in Seattle, and colleagues in JAMA Ophthalmology.

Odds of firework injuries were higher for patients under age 18 (OR 3.1, 95% CI 1.7-5.8, P<0.001) and for males (OR 3.3, 95% CI 1.5-7.1, P=0.004). They were also more likely to be vision threatening compared with non-firework-related injuries (57% vs 40%; OR 2.1, 95% CI 1.2-3.5, P=0.01).

The findings are surprising since they show that "local firework bans might reduce ocular injury even if someone could easily travel to a neighboring region to buy or detonate fireworks," Feng told MedPage Today. "We see firework stands just outside city boundaries so people have easy access to fireworks even if they are banned in the area where they live."

Toni Marie Rudisill, PhD, MS, of West Virginia University in Morgantown, who has studied firework safety, said in an interview that a small number of studies from around the world have suggested -- but not proven -- that firework laws reduce injury rates.

Firework injury visits to U.S. emergency departments rose from 2008 to 2017, according to a 2021 study, rising to an estimated 7,699 (2.37 per 100,000 population) from 5,727 (1.88 per 100,000 population). Nearly three-quarters of injuries occurred in July, and 28% of injuries were considered severe. "Hands are the most frequently injured anatomic site, followed by facial/head/neck and ocular injuries," Feng and team noted.

Rudisill said the study findings align with previous research and offer a unique perspective by looking at local laws. "It is safe to say, based on the injury literature in general, that regulatory changes can influence injury rates in populations," she noted. "If products such as fireworks are more easily attainable, people may be more apt to use them and possibly be injured."

The researchers launched the study because "there have been a lot of changes and controversy within our state in the past decade regarding firework regulations, so we felt that it was worth studying whether these local regulations made any difference in odds of firework-related injury," Feng explained.

The study was conducted at Harborview Medical Center, the only level 1 trauma center in its geographic region. It serves the entire state of Washington, plus Alaska, Montana, Wyoming, and parts of Idaho and Oregon.

Under Washington state law, fireworks can only be sold around July 4 and January 1, and counties and cities may be more restrictive. Fireworks are banned without special permits in Seattle, the state's largest city. They're also banned in other large cities, such as Tacoma and Spokane, but they're allowed in several counties.

The study tracked ocular trauma injuries during the 2 weeks surrounding July 4 (June 28 to July 11) from 2016 to 2022 and identified 230 cases. Of those, 94 patients had firework-related injuries (mean age 25, 92% male). The majority of injured patients came from urban areas (84%), and most were white (63%).

Corneal abrasion was the most common firework-related injury (52% of cases), followed by bleeding in the eye (32%) and corneal foreign bodies (15%). The most common non-firework-related injuries included orbital fractures (36%), corneal abrasion (29%), and conjunctival or corneal laceration (17%).

"Some injuries involve mild irritation without need for treatment and result in no long-term consequences," Feng said. "However, others involve severe vision loss despite extensive surgeries and can even cause eventual loss of the eye and cosmetic disfigurement."

Twenty-five percent of patients had 1-year follow-up visits. "Reasons for poor visual acuity at 1 year after injury included corneal scarring (2 eyes), severe open globe injury (2 eyes), macular hole (1 eye), glaucoma (1 eye), cystoid macular edema (1 eye), and amblyopia after firework-related cataract occurring at 5 months of age (1 eye)," the authors wrote.

Study limitations included the lack of information about where fireworks were purchased and the fact that it only looked at one center's experience.

Moving forward, Feng and team wrote, "legislation, including local bans, could be considered to decrease the morbidity of firework-related ocular trauma, and additional studies may determine what actions might lead to greater reductions in harm."

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