JRSM >
Volume 94, Number 8 >
Pp. 396-399
Bristol Eye Hospital, Lower Maudlin Street, Bristol BS1 2LX, UK
1
West of England Eye Unit, Royal Devon and Exeter Hospital, Barrack Road,
Wonford, Exeter EX2 5DW, UK
Correspondence to: GN Shuttleworth
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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.
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| METHODS |
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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.
| RESULTS |
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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.
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| DISCUSSION |
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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).
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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.
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  S Iqbal, M M K Muqit, B J O Mathews, and F Bishop Trans-oculofacial injury from airgun pellet Emerg. Med. J., May 1, 2007; 24(5): 370 - 370. [Full Text] [PDF]
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 H Ceylan, A McGowan, and M D Stringer Air weapon injuries: a serious and persistent problem Arch. Dis. Child., April 1, 2002; 86(4): 234 - 235. [Full Text] [PDF]
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presentation; 
last visit