Holidays are a time for festivities, celebrations, gatherings, and … ocular injuries. Though our minds may be on gifts and fun, holidays can provide scenarios with great potential for eye trauma. In this month's column, we will review some of the unique injuries that can occur on or near our red-letter days.

January: New Year's Eve
New Year's Eve typically starts the year on a jubilant and festive note. However, for some revelers, the evening can become dangerous as champagne bottles start to pop. The cork bottle stoppers can become hazardous projectiles, particularly injurious if aimed at the eye.

Looking back at the origins of champagne, some purport that Dom Perignon, the 17th century monk hailed as the drink's inventor, was, ironically, blind, and as such possessed a heightened sense of taste that allowed him to perfect the creation of champagne. This story is now dismissed by most historians as false, though the connection between ocular injury and champagne remains real.

Several epidemiological surveys have examined the incidence of champagne-related ocular injuries.1 One recent look at bottle-related ocular injuries compiled U.S., Hungarian, and Mexican data, totaling 12,889 injuries. This analysis found the overall incidence of injuries related to bottle tops, corks and/or bottle glass shards to be 0.7 percent (90 injuries). When examining how many of the bottle-related injuries were specifically due to champagne corks, this again was significantly higher in Hungary (71 percent of carbonated-beverage bottle injuries), followed by the United States (20 percent) and Mexico (0 percent). The high incidence in Hungary is hypothesized to be at least partially due to the lack of warning labels on champagne bottles in that country.

Of the bottle-related injuries in the United States, 80 percent resulted in open-globe injuries, half in retinal injuries, with 13 percent of these patients requiring three or more surgeries. Open-globe injuries were more likely to result from incidents with glass shards, either from the bottle or the injured person's eyeglasses. Overall, 43 percent of eyes injured in this manner remained legally blind.2

A separate case series of 13 patients injured by corks from sparkling wines noted that the most common initial injuries were anterior chamber hyphema (84.6 percent), corneal injury (62.2 percent), ocular hypertension (46.1 percent), lens subluxation (30.8 percent), traumatic cataract (23.1 percent) and post-traumatic retinal edema (23.1 percent). The most frequent late complications were anomalies in pupil motility (38.5 percent) and traumatic cataract (30.8 percent).3

As for Dom Perignon, though not blind, he actually may have experienced vision impairment at some point in his life. Some researchers hypothesized that this may have been due to cataracts, refractive error or injuries related to his work, such as alcohol toxicity or "champagne-related ocular/cerebral trauma."4

February/March: Mardi Gras
Though long celebrated around the world, Mardi Gras was first brought to the United States by French explorers navigating the coast of what is now Louisiana in 1699, on the day that Mardi Gras was being celebrated in their homeland. This prompted them to name the promontory on which they were encamped, "Point du Mardi Gras," though more than 150 years passed before New Orleans saw its first Mardi Gras parade. Today, millions of tourists flock to the city streets each year for parades and festivities, and that's where the eye injuries start.

A large component of the Mardi Gras celebration is the throwing of beads, doubloons and other small items from parade floats to spectators. These trinkets can be dangerous  when thrown into crowds. A survey of such injuries was conducted from 1998 to 1999, using standardized questionnaires to record injuries at New Orleans-area hospitals. Forty-eight Mardi Gras-related eye injuries were tallied in the two-year study.

Half the injuries resulted from beads and 11 percent from doubloons. Eighteen percent of all injuries were categorized as severe (defined as open globe, corneal foreign body, intraocular foreign body, retinal detachment, orbital wall fracture or hyphema). The most common presenting symptoms were pain, blurred vision, foreign body sensation, tearing and photophobia. Upon slit-lamp exam, the most common finding in 1998 was corneal abrasion, in six patients. In 1999, subconjunctival hemorrhage, corneal abrasions, and cell and flare were the most common, each in nine patients. Other findings included cut lids, conjunctival hyperemia and corneal foreign body.5

July: Independence Day
Independence Day fireworks are one of the more common causes of holiday-associated injuries.

The Centers for Disease Control and Prevention have published a report based on Morbidity and Mortality Weekly reports from July 1990 to December 1994 regarding serious eye injuries. During this time, 4,575 serious eye injuries were reported to the U.S. Eye Injury Registry, 6 percent (274) of which were associated with fireworks. Approximately 80 percent of fireworks-related eye injuries occurred around July 4th. In 45 percent of the cases, the injured party was a bystander, and in 35 percent the fireworks operator was the victim. Bottle rockets were most associated with ocular injury in this study, causing 58 percent of these accidents.6

The U.S. Consumer Product Safety Commission published a report of fireworks-related injuries in 2003, estimating that 9,300 fireworks-induced injuries required treatment at emergency rooms, 1,400 of which were ocular injuries. Of these, 400 were burns (from the firework itself or from its debris), 500 were contusions or lacerations and the remaining 500 were not specified. The common culprits in this report were firecrackers.7

One U.K. study documented ocular fireworks injuries at 25 eye centers and hospitals during the two weeks surrounding Guy Fawkes Day. The eye centers saw 39 patients, and the hospitals saw 18. A quarter of the injuries involved only lids or conjunctiva and 55 percent exhibited superficial corneal lesions. The remaining 20 percent were severe ocular injuries resulting in permanent visual loss, including lid, conjunctiva or corneal burns, dislocated lenses, hyphema, traumatic cataracts and/or iris sphincter ruptures. Most injuries occurred at home, to males, and with bystanders more often being the victims.8

October: Halloween
Halloween presents several problematic ocular health scenarios. Decorative and colored contact lenses are often worn by children or young adults with no prior lens wearing experience. This lack of knowledge is compounded by the fact that many of these decorative lenses are purchased directly through Internet- or phone-based sales companies. The role of the eye-care practitioner and the instructions which we relay to new lens wearers are lost. This egregious oversight translates to an increased potential for inexperienced wearers to inappropriately wear or care for these lenses.

The U.S. Food and Drug Administration has issued warnings on this topic, cautioning consumers about the direct distribution of decorative lenses.

Improper wear can result in corneal ulcers, scarring, ocular infection, and, rarely, blindness or loss of the eye. More commonly, a bad lens fit can result in ocular abrasions. The FDA has also attempted to halt the entry of these lenses into the United States and requested that doctors report any adverse patient outcomes due to decorative contact lens wear by participating voluntarily in their "MedWatch" program.9,10

Halloween also presents other, more bizarre dangers. One report has documented several Halloween-related injuries from "flying eggs." Five cases occurred on or near Halloween, in which thrown eggs hit people in the eyes. The ensuing ocular damage included periorbital contusions and swelling, corneal abrasions, retinal edema, papillary tears, anterior inflammation and hyphema. Two cases had permanent visual impairment.11

December: Yule Trees and BB Guns
Christmas is one final holiday that can be fraught with ocular peril.
Christmas trees can be the cause of eye injury due to branches or needles of the tree damaging the eye. One report has documented a series of 15 tree-related ocular injuries. Eleven were induced by natural trees, two by artificial. The cutting, carrying, transportation, and disposal of the natural trees seem to offer more potential for eye injury. All of the injuries from Christmas trees in this case series were corneal abrasions. The mildest involved punctate epithelial keratitis, while the more severe showed linear epithelial loss. For 13 patients, treatment included topical antibiotics and mydriatic agents or eye pad, and daily follow-up.12

Injuries can also result from gifts given on holidays or birthdays.
Many people are familiar with the movie "A Christmas Story" in which young Ralphie Parker is single-mindedly obsessed with receiving one gift for Christmas: a Red Ryder BB gun. Despite numerous warnings, he then proceeds to nearly shoot out his eye. Data from the United States Eye Injury Registry from 1982-2003 indicate that BB or pellet guns account for 5.1 percent of all ocular injuries.13 The victims of accidental BB gun injuries are predominately young males.

Data from the CPSC indicate that of the 22,800 air-powered/BB-gun injuries occurring during one year, 1,255 (0.6 percent) of these were ocular. Over 11 years, 22 patients were documented with penetrating injuries, 19 of which required enucleation.14

Another study examining the visual outcome of seven patients with BB-induced perforations found surgical intervention was required. This and other studies have noted that, though some eyes with perforating injury can have good visual outcomes,15 posterior perforation is typically associated with poor outcomes.16 It's clear that, in the case of BB injuries, prevention of the injury is most important.

Currently, the holiday calendar is almost complete, and a new year is just around the corner, meaning the festivities will soon begin again. Tools and surveys such as those compiled by the U.S. Eye Injury Registry as well as CDC and FDA reporting programs, help us track injuries and foster an awareness of their causes.

Watch out for those champagne corks as you welcome 2005, and keep your eye on the holidays. Remember they can present unexpected, but never unoriginal, potential hazards for ocular injury! 

Dr. Abelson, an associate clinical professor of ophthalmology at Harvard Medical School and senior clinical scientist at Schepens Eye Research Institute, consults in ophthalmic pharmaceuticals. Ms. Fink is manager of medical communications at Ophthalmic Research Associates in North Andover.

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