|Year : 2014 | Volume
| Issue : 2 | Page : 76-80
Pattern of gun pellet ocular injuries in Kashmir, India
Imtiyaz A Lone, Wasim Rashid, Nusrat Shaheen, Sheikh Sajjad
Department of Ophthalmology, Sher-i-Kashmir Institute of Medical Sciences Medical College, Srinagar, Jammu and Kashmir, India
|Date of Web Publication||10-Apr-2015|
Dr. Imtiyaz A Lone
Sher-i-Kashmir Institute of Medical Sciences Medical College, Srinagar - 190 017, Jammu and Kashmir
Source of Support: None, Conflict of Interest: None
Objective: The objective was to study the type and severity of ocular injuries in gun pellet victims.
Materials and Methods: The study is a retrospective case series conducted in the Department of Ophthalmology, SKIMS Medical College, Bemina, Srinagar. The study included gun pellet victims admitted in our department between January 2010 and September 2013.
Results: The study included 20 patients with 19 males and 1 female. Mean age of the subjects was 21.45 years. Ocular injury was unilateral in 17 cases and bilateral in 3 cases. The most common type of injuries encountered were hyphema in 82.60% of eyes, followed by corneo-scleral tear in 78.26% and vitreous hemorrhage in 47.82% of eyes. Of the 23 eyes, 18 eyes (78.26%) had an open globe injury, while only 3 eyes (13.04%) had closed globe injury at presentation in our hospital. The most commonly performed surgery was corneo-scleral repair in 18 eyes. Final corrected visual acuity (VA) remained unchanged in 34.78% and improved in 65.22% of eyes. About 47.83% of eyes had final VA < 6/60.
Conclusion: Gun pellet related ocular injuries are becoming increasingly common in Kashmir Valley. In severely injured eyes, the visual prognosis remained poor despite adequate treatment. Measures toward reducing violence in our society so as to reduce avoidable visual impairment are strongly advocated.
Keywords: Corneo-scleral tear, gun pellet, hyphema, ocular injuries
|How to cite this article:|
Lone IA, Rashid W, Shaheen N, Sajjad S. Pattern of gun pellet ocular injuries in Kashmir, India. Afr J Trauma 2014;3:76-80
| Introduction|| |
Ocular trauma has recently been highlighted as a major cause of visual morbidity. Worldwide there are approximately 1.6 million people blind from eye injuries, 2.3 million having bilateral visual impairment and 19 million with unilateral visual impairment.  Etiologically ocular injuries can be classified into domestic, occupational, sports, road traffic accidents, iatrogenic, fights and assaults, and war injuries.  In the 1960s and 1970s, road traffic accidents became the most common cause of serious ocular injuries.  In the 1980s, sports and leisure activities became a common cause of severe eye injury.  The home is now the most common location for eye injuries.  However, bomb blast and battlefield ocular injuries are becoming increasingly common in different parts of the world. 
Ocular injuries following pellet gun fire have been on the increase in Kashmir Valley (India) over the past few years. To curb agitated mobs, the security forces fire pellet gun cartridges, considered to be a nonlethal weapon.
It is of note that a single pellet gun cartridge when fired (from the pellet gun) breaks into more than 500 small iron pellets which can penetrate any body tissue including eyes. Therefore, an eye can be injured by one or multiple pellets. The velocity and distance of the pellet can determine the nature of the eye injury.
The study was conducted to determine the pattern of gun pellet ocular injuries in Kashmir Valley, India.
| Materials and Methods|| |
The present retrospective study was conducted in the Department of Ophthalmology, SKIMS Medical College, Bemina, Srinagar between January 2010 and September 2013.
The purpose of our study was to evaluate the type and severity of ocular injuries in gun pellet victims. The patient population was defined by reviewing the admission records of the hospital database. We retrospectively reviewed the clinical files of 20 patients who suffered an eye injury from gun pellets. All patients were admitted in the Department of Ophthalmology between January 2010 and September 2013. The presenting case records, operation theater notes, and out-patient follow-up of each of these patients were obtained and analyzed with regard to age and sex of the patient, circumstances surrounding the injury, presenting ocular signs, subsequent management, and final visual outcome. There was no subject with a preinjury history of ipsilateral amblyopia or previous ocular trauma. All patients were victims of gun pellet injuries, and all of them were resident of Kashmir Valley.
The terms used in the description of ocular injuries conform to the recommendations of Birmingham Eye Trauma Terminology System  which is an unambiguous, consistent, simple, and comprehensive system to describe any type of mechanical globe trauma.
Proper consent was taken from the hospital ethical committee as well as the hospital medical record department, for carrying out the study.
| Results|| |
Twenty patients were included in this study. All ocular injuries were due to gun pellets made of iron [Figure 1] and [Figure 2].
|Figure 2: Pellet removed from the anterior chamber of the eye with limbal tear at 6'o clock|
Click here to view
The age distribution of the patients is shown in [Figure 3]. Most were in the age range 15-25 years. The mean age of our study group was 21.45 years. The youngest patient in our study was 14 years old, and the eldest patient was 32 years of age, notably 75% of those injured were below the age of 23 years. Nineteen males and one female represent a 19:1 male to female ratio.
Ocular injuries were unilateral in 17 cases and bilateral in 3 cases. The pattern of eye injuries among 23 eyes of 20 patients is shown in [Table 1].
The most common type of injuries encountered were hyphema in 82.60% of eyes, followed by corneo-scleral laceration in 78.26% and vitreous hemorrhage and iridodialysis in 47.82% each.
Of the 23 eyes, 18 eyes (78.26%) had an open globe injury, while only 3 eyes (13.04%) had closed globe injury at presentation in our hospital. Two eyes had injury to ocular adnexa alone without injuring the eyeball.
Retained intraocular foreign body (IOFB) was seen in six eyes (26.08%), confirmed on B-scan ultrasonography and one patient developed features of siderosis bulbi due to retained IOFB.
The treatment varied according to the type of injury. Three eyes with closed globe injury were managed conservatively. Others underwent single/multiple surgical procedures. Corneo-scleral repair was the most commonly performed surgery. Scleral autografting was done in one patient because of tissue loss. Seven patients needed cataract extraction with intraocular lens implantation. Vitreo-retinal surgery was performed in patients who had nonresolving vitreous hemorrhage, retinal detachment or retained postsegment IOFB. Canalicular laceration repair with silicon tube implantation was done in two patients [Table 2].
The visual acuity (VA) on admission and final corrected VA are shown in [Table 3].
About 52.17% of the eyes had only perception of light (PL + ) at the time of presentation in the hospital, reflecting the severe nature of trauma caused by gun pellets. The final corrected VA remained unchanged in 34.78% and improved in 65.22% of cases. About 47.83% of the cases had final corrected VA <6/60.
Final corrected VA in open injury group was worse than closed globe injury group. In open globe injuries, 61.11% of the eyes had a final corrected VA <6/60, whereas in closed globe injury group, all patients had a final corrected VA of >6/12.
Factors that were associated with poor prognosis include poor VA at presentation (<6/60), penetrating injury, delayed presentation in the hospital (more than 10 days), presence of relative afferent pupillary defect (RAPD), retinal detachment, retinal IOFB, and macular scarring. Factors that were associated with a better prognosis were small wound and wound location anterior to the insertion of rectus muscles.
| Discussion|| |
Ocular injury is an important and preventable cause of ocular morbidity.  Even though the eye comprises only a small part of the surface area of the human body,  it is still injured quite frequently. 
Over the past few years, security forces in Kashmir Valley have been using pump action shot gun or pellet gun to disperse violent mobs. Pellet guns have been introduced as nonlethal weapons for crowd control.
Review of the age and sex of these patients demonstrates that the "typical" gun pellet casualties are young males. Of the 20 patients, 19 were males and 1 was female; notably, 75% of those injured were below the age of 23 years. This was due to the fact that these agitated mobs comprised primarily of young males. The only female patient in our study was hit by the pellet while looking out of the window of her house. Both hospital- and population-based studies indicate a large preponderance of ocular injuries affecting young males , as was the case in our study.
The spectrum of ocular injury in this series was found to be similar to other studies, but perhaps the most important feature to appreciate was the severity of this type of injuries. We noted hyphema to be the most common manifestation of gun pellet injuries (82.6%). This was found to be in accordance with the consequences of nonpowder fire arm injuries reported previously. 
In this study, we found that majority of the injuries (78.26%) were open globe penetrating type. This pattern could be explained by the fact that nonpowder fire arms can generate muzzle velocities of 200-900 foot pounds/s  whereas ocular penetration can occur at velocities as low as 130 foot pounds/s.  Moreover, from a single cartridge, more than 500 pellets can be fired, thus accounting for the high incidence of penetrating trauma in our study.
The prognosis for penetrating eye injury is poor. In this study, we found that the most important factor predictive of a poor visual outcome is poor VA at presentation (<6/60). This is in agreement with other studies. ,, Other factors that were associated with a poor visual outcome included delayed presentation in the hospital, presence of RAPD, retinal detachment, retained IOFB, and macular scarring. Wound location anterior to the insertion of rectus muscles and small wound were favorable prognostic factors. These findings are in agreement with other studies. ,
In this study, we found that retained IOFB was seen in six eyes (26.08%). Of these six eyes, one had IOFB in anterior segment and the rest were present in the posterior segment. One of the eye-developed features of siderosis bulbi in which the IOFB had been missed on presentation in the hospital. Siderosis bulbi developed because the gun pellets used were made of iron. Retained gun pellets are best localized by plain X-ray of the orbit, although in selected cases additional information can be obtained from computed tomography scans and ocular B-scans.
The final corrected VA also depended on the type of injury.  In patients with closed globe injury (three eyes) all had a best corrected VA of >6/12, whereas in those with penetrating eye injury about 61.11% had a final corrected VA of <6/60. The most common cause of permanently reduced VA was a severe perforation of the globe, retained IOFB, and retinal damage.
The final VA was a significant indicator of the extensive, disruptive nature of these ocular injuries, and despite improved microsurgical techniques, in the present study, 47.83% of the injured eyes had a final corrected VA of < 6/60. Earlier authors , have reported 29-42% of cases in poor VA category, again reflecting the severe nature of trauma caused by these gun pellets.
| Conclusion|| |
Gun pellet ocular injuries were cause of avoidable blindness (VA <3/60) in nearly half (48%) of the study population in Kashmir Valley, affecting mostly young adult males. The two most common ocular injuries were hyphema (82.60%) and corneo-scleral laceration (78.26%). Final corrected VA in open globe injury group was worse than closed globe injury group. The factors that were associated with poor prognosis include poor VA at presentation (<6/60), penetrating injury, delayed presentation in the hospital (more than 10 days), presence of RAPD, retinal detachment, retinal IOFB, and macular scarring. The need to reduce the level of violence in the community so as to reduce avoidable blindness among youths underscored.
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[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2], [Table 3]