Firearm ocular injury is a general term for trauma to the globe, ocular adnexa, and orbit caused by firearms. In addition to mechanical trauma, chemical and thermal injuries from gunpowder residue combine, resulting in a more complex pathology than blunt trauma.
In the United States, an estimated 3.15 ocular injuries per 1,000 population are treated in emergency departments annually. One-third of patients with severe ocular injuries do not recover vision to 20/200 or better. Analysis of the National Trauma Data Bank from 2008–2014 identified 8,715 (3.7%) ocular injuries among 235,254 patients presenting with firearm-related injuries 1. Of these, 1,972 (23%) were in children, most with risk of blindness and associated traumatic brain injury (TBI) 2.
Injury types are classified into the following three categories:
The nature of risk varies by age. Children aged 0–3 years often sustain accidental injuries at home, and those under 10 years have a high risk of open globe injury. Individuals aged 19–21 years frequently sustain injuries on the street due to assault. The in-hospital mortality rate for children is reported to be 12.2%.
Depending on the type of injury, the following findings are observed.
Open Globe Injury
Corneal perforation/laceration: Full-thickness defect of the ocular wall.
Hyphema: Accumulation of blood in the anterior chamber due to traumatic hemorrhage.
Shallow anterior chamber/low intraocular pressure: Due to aqueous humor leakage.
Traumatic mydriasis/traumatic cataract: Due to direct damage to the iris or lens.
Vitreous hemorrhage / retinal detachment: Due to extension of injury to the posterior segment.
Orbital injury
Orbital fracture: Orbital wall fracture, including blowout fracture.
Ocular motility disorder / ophthalmoplegia: Due to entrapment of extraocular muscles or nerve injury.
Proptosis / eyelid edema: Due to intraorbital hemorrhage/edema.
Optic nerve injury: Traumatic optic neuropathy. RAPD becomes positive.
The Zone classification of open globe injury (OGI) is shown below. The more posterior the extent of injury, the worse the prognosis.
| Zone | Injury site |
|---|---|
| Zone I | Cornea / limbus |
| Zone II | Up to 5 mm posterior to the limbus |
| Zone III | More than 5 mm posterior to the limbus (IIIb: posterior to the equator) |
The breakdown of injury types in pediatric firearm-related ocular trauma (2008–2014) was: open globe injury 41.6%, orbital injury or fracture 30.0%, open wound of ocular adnexa 25.5%, and contusion of eye or adnexa 21.1% 2.
The types of firearms causing ocular trauma are diverse, including handguns, rifles, as well as airsoft guns and pellet guns, which can also cause severe eye injuries 3. Injuries may combine mechanical trauma, chemical trauma (from gunpowder residue), and thermal trauma.
Age-specific risk factors are shown below.
| Age group | Main risk factors | Odds ratio |
|---|---|---|
| 0–3 years | Unintentional injury (at home) | OR 4.41 (home: OR 5.39) |
| Under 10 years | Open globe injury (OGI) | OR 1.84 |
| 19–21 years | Assault (on street) | OR 2.17 (street: OR 1.61) |
Severe eye injuries such as hyphema, traumatic mydriasis, and retinal hemorrhage from airsoft gun pellets have been reported 4. In a US pediatric case analysis, about 28% of injured patients had visual acuity less than 20/50 after initial treatment, and over 98% of cases were not wearing protective eyewear. Proper protective eyewear is essential when using firearms, including airsoft guns.
If an open globe injury is suspected, avoid pressure on the eye and immediately apply a rigid eye shield. Perform the following evaluations:
Even if anterior segment findings are normal, CT examination should be performed if there is a history of trauma to prevent oversight. Pay attention to subtle signs such as subconjunctival hemorrhage, edema, and foreign body entry sites.
| Test | Main Indications/Features |
|---|---|
| CT | Most useful for detecting metallic foreign bodies, orbital fractures, and evaluating globe rupture. |
| X-ray | Screening for metallic foreign bodies (detectable if length ≥2 mm, thickness ≥0.4 mm). |
| Ultrasound | Useful for evaluating retinal detachment and choroidal hemorrhage when fundus view is obscured. |
| MRI | Contraindicated if a magnetic metallic foreign body is suspected. |
| OCT | Useful for evaluating traumatic macular hole and anterior segment injury. |
CT can simultaneously evaluate not only the location and size of intraocular and orbital foreign bodies but also intracranial changes. When globe rupture is suspected, do not press the probe firmly during ultrasound.
MRI is contraindicated if a metallic foreign body is suspected. CT is the first-choice imaging modality, allowing simultaneous evaluation of intracranial changes and orbital/intraocular foreign bodies. MRI can only be performed if the foreign body is clearly non-magnetic.
Open globe injury (adult) antibiotic administration:
Open globe injury (pediatric) antibiotic administration:
Symptomatic therapy includes antiemetics (ondansetron IV) to reduce intraocular pressure elevation and risk of intraocular content extrusion from Valsalva maneuver. For pain, morphine IV and sedatives are used.
Antifungal prophylaxis is not given unless there is evidence of fungal infection. Antibiotic prophylaxis for non-surgical orbital fractures in adults is also not recommended.
Primary surgery (wound closure) is recommended within 12–24 hours. The goal is infection prevention and avoidance of intraocular content extrusion.
Secondary surgery (lensectomy, vitrectomy) is generally performed as a second-stage procedure after primary surgery, but may be performed in a single stage if conditions permit. In cases of severe vitreous hemorrhage precluding fundus visualization, 3-port vitrectomy for removal of opaque vitreous and gas or silicone oil tamponade is performed.
If globe preservation is difficult, primary evisceration or enucleation is performed 5.
Intraocular foreign bodies should be removed as promptly as possible. The time to removal affects visual prognosis. Currently, removal is mainly performed via vitreous surgery (pars plana vitrectomy, PPV).
Early ophthalmology consultation is important; a 2023 study reported survival rates of 92.3% when ophthalmology was involved in orbital fracture patients versus 43.8% when not involved.
If extraocular muscle entrapment is present, emergency surgery is required. For non-urgent fractures, surgery can be considered after 7–14 days of observation, and some cases do not require surgery. In children, entrapment can be suspected with high probability based on the triad of orbital fracture, vomiting, and nausea.
Tissue damage from firearm injuries is characterized by a combination of three factors: mechanical, chemical, and thermal.
Open globe injury (OGI) is defined as a full-thickness defect of the eyewall. It is classified by mechanism as follows:
Ocular Siderosis
Cause: Release of iron ions due to retained iron foreign body.
Course: Iron ions deposit in ocular tissues (retina, lens, trabecular meshwork).
Outcome: Leads to cataract, retinal degeneration, glaucoma, and phthisis bulbi. Early removal is essential.
Proliferative Vitreoretinopathy
Cause: Persistent retinal damage, vitreous hemorrhage, and chronic inflammation.
Course: Progresses in order: inflammation → cell proliferation → vitreous membrane formation → tractional retinal detachment.
Outcome: Can lead to severe visual impairment. Indication for secondary surgery (vitrectomy).
Post-traumatic endophthalmitis occurs in 2–7% of open globe injuries. Contamination from plants or soil leads to a high rate of blindness. Endophthalmitis caused by virulent bacteria such as Bacillus species is known. In the Zone classification, the more the injury extends to Zone III, the worse the visual prognosis.
The United States Eye Injury Registry (USEIR) ceased operations in 2013, and the National Trauma Data Bank stopped collecting firearm-related data in 2014. This has resulted in a significant lack of population-based data on firearm-related eye injuries. Reconstruction of a comprehensive ocular trauma registry has been identified as a public health challenge.
Hospital-based violence intervention programs (HVIP) are gaining attention. The longest-running HVIP reported a 60% reduction in criminal activity among participating patients. Community/hospital-based programs (CVIP/HVIP), gun buyback events, and firearm safety courses are implemented in combination.
Waiting periods and child-access prevention laws are evaluated as effective policies supported by sufficient data. Modeling studies have also reported that promoting safe storage can prevent up to 32% of firearm-related deaths in the home. The American Medical Association (AMA) has expressed support for strengthening policies and research to improve firearm safety.
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Erickson BP, Feng PW, Ko MJ, Modi YS, Johnson TE. Gun-related eye injuries: A primer. Surv Ophthalmol. 2020;65(1):67-78. doi:10.1016/j.survophthal.2019.06.003. PMID: 31229522. PubMed ↩
Lee R, Fredrick D. Pediatric eye injuries due to nonpowder guns in the United States, 2002-2012. J AAPOS. 2015;19(2):163-168.e1. doi:10.1016/j.jaapos.2015.01.010. PMID: 25818283. PubMed ↩
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