It's been said that "safety never takes a holiday." With the season of ongoing winter holidays––Thanksgiving, Chanukkah, Kwanzaa, Festivus, Christmas and New Year's–upon us, every physician dreads the idea of being called to the office for an emergency. More importantly, none of us want to find ourselves or our family members falling victim to an injury during this happy, normally carefree time.

So, as we get ready to celebrate the holidays, our gift to you is a few friendly words of advice and warning about the potential dangers that lurk in the guise of celebration, and how best to avoid or manage these untimely problems.

'Oh Christmas Tree, Oh Christmas Tree!'

As beautiful as it may be to have a lighted and decorated evergreen in the house while the trees outside are bare and snowcovered, Christmas trees can pose many potential ocular threats. Between the pine/fir/spruce needles, the electric light bulbs and the glass ornaments, there are multiple hazards awaiting the holiday reveler… particularly if he or she has been indulging in a few glasses of "Christmas cheer!" The needles of some conifer trees can be up to 1.5in long, providing a unique and dangerous source of ocular trauma––especially corneal abrasions and possibly even perforation.

Several studies have reviewed the incidence of eye injuries related to Christmas trees, and researchers have noted that just as many (or even more) instances of trauma occur during the harvesting, transporting and disposal of the trees as do during initial setup and decoration.^1,2

Children may be especially vulnerable to such injuries, either from low-hanging branches impeding their path to gifts, or from sharp, irregularly shaped ornaments hanging at eye level.³ Ideally, we can prevent these situations by counseling patients (and their family members) to take proper precautions when carrying or decorating Christmas trees, including using safety eyewear to prohibit abrasions and foreign bodies. Likewise, to avoid unwanted trauma, make sure that presents placed beneath the tree are easily accessible.

'You'll Shoot Your Eye Out, Kid!'

There are probably very few of us who don't recognize or recall this classic line from A Christmas Story, and it's a good line to remember—children's toys can be a significant cause of eye injuries. By far, the greatest culprits are projectile toys like paintball, pellet and even airsoft guns, which can all cause significant ocular trauma.^4-6

While not ubiquitous, these items are still very popular in some areas of the county and present a possible danger to ocular health. The risk can be mitigated, however, with the use of appropriate safety eyewear––a mandatory stipulation with any and all types of toy guns. Parental supervision is another important consideration whenever children are using such projectile-firing devices.

Common Treatments for Not-So-Merry Mishaps

Having practiced for the last 25+ years, we can attest to the fact that it's no fun taking call over the holidays. But as many of us know all too well, patients with ocular injuries quite often receive better and more appropriate care from their optometrist than they would from a hospital emergency room. If an injury should take you away from your holiday festivities, triage the patient thoroughly and assess the level of damage. Then remember these important points: • The most common traumatic injuries include corneal abrasions, burns and foreign bodies. Employ a potent cycloplegic (homatropine 5% or atropine 1% BID) to help suppress a secondary uveitis. Remove any superficial foreign bodies and debride any loose, burned or otherwise compromised epithelium. Then use a bandage contact lens with a prophylactic antibiotic (e.g., moxifloxacin 0.5% TID) to facilitate re-epithelialization. These types of injuries typically require follow-up daily or every other day until the cornea is re-epithelialized. • In cases of projectile injury, careful but gentle examination is required. If no sign of perforating injury is seen, conduct a thorough ocular evaluation and perform a dilated fundus examination. Giant retinal tears (defined as involving >90° degrees or the retina) require immediate surgery, as do detachments involving or threatening the macula. In the latter case, recommend supine bedrest until consultation and treatment can be arranged.14

Traumatic hyphema and uveitis are best managed with strong cycloplegics, potent topical steroids (e.g., difluprednate 0.05% dosed QID or greater) and relative immobilization. Hyphema patients must be examined daily for the first five days to guard against rebleed; uveitis patients may be seen for follow up as severity dictates. It is also important to rule out angle recession by performing gonioscopy on all closed globe injuries approximately 30 days after the incident. • Patients suspected of having penetrating or perforating injuries must be quickly referred to an appropriate surgical facility. It is recommended that no prophylactic or therapeutic drops be instilled, but rather efforts should be directed at carefully shielding the patient's eye from further damage. Contact appropriate specialists for consultation, and arrange transportation for the patient. Remember that MRI is generally contraindicated if a metallic foreign body (such as a BB or pellet) is suspected, so X-rays or CT scans are preferable options. In suspected perforating injuries, remember that "RSVP" isn't limited to holiday party invitations: Redness, Sensitivity to light, Vision loss and Pain are indicators of endophthalmitis resulting from orbital penetration.

A number of other toys also have been implicated in ocular trauma. Remote control helicopters, which are now widely available and affordable, are yet another potential source of devastating ocular injury.⁷ Additionally, toys or products that incorporate functioning lasers can lead to inadvertent, but sight-threatening, retinal burns.⁸

While we understand that accidents may happen, it is important to make sure that younger children receive safe and appropriate toys whenever possible and are counseled on proper use. In general, avoiding items with sharp edges, projectiles and high-intensity lights is good advice.

Happy New Year!

In the United States, it is often customary to pop champagne corks at the stroke of midnight on New Year's Eve and celebrate the incoming year with a glass of bubbly. As you can imagine, ocular contusion injuries due to airborne corks pose a small but real threat to revelers. The array of possible trauma-related diagnoses include corneal abrasion, hyphema, uveitis, iridodialysis, traumatic cataract, lens subluxation, retinal tears, retinal detachments and even globe rupture.^9,10

In other cultures, and some more localized areas of the US, New Year's festivities may include fireworks and even celebratory gunfire. The potential for ocular injuries due to recreational explosives and incendiary devices is well known: "party poppers" (hand-held, bottle-shaped plastic party favors that emit a shower of streamers and confetti when a string is pulled) can cause burns to the skin and eye if fired at close range, and more severe and sightthreatening injuries have been caused by firecrackers, cherry bombs, bottle rockets, roman candles and other such items.^11,12

It should come as no surprise that firing handguns into the air (a dangerous practice encountered every year on New Year's Eve in such places as Miami, Houston, Los Angeles and Puerto Rico) can lead to an array of injuries, including potentially to the eyes, and in some cases result in fatalities.¹³

So, with a little caution and a dash of common sense, you can help protect both your family and your patients from significant ocular injury during the coming weeks.

Here's wishing all of you a very happy, healthy and peaceful holiday season. We look forward to sharing our experiences and perspectives with you in 2015.

1. Brazier DJ. Eye damage from Christmas trees. Lancet. 1984 Dec 8;2(8415):1335.
2. Tsatsos M, Tsesmetzoglou E, Triandaffilidis C, et al. Christmas- related eye injuries: a prospective study. Clin Experiment Ophthalmol. 2010 Jan;38(1):85-6.
3. Kimia A, Lee L, Shannon M, et al. Holiday ornamentrelated injuries in children. Pediatr Emerg Care. 2009 Dec;25(12):819-22.
4. Pahk PJ, Adelman RA. Ocular trauma resulting from paintball injury. Graefes Arch Clin Exp Ophthalmol. 2009 Apr;247(4):469-75.
5. Shazly TA, Al-Hussaini AK. Pediatric ocular injuries from airsoft toy guns. J Pediatr Ophthalmol Strabismus. 2012 Jan- Feb;49(1):54-7.
6. Bisplinghoff JA, Duma SM. Evaluation of eye injury risk from projectile shooting toys using the focus headform - biomed 2009. Biomed Sci Instrum. 2009;45:107-12.
7. Alphonse VD, Kemper AR, Rowson S, Duma SM. Eye injury risk associated with remote control toy helicopter blades. Biomed Sci Instrum. 2012;48:20-6.
8. Raoof N, Chan TK, Rogers NK, et al. 'Toy' laser macular burns in children. Eye (Lond). 2014 Feb;28(2):231-4.
9. Cavallini GM, Lugli N, Campi L, et al. Bottle-cork injury to the eye: a review of 13 cases. Eur J Ophthalmol. 2003 Apr;13(3):287-91.
10. Kuhn F, Mester V, Morris R, Dalma J. Serious eye injuries caused by bottles containing carbonated drinks. Br J Ophthalmol. 2004 Jan;88(1):69-71.
11. Tadisina KK, Abcarian A, Omi E. Facial firework injury: a case series. West J Emerg Med. 2014 Jul;15(4):387-93.
12. Sacu S, Ségur-Eltz N, Stenng K, Zehetmayer M. Ocular firework injuries at New Year's eve. Ophthalmologica. 2002 Jan-Feb;216(1):55-9.
13. Centers for Disease Control and Prevention (CDC). New Year's Eve injuries caused by celebratory gunfire–– Puerto Rico, 2003. MMWR Morb Mortal Wkly Rep. 2004 Dec 24;53(50):1174-5.
14. García-Arumí J, Martínez-Castillo V, Boixadera A, et al. Rhegmatogenous retinal detachment treatment guidelines. Arch Soc Esp Oftalmol. 2013 Jan;88(1):11-35.