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Comment & Response
March 26, 2020

Nonpowder Firearm–Associated Eye Injury Prevention—Reply

Author Affiliations
  • 1Department of Surgery (Ophthalmology), Jacobi Medical Center, Bronx, New York
  • 2Department of Ophthalmology and Visual Sciences, Albert Einstein College of Medicine, Bronx, New York
  • 3Department of Pediatric Ophthalmology, New York Eye and Ear Infirmary, New York
  • 4Research Services, University of Pennsylvania, Philadelphia
  • 5Department of Surgery (Trauma), Jacobi Medical Center, Bronx, New York
JAMA Ophthalmol. Published online March 26, 2020. doi:10.1001/jamaophthalmol.2020.0552

In Reply We wish to thank Desapriya and Peng for their interest in our study titled “Patterns of Pediatric Firearm-Related Ocular Trauma in the United States.”1 They point out that we did not focus on nonpowder firearm–associated injuries and reports of these injuries rarely appear in academic journals. Although their assessment of our focus is correct, we referenced 5 articles focused on nonpowder firearm injuries and stressed their growing importance in the Limitations section of our article. We hope the recent efforts to categorize nonpowder firearm use as high-risk activity for ocular trauma and mandating protective head gear will have the measurable outcome of reducing ocular trauma.

Our study aimed to present the association of all firearm uses (powder and nonpowder) with ocular trauma. To this end, we extracted all pediatric patient data from the National Trauma Data Bank (NTDB) with firearms as a mechanism. This generated data categorized in broad firearm types and their associated intentions (assault, self-inflicted injury, and unintentional injury). Air guns were included, without the specificity of airsoft, pellet, or BB gun subtypes. Paintballs were not included in the firearms data set. However, a review of all pediatric firearm–associated injuries revealed that 94.6% were powder and 5.4% were nonpowder firearms. This underscores the observations made in the Invited Commentary that NTDB data represent an underestimation of the full burden of firearm injuries. Canner et al2 reviewed the Nationwide Emergency Department Sample, a more accurate estimate and, using the same International Classification of Diseases, Ninth Revision (ICD-9) code criteria for 2008-2014, found an annual rate of 2898 pediatric firearm–associated ocular injuries compared with the 282 we found. They attributed most of these differences to unintentional air gun and paintball gun injuries. Other sources of underestimation are constraints of the less precise ICD-9 coding system. An updated study of the available 2015-2017 NTDB data, with more precise International Classification of Diseases, Tenth Revision coding, which now includes paintball injury by assault (X95.01XA), may provide more accurate and current information.

We acknowledged these limitations in our report1 and stressed that NTDB data primarily detail trauma in admitted patients. Most patients with nonpowder firearm–associated ocular injuries may not be accounted for, since they likely were treated at outpatient centers not contributing to the NTDB. A recent study of nonpowder firearm injuries using the National Electronic Injury Surveillance System data (1990-2016) evaluated 364 133 pediatric cases and found that common eye injuries were corneal abrasions (35.1%), hyphema (12.5%), foreign bodies (10.9%), and globe rupture (10.4%).3 Most of these injuries typically are treated in outpatient settings.

In closing, firearms remain the second leading cause of pediatric morbidity and mortality.4 Additionally, mass school shootings, which typically use powder firearms, continue to rise annually.5 Although, we agree that nonpowder firearms are a growing concern, we feel addressing firearms collectively is not without merit. Canner et al2 stressed that addressing prevention in this public health crisis will require a multifaceted, tailored approach. We are hopeful that our study1 will inform clinicians and policy makers of the gravity and complexity of firearm injuries and inspire future studies, using more focused design and recent and representative data.

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Article Information

Corresponding Author: Joyce N. Mbekeani, MD, Department of Surgery (Ophthalmology), Jacobi Medical Center, 1400 Pelham Pkwy, Bronx, NY 10461 (jnanjinga888@gmail.com).

Published Online: March 26, 2020. doi:10.1001/jamaophthalmol.2020.0552

Conflict of Interest Disclosures: None reported.

Weiss  R, He  C, Gise  R, Parsikia  A, Mbekeani  JN.  Patterns of pediatric firearm-related ocular trauma in the United States.  JAMA Ophthalmol. 2019;137(12):1363-1370. doi:10.1001/jamaophthalmol.2019.3562PubMedGoogle ScholarCrossref
Canner  JK, Sakran  JV, Woreta  F.  A vision for the future of pediatric firearm-related ocular trauma.  JAMA Ophthalmol. 2019;137(12):1371-1372. doi:10.1001/jamaophthalmol.2019.3587PubMedGoogle ScholarCrossref
Jones  M, Kistamgari  S, Smith  GA.  Nonpowder firearm injuries to children treated in emergency departments.  Pediatrics. 2019;144(6):e20192739. doi:10.1542/peds.2019-2739PubMedGoogle Scholar
Cunningham  RM, Walton  MA, Carter  PM.  The major causes of death in children and adolescents in the United States.  N Engl J Med. 2018;379(25):2468-2475. doi:10.1056/NEJMsr1804754PubMedGoogle ScholarCrossref
Kalesan  B, Lagast  K, Villarreal  M, Pino  E, Fagan  J, Galea  S.  School shootings during 2013-2015 in the USA.  Inj Prev. 2017;23(5):321-327. doi:10.1136/injuryprev-2016-042162PubMedGoogle ScholarCrossref
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