Ocular Trauma from Paintball-Pellet War Games.

ABSTRACT

Background. We studied ocular injuries and visual outcome after blunt trauma from paintball pellets.

Methods. We retrospectively reviewed cases of ocular injury from paintball pellets occurring over 32 months.

Results. Ten cases of ocular injury from paintball pellets were recorded. Most patients (9) were injured at home or at a friend's home; only 1 was injured at a war game facility. Six patients had surgery. Final visual acuity was 20/25 or better in 6 patients, 20/30 to 20/50 in 2 patients, 20/60 to 20/100 in 2 patients, and 20/200 in 1 patient. Traumatic maculopathy and epiretinal membrane formation were determinants of worse final visual acuity.

Conclusions. Paintball pellet ocular injuries occur more frequently at home than at war game facilities. Advanced surgical techniques offer decreased ocular morbidity and improved visual acuity. Decreasing visual morbidity from paintball pellets requires public education, proper product labeling, and packaging of eye protection with all paintball-related products.

War Games, a combat-simulating sport, have become very popular over the last 15 years. These enterprises were begun by small businesses. These businesses rented equipment to participants, who played the game on a facility site where ocular protection was mandatory. However, as war games have increased in popularity, the equipment (Fig 1) has become easy to purchase and the games more often played at home, resulting in less use of ocular protection. We report 10 cases of ocular injury due to paintball pellets, 9 of which occurred at sites other than war game facilities.

METHODS

We retrospectively reviewed the clinical course of 10 patients who had ocular injury due to paintball pellets. Each patient was treated at one vitreoretinal referral practice over a period of 32 months. We documented the patients' sex, age, eye injury, place of injury, and ocular findings and whether the patient was wearing protective eyewear. Initial and follow-up examinations documented Snellen visual acuity and included slit lamp biomicroscopy, Tonopen intraocular pressure measurement, and indirect ophthalmoscopy.

Each patient's operative report was reviewed, and all ocular injuries were described. Each patient was contacted to ensure accuracy of the history originally taken. Final best-corrected visual acuity measurements were obtained for each patient from their general ophthalmologist.

RESULTS

Ocular injury from paintball pellets occurred in 10 patients (9 male and 1 female). Seven patients did not have ocular protection at the time of injury, 2 patients had goggles in position (the paint ball entered under the goggles), and 1 patient wore a full-face helmet. One patient was playing at a War game facility, and the other 9 patients were playing recreationally at home or a friend's home (Table 1). Initial vision was 20/100 or worse in 8 of 10 patients and was 20/70 in 2 patients. Initial intraocular pressure ranged from 13 to 42 mm Hg. Initial examination of the anterior segment revealed hyphema (8 patients), corneal abrasion (1 patient), cataracts (3 patients), lens subluxation (2 patients), and iris sphincter ruptures (3 patients). Initial posterior segment examination revealed vitreous hemorrhage (5 patients), choroidal rupture (1 patient), and commotio retinae (3 patients) (Table 2).

Late diagnoses included angle recession by gonioscopy (3), hyphema-induced glaucoma (1), phacolytic glaucoma (1), choroidal rupture (1, identified after cataract removal), epiretinal membrane (1), late traumatic cataract (1) (Fig 2), and traumatic maculopathy (2). No ruptured globes were observed.

Surgical management consisted of pars plana vitrectomy in 4 patients, pars plana lensectomy with intraocular lens placement in 3 patients, and anterior chamber washout in 1 patient. One of these patients had surgery due to phacolytic glaucoma 3 months after initial injury, and one had surgery at 5 months due to epiretinal membrane formation (Table 3). Four of the 10 patients were observed and did not have surgery.

The mean follow-up period for the 10 patients was 12 months (range, 6 to 32 months). Final visual acuity was 20/25 or better in 5 patients, 20/30 to 20/50 in 2 patients, 20/60 to 20/100 in 2 patients and 20/200 in 1 patient. All patients had improvement in final visual acuity compared with initial visual acuity. The 4 patients who did not have surgery had the best initial visual acuity, which did not necessarily correlate with best final visual acuity. Of 5 patients having surgery, 4 had a visual acuity of hand motion before surgery, and 1 had visual acuity of 20/200. The final visual acuity in the 5 patients who had surgery varied from 20/20 to 20/100. A final visual acuity of 20/25 or better occurred in 3 of 5 patients who had surgery. Determinants of a poorer final best-corrected visual acuity were traumatic matic maculopathy (3 of 10) and epiretinal membrane formation (1 of 10). No retinal detachments developed and no complications of surgery were noted.

DISCUSSION

War games using paintball pellets were first played in 1981. These recreational games have increased in popularity over the last two decades. Entrepreneurs initially purchased equipment and leased land to promote these war games, charging a fee to participants. More than one million people play the game annually in North America. (2)

Each war game consists of two teams varying in number of participants. Each person is equipped with a carbon dioxide-powered paintball gun (muzzle velocity, 250 ft/sec) (1) that fires 14-mm colored pellets composed of gelatin, glycerin, water, colored dyes, polyethylene glycol, and titanium oxide. The pellets shatter on impact, producing a "paint" stain. The goal of the war game is to capture an opponent's flag. Each player shot by a pellet is declared out of the game.

Each player at a war game facility is required to wear ocular protection consisting of goggles or full facial headgear. However, the goggles may often be knocked off during the physical play or may become foggy or dirty and be temporarily removed during the game. Although war game facilities do require ocular protection, no such requirements exist at other sites (eg, home). As the paintball guns and pellets have become easier to obtain, the use of these dangerous weapons at home has become more popular. Unfortunately, our study indicates that ocular protection is rarely worn when these games are played at non-- war-game-facility sites, such as at home.

Many case series have been reported since 1985 regarding paintball pellet ocular injuries (Table 4). (2-17) Most of these reports indicate that failure to wear ocular protection resulted in injury, though some injuries occurred despite proper use of ocular protection. Our series is similar with respect to the percentage of patients not wearing ocular protection. However, most of the injuries previously reported occurred when persons temporarily removed or adjusted their goggles, whereas our patients often did not have goggles since they were at sites other than war game facilities.

Where ocular injuries were specified in the literature, 26 (29%) had lens damage, 48 (53%) had vitreoretinal damage, and 73 (80%) had a hyphema. (1-17) Our series revealed similar findings on initial examination, including hyphema (7 of 10), vitreous hemorrhage (5 of 10), and lens damage (3 of 10).

The best-corrected final visual acuity in previous studies was variable. Of the 88 eyes in which final visual acuity was recorded, 36 (41%) had 20/40 or better visual acuity, 20 (23%) had 20/50 to 20/150 visual acuity, and 32 (36%) had 20/200 or worse visual acuity. Our series of patients tended to have a much better final visual acuity, with 6 of 10 maintaining vision of 20/25 or better and only 1 patient having a final visual acuity of 20/200 or worse. This trend might be explained by recent surgical and medical ophthalmologic advances or by less severe posterior segment trauma in our series of patients. Our rate of overall vitreoretinal injury is similar to that reported in the literature, but the severity of injury may vary between series. Five of our 10 patients did have surgery, with 4 requiring pars plana vitrectomy and 3 requiring a combination pars plana vitrectomy/pars plana lensectomy procedure.

Ocular blunt trauma caused by paintball pellets can result in severe ocular injury and permanent loss of vision. Although war game facilities mandate the use of ocular protection, these war games are more frequently being played at home, where protective eyewear is rarely used. Although advancements in medical and surgical ophthalmology may improve the prognosis for vision, public education and awareness should be emphasized to prevent the possible morbidity related to ocular paintball pellet trauma. Emphasis by manufacturers on eye safety measures and mandatory packaging of eye protection with all paintball-related items might be useful adjuncts to public safety education in reducing visual morbidity from paintball war games.

From the Departments of Ophthalmology and vitreoretinal Surgery, University of Alabama at Birmingham School of Medicine.

This work was supported by a Research to Prevent Blindness departmental grant.

Reprint requests to John O. Mason III, MD, Department of Ophthalmology and Vitreoretinal Surgery, University of Alabama at Birmingham School of Medicine, 700 S 18th St, Suite 505, Birmingham, AL 35233.

References

(1.) Standard Practice for Paintball Field Operation. Designation F#1777-97. West Conshocken, Pa, American Society of Testing and Materials, August 1997, pp 1400-1401

(2.) Easterbrook M, Pash by TJ: Eye injuries associated with war games. Can Med Assor J 1985; 133:415-419

(3.) Ryan EH Jr, Lissner G: Eye injuries during 'war games.' (Letter) Arch Ophthalmol 1986; 104:1435-1436

(4.) Tardif D, Little J, Mercier M, et al: Ocular trauma in war games. Phys Sportsmed 1986; 14:90-94

(5.) Martin PL, Magolan JJ Jr: Eye injury during war games despite use of goggles. case report. Arch Ophthalmol 1987; 105:321-322

(6.) Easterbrook M, Pash by TJ: Ocular injuries and war games. Jut Ophthalmol Gun 1988; 28:222-224

(7.) Welsh NH, Howes F, Lever J: Eye injuries associated with war games.' S Afr Med J l989; 76:2700-2701

(8.) Acheson JF, Griffiths MFP, Cooling RJ: Serious eye injuries due to war games. BMJ 1989; 298:26

(9.) Pakoulas C, Shar S, Frangoulis MA: Serious eye injuries due to war games. (Letter) BMJ 1989; 298:299

(10.) Morgan SJ: Serious eye injuries due to war games. (Letter) BMJ 1989; 298:383

(11.) Dawidek GMB: Serious eye injuries due to war games. (Letter) BMJ 1989; 298:383

(12.) Wellington DP, Johnstone MA, Hopkins RJ: Bull's-eye corneal lesion resulting from war game injury. Arch Ophthalmol 1989; 107:1727

(13.) Mamalis N, Monson MC, Farnsworth ST, et al: Blunt ocular trauma secondary to "war games." Ann Ophthalmol 1990; 22:416-418

(14.) Wrenn KD, White SJ: Injury potential in "paintball" combat simulation games: a report of two cases. (Letter) Am J Emerg Med 1991; 9:402-404

(15.) Zwaan J, Bybee L, Casey P: Eye injuries during training exercises with paint balls. Mil Med 1996; 161:720-722

(16.) Moore AT, McCartney A, Cooling RJ: Ocular injuries associated with the use of airguns. Eye 1987; 1:422-429

(17.) Thach AB, Ward P, Hollifield RO, et al: Ocular injuries from paintball pellets. Ophthalmology 1999; 106:533-537

TABLE 1

Demographic Data

Sex
 Male                                9
 Female                              1
Average age, yrs             16 (range, 12-21)
Eye injured
 Right                               5
 Left                                5
Eyewear protection
 Yes (paintball entered              3
  under goggles)
 None
Average time from injury to          7
 initial examination, hr             6
Place of injury
 Home                                6
 Friend's home                       3
 Paintball facility                  1
TABLE 2

Initial Ocular Injury

Injury Location           No.

Anterior segment
  Corneal abrasion        1
  Hyphema                 7
  Iris sphincter rupture  3
  Subluxated lens         2
  Cataract                3
  Vitreous prolapse into  1
   anterior champer
Posterior segment
  Vitreous hemorrhage     6
  Commotio retinae        3
  Choroidal rupture       1
TABLE 3

Surgical Procedures

Procedure                         No. (*)

Pars plana vitrectomy                5
Pars plana lensectomy                4
Scleral-sutured intraocular lens     1
Sulcus-placed intraocular lens       3
Anterior chamber washout             1
Epiretinal membrane peel             1

(*)Some patients had more than one procedure.
TABLE 4

Comparison of Previous Reports (2-17) with the Current Report

                               Previous Reports    Current Report

No. patients                          91                10
Eye protection, no. (%)
 Yes                                9 (10)            3 (30)
 No                                 63(69)            7 (70)
 Not recorded                       19(21)
Injury site
 War game facility            No accurate history     1 (10)
 Non-war game facility        No accurate history     9 (90)
Ocular injury, no. (%)
 Lens damage                        26 (29)           4 (40)
 Hyphema                            73 (80)           7 (70)
 Vitreoretinal damage               48 (53)           4 (40)
Final visual acuity, no. (%)
 20/40 or better                    36 (40)           6 (60)
 20/50 to 20/150                    20 (22)           3 (30)
 20/200 or worse                    32 (35)           1 (10)
 Not recorded                        3 (3)

RELATED ARTICLE: KEY POINTS

* Ocular injuries from paintball pellets occur more frequently at home than at paintball war game facilities.

* Advanced surgical techniques offer decreased ocular morbidity and improved visual acuity.

* Decreasing visual morbidity from paintball pellets requires public education, proper labeling on all paintball-related products, and packaging of eye protection with all products related to war games.