Decreasing total numbers of patients in the Netherlands, increasing numbers in Germany

The total numbers of firework induced eye injuries have evolved over the years closely related to the legislative regulations and protective actions taken in both countries.

In the Netherlands total numbers of patients have decreased over the years, apparently due to stricter rules like a ban on baby crackers, Roman candles, rockets and crackers, reduced hours of permission to use fireworks and firework free areas and public information for example by the Vuurwerkmanifest.

In Germany between 2017 and 2020 we have seen stable total numbers of roughly 500 affected patients per year.

The pandemic regulations with a sales ban of consumer fireworks 2020–2022 have most effectively reduced the total numbers of patients in both countries to roughly 85% of pre-pandemic total numbers. This rate is very much in accordance to the 87% reduction of firework induced eye injuries in regions with restrictive firework regulation compared to non-restrictive regulations that has been shown in the literature review by Wisse et al. [11]. The pandemic sales ban also had a positive effect on minors´ protection as shown by a decrease of minor to total number of patients ratio in both countries. After the pandemic years, however, the number and the severity of injuries in minors, reflected by bilaterality and hospital admission rates has increased Figure 5.

Fig. 5

10 years old girl who was hit by a rocket as a bystander. She suffered from an upper lid injury and a severe blunt eye trauma with choroidal rupture. Resulting Snellen visual acuity was 0,1 in the right eye

Germany´s increase of firework induced eye injuries in 2022/23 is alerting to us and made us have a closer look on the statistic relevance of these injuries and the involved persons: minors and bystanders.

Incidence numbers correct for the number of inhabitants and thus give an orientation on the individual risk. Yet, incidences rely on many variables for example rate of hospitals participating reflecting nationwide coverage and the number of inhabitants. The participation of all eye departments in the Netherlands was nearly 90% in all years, whereas the participation of German eye departments was steadily increased in the first years of the study. Yet, in all years with a less than 80% participation rate, due to technical reasons we have missed mostly no-patient-showed-up answers, so incidences might not have been remarkably influenced. In this analysis we have calculated the incidences per year with the actual number of inhabitants.

In 2022/23 the German incidence of fire work induced eye injuries exceeded the Dutch for the first time, indicating that regulations and actions aimed at protecting the inhabitants might be more effective in the Netherlands than in Germany. As a consequence, we are working on establishing a similarly effective alliance through different medical and social societies for Germany that ideally should be comparable to the Vuurwerkmanifest in The Netherlands.

Higher numbers of young affected minors in Germany compared to the Netherlands

Numerous international publications for e.g. from the US [3, 12,13,14], China [4], India [15], Switzerland [16] and Saudi Arabia [17] have documented, that minors are clearly overrepresented among patients with firework induced eye injuries.

Besides the difficulties of examination, treatment and follow up, firework induced eye injuries to young minors imply the risk for the development of amblyopia. We have thus divided the data of affected minors into two age groups and compared the Netherlands´ data to Germany´s.

In Germany during all the past seven years, the total number of minors younger than 12 years of age was higher than the number of affected adolescents between 12 and 17 years. Compared to the Netherlands, where minors under 12 years accounted for the minority of all injured minors during the past 15 years that is a fundamental difference.

As in Germany children under 12 years are not at all allowed to use any private firework products other than category 1 devices [18] we wonder how young children get access to fireworks and if regulations were followed consequently enough to prevent young children from harm.

Due to our study desing we cannot give a complete answer, but eventual examiner notes on the answer form indicate a portion of eye injuries in young children caused by remnants of fireworks picked up. Two easy strategies to reduce these injuries would be: Every active fire work operator should clear up firework remnants immediately and children should be comprehensively instructed. Yet, apparently, children younger than 12 years in Germany seem to have access to fire work devices in a significant portion of incidents.

Referring to the data of the two pandemic years, a sales ban appears to be the most effective method of reducing the volume of fire work articles to be handled by private hands. Recent publications from India [19] and Hawaii [20] also show this effect.

Such a regulation would reduce the high risk of lifelong accumulated risk of permanent visual impairment through scar tissue development of lids, conjunctiva or cornea, loss of accommodation in lens injuries after cataract surgery, secondary glaucoma, posttraumatic retinal detachment with eventual proliferative vitreoretinopathy, retinal pigment epithelium and/or choroidal ruptures in minors and young adults [2, 21,22,23,24]. Our study does not include follow up or visual results, yet several studies have documented a high risk for visual impairment after severe eye injuries [6, 16, 25,26,27].

As eye injuries account for roughly 20% of all injuries caused by fireworks [3, 12], hand injuries [28], head-, neck [29] and bang traumas [30] could also significantly be reduced by such regulations.

Almost half of the patients are bystanders

With a height range of up to 100 m, rockets can cause injuries far from the site of ignition. The high number of injured bystanders is alerting. We have documented 1278 injured bystanders in Germany and 1300 affected bystanders in The Netherlands. Spectators or passers-by who were at the wrong place at the wrong time and involuntarily hit by an unidentifiable firework article (Fig. 6).

Fig. 6

Enucleated globe of a bystander, who sustained a severe blunt trauma with total loss of iris and lens into the vitreous by an unknown consumer firework on New Year´s Eve 2022/23. Recurrent retinal detachments due to proliferative vitreoretinopathy (PVR) and a painful secondary glaucoma led to the total loss of vision and an enucleation within 6 months from the incident

A very tragic case in Germany: A janitor collecting the leftovers of a third party´ s firework, who was severely injured in one eye and was expected to be left with a severe visual limitation. One fourth, in numbers 320 bystanders, were severely injured in Germany during the past 7 years and sustained a high risk of visual loss. Beside the psychological effect of an injury that limits visual acuity, these patients usually have limited possibilities to sue the responsible operator for legal or financial consequences.