How lethal is a pellet gun for eyes?

Abstract

Background: Etiologically ocular injuries can be classified into domestic, occupational, sports, road traffic accidents, iatrogenic, fights and assaults, and war injuries. In the 1960s and 1970s, road traffic accidents became the most common cause of serious ocular injuries. In the 1980s, sports and leisure activities became a common cause of severe eye injury. The home is now the most common location for eye injuries. However, bomb blast and battlefield ocular injuries are becoming increasingly common in different parts of the world. Recently introduced non-lethal pellet guns used by law enforcement Indian agencies in Kashmir were the most common cause of ocular injuries in the valley.
Objective: The objective of this study was to evaluate ocular pellet gun injuries in patients of a conflict zone by a so called non-lethal weapon as a mass control measure.
Method: The study was conducted in post graduate department of Radiodiagnosis and imaging, Government Medical College, Srinagar Jammu and Kashmir. Our study was conducted between January 2019 to 15th May 2019. A total of 30 patients with ocular pellet injuries were taken up for study.
Results: The most common type of injuries encountered were corneal laceration in 66.7 % eyes, vitreous haemorrhage in 52.8% and scleral laceration in 33.3% of eyes. Indirect signs like decreased volume of anterior chamber were suggestive of corneal laceration.
Retained intraocular foreign body (IOFB) was seen in 7 patients and intraorbital foreign body excluding intraocular foreign body in 3 patients.
Conclusion: In conclusion a so called non-lethal pellet gun used by law enforcement agencies has the potential to cause devastating ocular injuries.

Full text

© 2020 The Pan-American Journal of Ophthalmology | Published by Wolters Kluwer - Medknow 1
How lethal is a pellet gun for eyes?
Suhail Raq, Musaib Ahmad Dar, Jan Muhammad Suhail, Arshid Ahmad Bhat1, Irshad Mohideen
Department of Radiodiagnosis and Imaging, Government Medical College, 1Department of Radiodiagnosis and Imaging, SKIMS, Srinagar,
Jammu and Kashmir, India
Original Article
INTRODUCTION
The purpose of this study was to evaluate the ocular
injuries which occurred due to pellet gunre in Kashmir.
Etiologically, ocular injuries can be classied into domestic,
occupational, sports, road trafc accidents, iatrogenic,
ghts and assaults, and war injuries.[1] In the 1960s and
1970s, road trafc accidents became the most common
cause of serious ocular injuries.[2] In the 1980s, sports and
leisure activities became a common cause of severe eye
Background: Etiologically ocular injuries can be classified into domestic, occupational, sports, road traffic
accidents, iatrogenic, fights and assaults, and war injuries. In the 1960s and 1970s, road traffic accidents
became the most common cause of serious ocular injuries. In the 1980s, sports and leisure activities
became a common cause of severe eye injury. The home is now the most common location for eye injuries.
However, bomb blast and battlefield ocular injuries are becoming increasingly common in different parts of
the world. Recently introduced non-lethal pellet guns used by law enforcement Indian agencies in Kashmir
were the most common cause of ocular injuries in the valley.
Objective: The objective of this study was to evaluate ocular pellet gun injuries in patients of a conflict
zone by a so called non-lethal weapon as a mass control measure.
Method: The study was conducted in post graduate department of Radiodiagnosis and imaging, Government
Medical College, Srinagar Jammu and Kashmir. Our study was conducted between January 2019 to 15th
May 2019. A total of 30 patients with ocular pellet injuries were taken up for study.
Results: The most common type of injuries encountered were corneal laceration in 66.7 % eyes, vitreous
haemorrhage in 52.8% and scleral laceration in 33.3% of eyes. Indirect signs like decreased volume of
anterior chamber were suggestive of corneal laceration.
Retained intraocular foreign body (IOFB) was seen in 7 patients and intraorbital foreign body excluding
intraocular foreign body in 3 patients.
Conclusion: In conclusion a so called non-lethal pellet gun used by law enforcement agencies has the
potential to cause devastating ocular injuries.
Keywords: Globe, Kashmir, lethal, pellet, vitreous
Address for correspondence: Dr. Musaib Ahmad Dar, Department of Radiodiagnosis and Imaging, Government Medical College, Srinagar,
Jammu and Kashmir, India.
E‑mail: drmusaib57@gmail.com
Received: 21 January 2020, Revised: 07 February 2020, Accepted: 08 February 2020, Published Online: 27 February 2020
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10.4103/PAJO.PAJO_6_20 How to cite this article: Raq S, Dar MA, Suhail JM, Bhat AA, Mohideen I.
How lethal is a pellet gun for eyes? Pan Am J Ophthalmol 2020;2:5.
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Raq, et al.: Safety of pellet guns for eyes
2 The Pan-American Journal of Ophthalmology | 2020
injury.[3] The home is now the most common location for
eye injuries.[4] However, bomb blast and battleeld ocular
injuries are becoming increasingly common in different
parts of the world.[5] Weapons used by the law enforcement
agencies in civil unrest can be divided into:
1. Lethal weapons including traditional sharp‑pointed
rearms such as pistol or rie
2. Less lethal or nonlethal weapons, including.
• Weapons that utilize chemical or electronic methods
• Rubber bullets
• Pellet gun.
Considered a “less‑lethal” or “nonlethal” weapon, rubber
or plastic‑coated nonlive rounds are used across the world
to manage agitating mobs with the intention of causing
no severe injury or death.[6,7] However, studies across the
world,[6‑9] including from Kashmir,[10,11] have repeatedly
shown that the use of these “nonlethal” weapons often
leads to serious injuries, permanent disability, and death.
First used in response to the civil unrest in Northern
Ireland in the 1970s, such “nonlethal” weapons have
been documented to cause injuries and death.[12] In India,
the paramilitary forces rst used pellet guns during mob
demonstrations in 2010 in Kashmir, which resulted in the
death of 120 people; since then, these guns have been used
for crowd control in Kashmir.[13]
The “nonlethal” guns are reported to be shotguns of
12‑gauge pump action, which are primarily used in hunting
with a wide range of pellet sizes and numbers.[14] The
smaller the size of the pellet, the larger the number of
pellets in one cartridge; hence, a number 1 cartridge has a
smaller number of bigger size pellets, while a number 12
cartridge has a larger number of smaller size pellets.[14] In
the current protests in Kashmir, mostly, cartridges number
6 (300 pellets of 2.79 mm each) and number 9 (600 pellets
of 2.30 mm each) were used.[14] As for as extent of damage
was concerned, size of pellet was not as much important
as the distance from which it was red.
If used at closer ranges, the pellets do not have enough
time to disperse and travel in a compact group, which move
at very high velocities, making them extremely harmful,
almost behaving like handgun bullets, enough to
penetrate deep, and cause severe damage to softer tissues,
especially eyes.[15,16] The velocity and distance of the
pellet can determine the nature of the eye injury.
Objective
The objective of this study was to evaluate the ocular pellet
gun injuries in patients of a conict zone by a so‑called
nonlethal weapon as a mass control measure.
METHODS
The study was conducted in Postgraduate Department of
Radiodiagnosis and Imaging, Government Medical College,
Srinagar, Jammu and Kashmir. Our study was conducted
between January 2019 and May 15, 2019. A total of thirty
patients with ocular pellet injuries were taken up for the
study.
Inclusion criteria
Inclusion criteria were patients with ocular pellet gun
injuries without any immediate life‑threatening injury, such
as head injury, cardiac injury, or major vessel injury, and
patients willing to be part of study.
All the patients were initially received in the accident and
66.7%
52.8%
33.3%
13.9% 19.4% 13.9%8.3%5.6%
0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
70.0%
80.0%
90.0%
100.0%
corneal laceration
Vitreous Haemorrhage
Scleral Laceration
Lens Subluxation
Intra Ocular Foreign Body
retinal Detachment
Intra Orbital Foreign Body
Optic Nerve Injury
Type of Injury
Number of Eye Injuries incurred based on
Type of Injury
Figure 1: Bar diagram showing percentage of ocular injury type due
to pellet gun
Table 1: Categorization of injured patients based on age
groups
Age group (years) Number of patients
10-20 6
20-30 11
30-40 10
40-50 3
Table 2: Number of eye injuries incurred based on type of
injury
Type of injury Number of eyes (%)
Corneal laceration 24 (66.7)
Vitreous hemorrhage 19 (52.8)
Scleral laceration 12 (33.3)
Lens subluxation 5 (13.9)
Intraocular foreign body 7 (19.4)
Retinal detachment 5 (13.9)
Intraorbital foreign body 3 (8.3)
Optic nerve injury 2 (5.6)
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Raq, et al.: Safety of pellet guns for eyes
The Pan-American Journal of Ophthalmology | 2020 3
emergency department of our institute. Complete history
was taken, and examination of all the patients was done.
Relevant investigations were ordered for all the patients.
Radiographs of all the patients were studied. Computed
tomography (CT) scan was done, when needed. We
obtained thin‑section axial CT scans (0.625–1.25 mm) with
multiplanar reformation. Proper treatment follow‑up was
available from the department of ophthalmology.
RESULTS
Thirty patients with ocular pellet injuries who met the inclusion
criteria were included in this study. Of total 30 patients with
pellet injuries, 28 were male and two were female.
There was a wide range in the age of the patients
(14–49 years). Maximum number of the patients were in
age group of 11‑30 years as shown in Table 1.
Ocular injuries were unilateral in 24 cases and bilateral in
six cases. The pattern of eye injuries among 36 eyes of
30 patients is shown in Table 2.
Figure 3: Evidence of pellet along right optic nerve and ophthalmic
artery. Patient had clinically proven optic nerve injury
Figure 4: Axial CT showing posterior chamber hemorrhage and scleral
irregularity in the left eye suggestive of scleral laceration. Right eye
showing evidence of pellet traversing anterior scleral coat
Figure 2: Right eye showing evidence of posterior chamber
hemorrhage with pellet within posterior chamber
Figure 5: Axial Ct showing at tire sign with pellet within right eye,
suggestive of globe rupture
Figure 7: There is evidence of air‑containing collection seen with
discontinuity of posterior sclera on the left side
Figure 6: Axial CT showing left corneal laceration with small air
containing collection (arrow) with multiple pellets in the left eye and
one pellet close to lateral wall of nose
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Raq, et al.: Safety of pellet guns for eyes
4 The Pan-American Journal of Ophthalmology | 2020
The most common type of injuries encountered was
corneal laceration in 66.7% of eyes, vitreous hemorrhage
in 52.8%, and scleral laceration in 33.3% Figure 1. Indirect
signs such as decreased volume of anterior chamber were
suggestive of corneal laceration.
Retained intraocular foreign body (IOFB) was seen in
seven patients and intraorbital foreign body excluding
IOFB in three patients. Many of the patients had combined
spectrum of injuries. CT ndings of open‑globe injury
include change in globe contour, loss of volume, at tire
sign, scleral discontinuity [Figures 2‑6], intraocular air,
and IOFB [Figures 7‑9]. However, posttraumatic orbital
hematoma may deform the globe mimicking an open‑globe
injury. Traumatic rupture of the sclera may permit the
vitreous to prolapse through the defect. Because of the
decreased volume of the posterior segment, the lens can
move posteriorly by a few millimeters, while the zonular
attachments remain intact. Posterior movement of the
lens enlarges or deepens the anterior chamber. A deep
anterior chamber has been described as a clinical nding
in patients with a ruptured globe and can also be a useful
clue on CT images.
Lens subluxation or dislocation was found in ve patients.
CT images can readily show the displacement of the lens, as
well as any associated injuries. Trauma is the most common
cause of lens dislocation; it accounts for more than half of
all cases. An important pitfall for the radiologist to avoid
is that of the spontaneous dislocated lens. Nontraumatic
lens dislocation may be associated with systemic connective
tissue disorders, such as Marfan syndrome, Ehlers–Danlos
syndrome, and homocystinuria.
The treatment varied according to the type of injury. Six
eyes with closed‑globe injury were managed conservatively.
Others underwent single/multiple surgical procedures.
Corneoscleral repair was the most commonly performed
surgery. Scleral autografting was done in one patient
because of tissue loss. Four patients needed intraocular
lens implantation. Vitreoretinal surgery was performed in
patients who had nonresolving vitreous hemorrhage, retinal
detachment, or retained postsegment IOFB.
Two eyes with optic nerve injuries completely lost vision
beyond repair. Of 24 corneal lacerations, 16 were supercial
which were treated by laser and recovered completely.
Among remaining eight, six had deep corneal involvement
and permanent scar remains in their cornea while two
corneas were injured beyond repair and are waiting for
appropriate corneal transplant. No loss of vision was
noted due to scleral injuries. Subluxed lenses were removed,
and articial intraocular lenses were implanted to restore
normal visual acuity. Intraorbital foreign bodies were left
as such and are followed by close monitoring. Of seven
eyes with intraocular foreign body, ve were never able to
see again with that eye and the rest two patients had some
vision and were not intervened.
DISCUSSION
Ocular injury is an important and preventable cause of
ocular morbidity.[17] Even though the eye comprises only
a small part of the surface area of the human body,[5] it
is still injured quite frequently.[18] Over the past few years,
security forces in Kashmir Valley have been using pump
action shotgun or pellet gun to disperse violent mobs. Pellet
guns have been introduced as nonlethal weapons for crowd
control. The review of the age and sex of these patients
demonstrates that the “typical” gun pellet casualties are
young males. This was due to the fact that these agitated
mobs comprised primarily young males. The female patients
in our study were accidentally hit by the pellet while walking
on the road. Both hospital‑ and population‑based studies
Figure 9: Air attenuation areas seen in posterior chamber of right eye
with vitreous hemorrhage. Another air containing collection adjacent
to right bulky optic nerve
Figure 8: Non contrast CT showing air containing collection in relation
to left lens with posterior chamber hemorrhage. Patient also had mild
subluxation of left lens
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Raq, et al.: Safety of pellet guns for eyes
The Pan-American Journal of Ophthalmology | 2020 5
indicate a large preponderance of ocular injuries affecting
young males,[19,20] as was the case in our study.
We noted corneal laceration with hyphema to be the
most common manifestation of gun pellet injuries. This
was found to be in accordance with the consequences
of nonpowder rearm injuries reported previously.[21]
In this study, we found that the majority of the injuries
were open‑globe penetrating type. This pattern could be
explained by the fact that nonpowder rearms can generate
muzzle velocities of 200–900 foot pounds/s,[22] whereas
ocular penetration can occur at velocities as low as 130
foot pounds/s.[23] Moreover, from a single cartridge, more
than 500 pellets can be red, thus accounting for the high
incidence of penetrating trauma in our study.
CONCLUSION
A so‑called nonlethal pellet gun used by the law
enforcement agencies has the potential to cause devastating
ocular injuries.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conicts of interest.
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