Purpose
To quantify and characterize eye injuries related to aerosol container consumer products treated in United States hospital emergency departments (EDs) from 1997 through 2009.
Design
Retrospective study.
Methods
Descriptive analysis of aerosol container-related eye injury data derived from the National Electronic Injury Surveillance System, a stratified probability sample of hospital-affiliated United States EDs. Data collected included demographic variables (gender and age), locale, diagnoses, and hospital disposition associated with aerosol container-related eye injuries treated in United States EDs from 1997 through 2009. Products associated with injury and mechanisms of injury also were extracted and analyzed.
Results
There were an estimated 10 765 (95% confidence interval [CI], 9842 to 11 688) visits to United States EDs for aerosol container-related eye injuries during the study period; 6756 (95% CI, 5771 to 7742; 63%) patients were male; 5927 (95% CI, 4956 to 6897; 55%) injuries occurred in children (age < 18 years). The most common product was spray paint, accounting for 2048 (95% CI, 1402 to 2694; 19%) injuries. The most common mechanism of injury was self-inflicted spray to the eye, occurring in 4649 (95% CI, 3746 to 5552; 43%) cases. The most common diagnosis was dermatitis or conjunctivitis, occurring in 3880 (95% CI, 2995 to 4765; 36%) cases.
Conclusions
This study suggests that most aerosol container-related eye injuries in the United States occur in men and children and that self-inflicted spray to the eye is the most common mechanism of injury. Further research is needed to devise effective prevention strategies for these types of injuries.
Ocular trauma is a common cause of unilateral blindness and is associated with significant emotional stress, numerous emergency department (ED) and outpatient visits, potential long-term morbidity, and an estimated cost of more than $4 billion per year in the United States. Consumer products—defined as any articles produced or distributed for use by the public in or around a home, school, or recreational area —have been identified as a significant source of eye injuries. They account for an estimated 280 000 eye injuries per year, including 57 000 in children younger than 12 years. Children are especially vulnerable to eye injuries from household cleaning products, including those packaged in spray bottles.
Aerosol containers are a common vehicle through which a wide variety of cleaning solutions and other consumer products are dispensed. Similar to spray bottles, aerosol containers dispense products in the form of a fine mist. However, they differ in that aerosol solutions are delivered by propellants under high pressure, and thus may present an even greater potential for injury. The hazards of aerosol containers are well described; the propellants (including propane or butane) or the products themselves may be toxic, corrosive, explosive, or flammable. Misdirected aerosol nozzles can cause eye injury or chemical burns; stray particles can enter the respiratory tract and result in inhalation injury.
However, despite these potential hazards, eye injuries from aerosol containers have not been well studied. The aim of this study was to describe the epidemiology of aerosol-related eye injuries in the United States using information collected through the Consumer Product Safety Commission’s (CPSC) National Electronic Injury Surveillance Survey (NEISS) from 1997 through 2009.
Methods
Data Source and Study Population
The data for this study were derived from the NEISS, a statistically valid database representing ED visits for consumer product-related injuries that occurred from 1997 through 2009. It was designed with the goals of identifying the need for product recall, product safety standards, and product awareness campaigns. Since 1999, the NEISS has consisted of a statistically selected sample of 100 EDs nationwide (between 1997 and 1999, 101 EDs were involved); the hospitals are grouped into 5 strata. Four include EDs of different sizes (based on number of annual visits) and geographic locations; a fifth stratum includes a sample of children’s hospitals. Weights based on the sample design can be applied to these data to produce a national probability estimate of injury visits to the more than 5300 total United States EDs.
When a patient with a consumer product-related injury is admitted to the ED of a NEISS institution, a healthcare provider assigns the case a NEISS-specific code from an alphabetical listing of hundreds of products. The following data also are recorded: victim’s age, gender, diagnosis, injured body part, incident locale, and case disposition. A brief narrative description of the incident also is included. At each NEISS institution, an appointed coordinator reviews ED records daily and sends pertinent information to the CPSC. For the purposes of this study, only cases in which the consumer product involved was coded as an aerosol container and the injured body part was coded as an eyeball met the criteria for analysis.
Data Analysis
Before statistical analysis, the narratives accompanying all cases of aerosol container-related eye injuries were reviewed independently by 2 authors (C.J.S., J.G.L.) and were categorized based on circumscribed parameters; any disagreements were reconciled with a third author (P.B.G.) as tiebreaker. The specific product associated with each case was gleaned from each narrative and was assigned a numeric code (i.e., 1 = spray paint, 2 = pepper spray, 3 = bug spray, 4 = personal hygiene product, 5 = cleaning product, and 6 = other). Hairspray, shaving cream, deodorant, and perfume were classified as personal hygiene products. Air freshener, wood cleaner, starch, carpet shampoo, and any mention of the generic term cleaner were classified as cleaning products.
With the exception of pepper spray, all products selected to receive a numeric code were associated with at least 20 injuries. The CPSC considers weighted national estimates derived from NEISS data to be unstable and potentially unreliable if any of the following are true: the number of records is fewer than 20, a weighted estimate is less than 1200, or the coefficient of variation exceeds 30%. Despite only 13 records of pepper spray-related eye injury in the NEISS, which precluded our ability to calculate a stable weighted estimate, the product was still included as an item of interest because of reports of related corneal complications. All other products with fewer than 20 records were classified as other.
Mechanisms of injury also were derived from the narrative data by the 2 reviewing authors (C.J.S., J.G.L.). Cases in which the patient was described as spraying himself or herself in the eye with an aerosol container were assigned a numeric code (ie, 1 = sprayed by self). No other mechanism of injury occurred frequently enough to produce a stable weighted estimate; thus all other cases, including those in which mechanisms were unknown, were classified as other.
After the addition of product and mechanism of injury codes, the data were analyzed with SAS software version 9.1.2 (SAS Institute, Inc, Cary, North Carolina, USA) using the Survey Procedures (PROC SURVEYFREQ) to account for the complex sampling design and the weighting structure used by NEISS. Each case was assigned a sample weight based on the inverse probability of selection (provided by NEISS). Confidence intervals and coefficients of variation were calculated using a direct variance estimation procedure that accounted for the sample weights.
The proportion of all aerosol container-related injury visits that involved the eye was calculated. Similarly, the proportions of visits for aerosol container-related eye injuries were calculated by gender, age, diagnosis, locale, disposition, product involved, and mechanism of injury. Denominators obtained from the United States Bureau of the Census at the study midpoint (July 2003) were used to calculate aerosol container-related eye injury incidence rates according to gender and age. Mechanism of injury also was calculated as a function of age.
Of note, when calculating weighted estimates of visits for eye injuries by age, patients initially were grouped into both 5-year and 10-year intervals. Intervals producing unstable weighted estimates were excluded from the final report. Because there were fewer than 20 records within each 10-year interval over the age of 19 years, to obtain a stable weighted estimate of injuries in adults, patients also were grouped into 0 to 18 years and 19+ years intervals.
Results
From 1997 to 2009, there were an estimated 41 869 visits for injuries related to aerosol containers in United States EDs; 26% (10 765/41 869) of these injuries involved the eye, making it the most commonly injured body part. Year-by-year examination of injury frequency did not reveal sufficient observations to permit a reliable estimate of the overall trend over time. The demographics of the eye injuries are outlined in Table 1 . There was a preponderance of injuries in males (63%; 6756/10 765) and children (55%; 5927/10 765).
| Characteristics | National Estimates (95% Confidence Interval) a | Percent of Emergency Department Visits | Estimated Rates per 100 000 Population b |
|---|---|---|---|
| Total | 10765 (9842 to 11688) | 100% | 3.81 |
| Gender | |||
| Male | 6756 (5771 to 7742) | 63% | 4.88 |
| Female | 4009 (3133 to 4884) | 37% | 2.77 |
| Age (yrs) | |||
| 0 to 18 | 5927 (4956 to 6897) | 55% | 7.46 |
| 0 to 4 | 2830 (2053 to 3606) | 26% | 14.38 |
| 5 to 9 | 1262 (725 to 1798) | 12% | 6.39 |
| 10 to 14 c | 1118 (612 to 1623) | 10% | 5.29 |
| 15 to 19 c | 800 (352 to 1249) | 7% | 4.24 |
| 19 and older | 4838 (3918 to 5759) | 45% | 2.38 |
a National probability estimate based on the National Electronic Injury Surveillance Survey sample of 100 United States emergency departments.
b Denominators derived from United States Bureau of the Census, July 2003.
c Estimate based on < 20 actual cases and may not be statistically stable.
The locale, diagnosis, ED disposition, specific products, and mechanism associated with aerosol container-related eye injuries are outlined in Table 2 . Products classified as other (20 or fewer records) included acetone, adhesive spray, analgesic spray, automotive bug cleaner, breath spray, deicer, dog repellant, fix-a-flat, lubricant, paint stripper, pesticide or roach spray, rubbing alcohol, soda, starch, and vegetable spray; other products were unable to be identified from the NEISS narrative data. Most injuries occurred in the home (71%; 7680/10 765). The most common diagnosis was dermatitis or conjunctivitis (36%; 3880/10 765); most patients were treated and released from the ED (99%; 10 654/10 765). Spray paint was the most common product involved, responsible for 19% (2048/10 765) of ED visits; 70% (1474/2048) of these injuries occurred in males. Spraying oneself in the eye with an aerosol container was the single most common mechanism of injury across all age groups, accounting for 43% (4649/10 765) of ED visits; 49% (2269/4649) of these injuries occurred in children younger than 9 years.
| Variable | National Estimates (95% Confidence Interval) a | Percent of Emergency Department Visits |
|---|---|---|
| Locale | ||
| Home | 7680 (6665 to 8695) | 71% |
| Other/unknown b | 2159 (1509 to 2809) | 20% |
| Diagnosis | ||
| Dermatitis/conjunctivitis | 3880 (2995 to 4765) | 36% |
| Chemical burn | 3248 (2422 to 4074) | 30% |
| Contusion/abrasion/foreign body | 1749 (1163 to 2335) | 16% |
| Other/unknown c | 1888 (1245 to 2530) | 18% |
| ED disposition | ||
| Treated and released | 10654 (9727 to 11581) | 99% |
| Admitted to hospital d | 86 (86 to 257) | < 1% |
| Product d | ||
| Spray paint | 2048 (1402 to 2694) | 19% |
| 0 to 18 | 1125 (618 to 1632) | 10% |
| 19 and older | 923 (482 to 1363) | 9% |
| Personal hygiene product e | 1280 (735 to 1824) | 12% |
| 0 to 18 | 825 (381 to 1269) | 8% |
| 19 and older | 455 (121 to 789) | 4% |
| Cleaning product f | 1260 (714 to 1806) | 12% |
| 0 to 18 | 911 (443 to 1378) | 9% |
| 19 and older | 349 (49 to 649) | 3% |
| Bug spray | 1216 (685 to 1747) | 11% |
| 0 to 18 | 747 (324 to 1170) | 7% |
| 19 and older | 469 (131 to 507) | 4% |
| Pepper spray | 493 (130 to 856) | 4% |
| 0 to 18 | 355 (45 to 665) | 3% |
| 19 and older | 138 (0 to 330) | 1% |
| Other g | 4468 (3547 to 5389) | 42% |
| 0 to 18 | 1964 (1293 to 2635) | 18% |
| 19 and older | 2504 (1756 to 3251) | 24% |
| Mechanism of injury | ||
| Sprayed self in eye | 4649 (3746 to 5552) | 43% |
| 0 to 4 | 1715 (1106 to 2324) | 16% |
| 5 to 9 | 575 (201 to 948) | 5% |
| 10 to 14 | 408 (85 to 731) | 4% |
| 15 to 19 | 292 (40 to 523) | 3% |
| 19 and older | 1727 (1092 to 2361) | 16% |
| Other/unknown h | 6116 (5132 to 7099) | 57% |
| 0 to 18 | 3004 (2197 to 3812) | 28% |
| 19 and older | 3111 (2323 to 3900) | 29% |
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