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ORIGINAL ARTICLE
‘‘Here’s egg in your eye’’: a prospective study of blunt
ocular trauma resulting from thrown eggs
R M K Stewart, J M Durnian, M C Briggs
...............................................................................................................................
Emerg Med J 2006;23:756–758. doi: 10.1136/emj.2006.035501
Objective: To see if a public awareness campaign might be justified around Halloween with regard to the
dangers of egg throwing.
Method: A prospective study was carried out of all patients who attended the St Paul’s Eye Unit’s Primary
See end of article for Care Department with ocular injuries resulting from a thrown egg over a 14-month period from November
authors’ affiliations 2004. All injuries were classified as minor, intermediate or major and patients were followed up until
.......................
discharge.
Correspondence to: Results: 13 ocular injuries that were attributed to assault with a raw egg were reported. In all the 13 cases,
J M Durnian, St Paul’s Eye the eggs had been thrown by strangers. 12 of the patients were men and the average age of the victims
Unit, Royal Liverpool was 27.9 years. 9 patients were injured in the left eye and there were no bilateral injuries. On
University Hospital, Prescot
Street, Liverpool L7 9XP, presentation, only 1 patient had a visual acuity of 6/6, 7 presented at 6/9, with the remainder having
UK; jon_durnian@hotmail. 6/18 or worse. All the patients had closed globe injuries. 8 injuries were classified as major injuries. 4
com patients had permanent sequelae, with one suffering permanent, severe visual loss.
Accepted for publication
Conclusions: Although most of our patients showed improvement in visual acuity, there were severe injuries,
12 May 2006 with the potential for severe ocular morbidity. We conclude that there is sufficient injury caused by this prank to
....................... warrant a public health message. At the least this practice should not be promoted by the press.
A
s anyone who has woken up on 1 November each year presentation it may not look as serious as penetrating
and looked out at the chaos left in the wake of the injuries, major morbidity is common. It is essential that a
previous night’s activities can attest, Halloween and so- complete ophthalmological examination is carried out, as an
called ‘‘mischief night’’ is now becoming an annual excuse eye with minimal (or no) anterior segment damage may have
for anti-social behaviour ranging from mild annoyance to the a severe posterior segment injury. Although no consensus is
sheer dangerous. One particular prank that seems to be available on the timing of the ophthalmic examination,
becoming more common is the practice of throwing raw eggs within 24 h is adequate if there is no suspicion of globe
either at buildings or at innocent passers-by. Aside from the rupture. The serious sequelae of blunt trauma include
drycleaning bills, a raw egg can lead to severe ocular injury
due to its weight and size, as has been reported previously.1 2 1. Angle recession (posterior contusion deformity of the
Guy Fawkes night attracts numerous public service anterior chamber angle), which is the posterior dis-
announcements, but the hazards of egg throwing, on and placement of the iris root and associated tearing of part
around Halloween, seem to go unnoticed. of the ciliary muscle. Glaucoma develops in 7–9% of eyes
We carried out a prospective study of all ocular injuries with angle recession.
seen in our casualty service that were caused by a thrown egg 2. Vitreous haemorrhage or haemorrhage into the anterior
during a 14-month period to see if a public awareness chamber (hyphaema).
campaign may be justified, in particular around 31 October.
3. Commotio retinae—damage to the outer retinal layers
due to the force of the injury traversing the eye. On
METHODS examination by ophthalmoscopy, it appears as a white
This was a prospective, observational study of all patients sheen on the retina and can be associated with retinal
who attended St Paul’s Primary Care Department, Royal tear development.
Liverpool University Hospital, Liverpool, UK, between 1
4. Retinal tear or dialysis and subsequent retinal detach-
November 2004 and 31 December 2005, with ocular trauma
ment.
as a direct result of a thrown egg. All patients were followed
up until discharged from care. The patients were treated by 5. Rupture of the choroid or sclera.
the duty ophthalmologist as he or she thought appropriate
for the condition. All patients had full anterior segment and
dilated posterior segment examination. Description of inju- RESULTS
ries followed the Birmingham classification3 and was graded During the study period there were 18 651 admissions to our
as minor—lid haematoma, subconjunctival haemorrhage or primary care department, and of these 13 were due to ocular
corneal abrasion; intermediate—transient rise in intraocular injuries attributed to assault with a raw egg (0.07%; table 1).
pressure (IOP) or trauma uveitis; or major—hyphaema, All 13 eye injuries were due to eggs thrown by strangers.
commotio retinae, retinal detachment, globe breach or Twelve patients were men and the average age of the
longlasting sequelae. All statistics used are purely descriptive. victims was 27.9 years. Nine patients were injured in the left
eye and there were no bilateral injuries. On presentation only
BLUNT OCULAR TRAUMA one patient had a visual acuity of 6/6, seven presented at 6/9
Blunt trauma to the eye is a common presentation to
ophthalmology emergency services and, although on Abbreviation: IOP, intraocular pressure
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Blunt ocular trauma resulting from thrown eggs 757
Table 1 Classification of ocular injuries in 13 patients
Case Age Month Sex Eye Presenting VA Injury classification Discharge VA Sequelae
1 27 November Male Left 2/60 Major 3/60 Macula damage, angle
recession
2 17 April Male Right 6/24 Major 6/6 None
3 20 April Male Left 6/18 Major 6/5 Corneal scar
4 21 May Male Left 6/9 Major 6/6 Retinal detachment
5 24 May Male Right 6/9 Major 6/9 None
6 32 June Male Left 6/9 Minor 6/9 None
7 44 June Male Left 6/24 Major 6/9 None
8 22 July Male Right 6/18 Major 6/9 Angle recession
9 16 October Male Left 6/9 Major 6/6 None
10 20 October Female Right 6/9 Minor 6/9 None
11 50 October Male Left 6/9 Minor 6/9 None
12 54 October Male Left 6/6 Intermediate 6/5 None
13 16 October Male Left 6/60 (amblyopic) Intermediate 6/60 None
VA, visual acuity.
with the remainder having 6/18 or worse (one had a visual
acuity of 6/60 but was densely amblyopic).
All patients had closed globe injuries; however, only three
injuries were classed as minor with corneal abrasions,
subconjunctival haemorrhage or, as in one patient, a simple
lid haematoma. As would be expected with such injuries, all
were given antibiotic treatment and discharged from care.
Two injuries were classed as intermediate injuries. One
patient presented with an amblyopic eye with a corneal
abrasion and traumatic uveitis—this had settled at the 1-
week review after treatment with steroid and antibiotic. On
presentation, the vision was 6/60 due to amblyopia and on
discharge this remained unchanged. The second case was a
subconjunctival haemorrhage with traumatic uveitis that
again settled after appropriate treatment.
Most of the injuries (n = 8) were classified as major ocular
injuries. Five of these had various combinations of commotio
retinae, IOP rise and hyphaema, all of which settled after
appropriate treatment. We will discuss the remaining three Figure 1 Marked commotio of the macula (Berlin’s disease).
cases in detail.
Case 1 was a 27-year-old man who presented with
markedly reduced visual acuity (2/60) after being hit with gas tamponnade. This treatment was successful and the
an egg while he was a passenger in a moving car. patient was discharged from care with no retinal detachment
Examination showed subconjunctival haemorrhage and and vision of 6/6, six months after the incident.
corneal abrasions; however, there was marked commotio of Case 8 was a 22-year-old man who presented immediately
the macula region (Berlin’s disease; fig 1). On review, after the alleged assault with a visual acuity of 6/18. On
although the anterior segment injuries and, clinically, the examination, there was a large corneal abrasion, small
commotio settled, the patient’s vision did not improve. hyphaema with secondary rise in IOP (31 mm Hg), and
Electrodiagnostic testing 2 months after the incident showed extensive inferior commotio retinae with some peripheral
permanent damage to the middle and outer retinal layers of retinal haemorrhages. As the hyphaema settled, inferior
the macula corresponding to the photoreceptor layer. Testing angle recession was also noted. On day 34 after the injury, his
showed the ganglion cell layer to be functioning. Clinically, vision had improved to 6/9 and IOP was normal, with no
he developed mottling of the macula region, signifying retinal drugs being taken. A thorough examination showed no
pigment epithelium damage. In addition, there was angle retinal breaks. As with case 1, this patient now has a higher
recession of the anterior segment, giving the patient a probability of developing glaucoma throughout his life and
lifelong risk of developing glaucoma. On discharge, his vision must undergo yearly checks with his ophthalmologist.
remained poor at 3/60.
Case 4 presented, immediately after an assault with an egg
thrown from a passing car, with pain and mildly reduced COMMENTS
vision. Examination showed a subconjunctival haemorrhage, Ocular trauma of any sort accounts for a considerable
hyphaema, mild vitreous haemorrhage and extensive com- proportion of cases seen in ophthalmic primary care
motio retinae involving the macula; no retinal breaks were clinics—38–52% according to previous studies. In 1996,
identified. Over the next few visits he gradually improved. Desai et al4 reported on all ocular trauma cases admitted to
However, 35 days after the injury he sneezed and noticed an Scottish hospitals, and assault accounted for 21.8% of these
immediate drop in visual acuity (6/18). Examination showed cases. Our case series shows similarity to these results in that
a marked vitreous haemorrhage, and due to the mechanism most of the victims are young men. There was no mention of
of injury he underwent vitrectomy and cryotherapy to a large assault with thrown egg in the 1996 paper, and that would
inferior retinal tear and gas endotamponnade. Follow-up in seem coincident with the rise in popularity of this prank.
our vitreoretinal service showed satisfactory progress, but There have been previous reports of ocular trauma caused by
3 months after the initial injury he developed a macula on thrown eggs elsewhere. In 1988, around Halloween, a series
retinal detachment that necessitated further vitrectomy with of five cases was reported in the US and two of these patients
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758 Stewart, Durnian, Briggs
had permanent loss of vision.2 In 2003, three patients were
reported from Ireland, one of whom had severe visual loss.1
Thankfully, with one exception, all our patients did recover
well, although when looking at the major injuries in detail,
we find some potentially serious injuries such as macula
damage, retinal detachment and angle recession. Although
the final visual acuities in most cases are reassuring, we must
look at the potential serious long-term damage when
discussing such injuries. One limitation of our study is that
our department does not deal with childhood injuries and
this may have led to under-reporting. However, we may
expect the younger members of our community to do much
of the egg throwing, but their targets may be the older
population.
The dimensions of an egg are similar to those of a squash
ball, with a considerably greater weight, meaning that eggs,
as missiles, can easily fit in the orbital rim, causing severe
blunt injury even when thrown by hand. In our series, there
were no cases of open globe injury, which is the immediate
fear with such a mechanism of injury, but other sequelae of
severe, blunt trauma—hyphaema, commotio, retinal tears,
haemorrhage—were present.
As is evident from the table, although these cases are Figure 2 A commercial brand of eggs.
spread across the period, there is a cluster in October, which
is coincident with the Halloween season. This sort of mischief
.....................
can be interpreted as innocent, but as seen in our series, can
lead to severe ocular morbidity. For years now, resources Authors’ affiliations
R M K Stewart, J M Durnian, M C Briggs, St Paul’s Eye Unit, Royal
have been placed on public education surrounding the
Liverpool University Hospital, Liverpool, UK
dangers of fireworks, but no mention has been made of the
dangers of egg throwing either around Halloween or at other Competing interests: None.
times. Obviously, you cannot educate people against throw-
ing objects at each other; you rely on their common sense.
However, the recent advertising stunt by a leading super- REFERENCES
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''Here's egg in your eye'': a prospective study
of blunt ocular trauma resulting from thrown
eggs
R M K Stewart, J M Durnian and M C Briggs
Emerg Med J 2006 23: 756-758
doi: 10.1136/emj.2006.035501
Updated information and services can be found at:
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References This article cites 4 articles, 1 of which can be accessed free at:
http://emj.bmj.com/content/23/10/756.full.html#ref-list-1
Article cited in:
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