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LIVERPOOL, England, Sept. 21 -- Throwing a raw egg is a prank gone bad all too often, warned emergency physicians here who cited blunt ocular trauma.

Hurling eggs at passersby has become something of a ritual among teens and young adults here on Halloween, and outraged emergency room physicians reported seeing 13 patients with blunt ocular trauma as a result.

Eight of the 13 patients had major injuries, four had permanent complications, and one suffered severe, irreversible visual loss, wrote Jon Durian, M.D., of the St. Paul's Eye Unit at the Royal Liverpool University Hospital, and colleagues, in the October issue of Emergency Medicine Journal.

"As anyone who has woken up on 1 November each year and looked out at the chaos left in the wake of the previous night's activities can attest, Halloween and so-called mischief night (the night before) is now becoming an annual excuse for anti-social behavior ranging from mild annoyance to the sheer dangerous," the authors wrote.

"One particular prank that seems to be becoming more common is the practice of throwing raw eggs either at buildings or at innocent passersby," they added. "Aside from the dry-cleaning bills, a raw egg can lead to severe ocular injury due to its weight and size, as has been reported previously."

The authors conducted a prospective study of all egg-induced ocular injuries seen in their department over 14 months.

They divided the eye injuries into minor, intermediate, and major categories. Minor injuries included hematoma of the eyelid, subconjunctival hemorrhage or corneal abrasion. Intermediate injuries included those resulting in a transient rise in intraocular pressure (IOP) or traumatic uveitis.

Major injuries included hyphema, commotio retinae (edema around the macula due to the force of the injury; a risk factor for retinal tears), retinal detachment, globe breach, or long-lasting sequelae.

Although the rate of ocular trauma was small (13 out 18,651 cases), the majority of the episodes resulted in major injuries, the authors reported.

Twelve of the 13 patients were men. The average age was 27.9 years. All had been hit in the eye with raw eggs thrown by strangers, and all had injuries to one eye only (nine left eyes and four right eyes).

The authors found that on initial examination, only one patient had 20/20 visual acuity, seven presented with 20/30 and the remainder had 20/60 or worse (one of these five patients was densely amblyopic, with acuity of only 20/200 before presentation).

All of the patients had closed globe injuries, but only three were minor, consisting of corneal abrasions, subconjunctival hemorrhage, and a simple lid hematoma. These patients were give antibiotics and were discharged.

Two patients had intermediate injuries. One, the patient with amblyopia, presented with corneal abrasion and traumatic uveitis in the amblyopic eye. This patient was treated with steroids and antibiotics, and his injuries had settled after one week of follow-up. The second intermediate injury was a case of subconjunctival hemorrhage with traumatic uveitis that again settled after appropriate treatment.

The remaining eight injuries were classified as major. Five of these patients had combinations of commotio retinae, rise in intraocular pressure, and hyphema, all of which settled after appropriate treatment.

Of the remaining three patients with major injuries, one had subconjunctival hemorrhage and corneal abrasions, as well as marked commotio of the macula region. On electrodiagnostic testing at two months, he was found to have to permanent damage to the middle and outer retinal layers of the macula corresponding to the photoreceptor layer. On discharge, his vision remained poor, at 20/300.

The second patient, who had been hit in the eye with an egg thrown from a passing car, presented with pain and mildly reduced vision. He was found on examination to have a subconjunctival hemorrhage, hyphema, mild vitreous haemorrhage, and extensive commotio retinae involving the macula, although no retinal breaks were seen. He subsequently suffered a marked vitreous hemorrhage leading to a large retinal tear requiring vitrectomy, cryotherapy, and gas endo-tamponnade.

At three months, the patient developed a macula on retinal detachment requiring additional vitreoretinal surgery. This patient was eventually discharged with 20/20 vision, but only after six months of treatment.

The last case was that of a 22-year-old man who presented immediately after being hit in the eye with an egg with a visual acuity of 20/60. On examination, he was seen to have a large corneal abrasion, small hyphema with secondary rise in intraocular pressure (31 mm Hg), and extensive inferior commotio retinae with some peripheral retinal hemorrhages.

He was subsequently found to have inferior angle recession, putting him at enhanced risk for glaucoma, although a little more than a month later his vision had improved to 20/30, and his intraocular pressure had normalized.

"Obviously, you cannot educate people against throwing objects at each other; you rely on their common sense," the authors wrote. "However, the recent advertising stunt by a leading supermarket in re-branding their eggs as 'mischief eggs' must at least be considered to be irresponsible and at worst almost incitement to this type of assault. The medical community should expect those with most access to the nation's conscience -- advertisers, retailers and TV program makers -- to act in a responsible manner against these and other easily preventable injuries."

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