The limitations of the NEISS notwithstanding [1], this analysis underscores the vulnerability of children to NPF-related eye injuries [3, 4]. There are several possible explanations. First, NPFs are mostly marketed to children and teens as “toys” and are readily available in department and toy stores [4]. Second, there is no regulation of NPFs on the Federal level despite NPFs’ ability to cause severe injury, disability and death [2]. The Consumer Product Safety Commission regulates safety standards for NPFs. However, only 24 states regulate the possession, use, or transfer of NPFs; 26 have no NPF regulations [5].

The rate of NPF-related eye injuries in children declined over the study period. In 2015 and 2016, the American Medical Association adopted new policies to encourage protective eyewear and provide education to avoid eye injury [6,7,8,9]. Also, more publications like those from the American Academy of Pediatrics in 2018 and increased media attention during the study period may explain the heightened awareness of NPF-related eye injuries compared to years prior [2, 4, 10,11,12]. Furthermore, against the backdrop of the deadliest mass shootings in the US–Orlando, Florida in 2016 and Las Vegas, Nevada in 2017–there may have been a shift in societal attitudes, with firearms being less casually regarded as “toys” for children and teenagers due to heightened media scrutiny and coverage of these events [13, 14].

Conversely, adult cases of NPF-related eye injury increased from 2019 to 2022. While NPF injuries disproportionately affect children, there is a notable lack of focus on adult injury prevention. In the study period, US medical organizations like the American Academy of Ophthalmology, American Academy of Family Physicians, and the American College of Physicians had few publications focused solely on adult NPF injury prevention.

The rise in the overall injury rate in 2019 was most likely driven by the sharp increase in adult injuries and temporary rise in child injuries. This trend may be explained by the stay-at-home orders and social distancing policies related to the COVID-19 pandemic [15, 16] as eye injuries from NPFs may be more likely to occur at home (89%) than in public areas (11%) [2]. Additionally, while sports/recreational businesses may enforce mandatory eye and face protection, wearing eye protection is otherwise voluntary [2].

While occurring less frequently and leading to fewer serious eye injuries compared to other sports like basketball and baseball, NPF-related eye injuries are preventable [2] and can impact long-term ocular health and quality of life. The National Rifle Association recommends that NPFs be treated like powder firearms for all age groups [17]. This includes federally mandated age requirements and background checks for the purchase of NPFs. While Federal law allows states to regulate the sale of NPFs, only New Jersey and Rhode Island legally recognize and regulate NPFs as firearms and require background checks [5].

Currently, there are no federal regulations mandating protective eyewear for non-recreational NPF use, and state-level regulations are either inconsistent or entirely absent [2, 5]. State regulations should require adult supervision and enforce the proper use of safety equipment when using NPFs. Despite advancements in protective equipment, NPF-related injuries leading to blindness persist across all age groups [18, 19]. National efforts to enhance education and awareness regarding NPF hazards are essential, as a significant portion of injuries occur when individuals remove their masks due to fogging, paint splatter, or misunderstanding the safety protocols [20].

Policy changes require data, ideally from a national database. The US Eye Injury Registry (USEIR) collected all ocular trauma presenting to EDs as well as outpatient settings [18]. However, the USEIR ceased data collection in 2013. Current databases such as the Walter Reed Ocular Trauma Database, Elmhurst Ocular Trauma Registry, and IRIS registry are not publicly accessible and have limitations in the categories of trauma they cover and their generalizability across different populations [21]. Establishing a publicly accessible national database in collaboration with the American Society of Ophthalmic Trauma would facilitate evidence-based research and support legislative efforts to reduce preventable eye injuries, including those from NPFs.