Orbital Compartment Syndrome in COVID-19 after Prolonged Prone Position Ventilation: JAMA

Prolonged prone positioning is an adjunctive strategy deployed in severely ill patients of COVID-19 with acute respiratory distress syndrome who are unresponsive to maximum optimal ventilator settings in order to improve oxygenation. It is recognized that patients in the prone position during surgery for extended periods of time are at risk of developing orbital compartment syndrome if the eyes are not protected because of direct pressure to the orbit and the globe. COVID-19 is further known to be associated with a high prevalence of coagulopathy and thromboembolism that affect different organs including the eye. The prevalence of hypercoagulable state is more in severely ill patients who have elevated levels of fibrinogen and dimerized plasmin fragment D levels. Therefore, concern has been raised about the possibility of vision loss in severely ill patients of COVID-19 undergoing prolonged treatment in ICU, especially in prone position.

The case series includes four patients with severe COVID-19 who required prolonged prone position ventilation in the intensive care unit of a tertiary care hospital. They were noted to have significant periorbital oedema and a bedside ophthalmic examination was undertaken.

Visual assessment was not possible as the patients were deeply sedated. All patients had peri-orbital oedema which was more pronounced in the dependent eye. Of the 4 patients, 2 had bilateral fundoscopic findings of optic disc oedema and retinal haemorrhages, most consistent with a presumed diagnosis of COVID-19–associated papillophlebitis. One of the patients also had scattered Roth spots in the retina. These patients were also found to have substantially elevated IOP in the prone position when compared with the supine position. Both patients also had abnormally elevated dimerized plasmin fragment D levels. The fundus findings in the other two patients were normal.