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.

The authors postulate that prolonged prone positioning of patients with COVID-19 can be associated with elevated intraocular pressure from periorbital edema, direct compression on the eye, and increased orbital venous pressure. Development of papillophlebitis with optic disc edema and retinal hemorrhages may be associated with the hypercoagulable state caused by COVID-19.

According to the authors, awareness about these possible ophthalmic complications is necessary while treating severely ill patients with COVID -19 so as to prevent devastating permanent visual loss. In conclusion, the authors suggest the following recommendations: (1) Raising awareness of the potential risk of vision loss following prolonged prone positioning, (2) Encouraging the use of protective cushioning of the eyes to avoid mechanical pressure on the globe during prone positioning, (3) If appropriate, maintaining the patient's head position above heart level, and (4) consideration of performing a fundus examination to evaluate for the presence of optic disc or retinal abnormalities in prone-positioned patients in the ICU.

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https://jamanetwork.com/journals/jamaophthalmology/fullarticle/2772984