Eye Protection for Patients With COVID-19 Undergoing Prolonged Prone-Position Ventilation | Critical Care Medicine | JN Learning | AMA Ed Hub [Skip to Content]
[Skip to Content Landing]

Eye Protection for Patients With COVID-19 Undergoing Prolonged Prone-Position Ventilation

Educational Objective
To identify the key insights or developments described in this article
1 Credit CME
Key Points

Question  What ophthalmic abnormalities are present in patients with coronavirus disease 2019 in the intensive care unit requiring prolonged prone-position ventilation?

Findings  In this case series, 2 patients with periorbital edema in the prone position had bilateral findings of optic disc edema and retinal hemorrhages as well as a substantial increase in intraocular pressure.

Meaning  Clinicians should be aware of the possible presence of elevated intraocular pressure from periorbital edema due to direct compression of the eye and orbit, and optic disc edema and retinal hemorrhages, which may be associated with a hypercoagulable state, in patients with coronavirus disease 2019 in prolonged prone position in the intensive care unit.

Abstract

Importance  Critically ill patients with coronavirus disease 2019 (COVID-19) who are unresponsive to maximum optimal ventilator settings may be in a prone position for at least 16 hours per day to improve oxygenation. This extended duration of prone positioning puts patients at risk of developing orbital compartment syndrome if direct pressure to the orbit and the globe occurs and concomitant protection of the eyes is not undertaken.

Objective  To report 2 cases of orbital compartment syndrome, as well as optic disc edema and retinal hemorrhages, in the setting of prolonged prone positioning of patients in the intensive care unit during the COVID-19 pandemic.

Design, Setting, and Participants  The cases took place from April 27, 2020, to May 4, 2020, at a COVID-19 intensive care unit of a tertiary care hospital. Four of 16 patients in the intensive care unit required prolonged prone-position ventilation. A bedside eye examination was performed on 4 selected patients due to the observed presence of substantial periorbital edema.

Main Outcomes and Measures  Intraocular pressures and fundus findings of 4 patients with periorbital edema.

Results  Two of 4 patients who were in the prone position for extended periods of time had bilateral fundoscopic findings of optic disc edema and retinal hemorrhages, possibly consistent with a papillophlebitis. Additionally, both patients had a substantial increase in intraocular pressure of 2- to 3-fold in the prone position compared with the supine position.

Conclusions and Relevance  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. Orbital compartment syndrome can be avoided by the use of protective cushioning around the eyes and maintaining the patient’s head position above heart level during prone positioning. Patients with COVID-19 may also develop papillophlebitis with optic disc edema and retinal hemorrhages, which may be associated with a hypercoagulable state caused by COVID-19. These observations suggest awareness for the possible presence of these ophthalmic findings while treating severely ill patients with COVID-19.

Sign in to take quiz and track your certificates

Buy This Activity

JN Learning™ is the home for CME and MOC from the JAMA Network. Search by specialty or US state and earn AMA PRA Category 1 CME Credit™ from articles, audio, Clinical Challenges and more. Learn more about CME/MOC

CME Disclosure Statement: Unless noted, all individuals in control of content reported no relevant financial relationships. If applicable, all relevant financial relationships have been mitigated.

Article Information

Corresponding Author: Howard D. Pomeranz, MD, PhD, Department of Ophthalmology Northwell Health, 600 Northern Blvd, Ste 214, Great Neck, NY 11021 (hpomeran@northwell.edu).

Accepted for Publication: September 18, 2020.

Published Online: November 19, 2020. doi:10.1001/jamaophthalmol.2020.4988

Author Contributions: Drs Pomeranz and Hymowitz had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: All authors.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: All authors.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Hymowitz, Sun.

Administrative, technical, or material support: Hymowitz, Sun.

Supervision: Pomeranz, Hymowitz.

Conflict of Interest Disclosures: None reported.

Funding/Support: This study was supported by the Department of Ophthalmology and Northwell Eye Institute at Northwell Health.

Role of the Funder/Sponsor: The funders supported the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Additional Contributions: We would like to acknowledge the contributions of the Northwell Health COVID-19 Research Consortium.

References
1.
Guérin  C , Reignier  J , Richard  JC ,  et al; PROSEVA Study Group.  Prone positioning in severe acute respiratory distress syndrome.   N Engl J Med. 2013;368(23):2159-2168. doi:10.1056/NEJMoa1214103PubMedGoogle ScholarCrossref
2.
Iba  T , Levy  JH , Levi  M , Connors  JM , Thachil  J .  Coagulopathy of coronavirus disease 2019.   Crit Care Med. 2020;48(9):1358-1364.PubMedGoogle Scholar
3.
Epstein  NE .  Perioperative visual loss following prone spinal surgery: a review.   Surg Neurol Int. 2016;7(suppl 13):S347-S360. doi:10.4103/2152-7806.182550PubMedGoogle ScholarCrossref
4.
Nickels  TJ , Manlapaz  MR , Farag  E .  Perioperative visual loss after spine surgery.   World J Orthop. 2014;5(2):100-106. doi:10.5312/wjo.v5.i2.100PubMedGoogle ScholarCrossref
5.
Insausti-García  A , Reche-Sainz  JA , Ruiz-Arranz  C , Vázquez  ÁL , Ferro-Osuna  M .  Papillophlebitis in a COVID-19 patient: inflammation and hypercoagulable state.   Eur J Ophthalmol. 2020;1120672120947591. doi:10.1177/1120672120947591Google Scholar
6.
Marinho  PM , Marcos  AAA , Romano  AC , Nascimento  H , Belfort  R  Jr .  Retinal findings in patients with COVID-19.   Lancet. 2020;395(10237):1610. doi:10.1016/S0140-6736(20)31014-XPubMedGoogle ScholarCrossref
7.
Landecho  MF , Yuste  JR , Gandara  E ,  et al.  COVID-19 retinal microangiopathy as an in vivo biomarker of systemic vascular disease?   J Intern Med. Published online July 30, 2020. doi:10.1111/joim.13156Google Scholar
8.
Amorim Correa  JL , Acioly  MA .  The enigma of orbital compartment syndrome after lumbar spine surgery in the prone position: case report and literature review.   World Neurosurg. 2018;110:309-314. doi:10.1016/j.wneu.2017.11.111PubMedGoogle ScholarCrossref
9.
Richardson  S , Hirsch  JS , Narasimhan  M ,  et al; the Northwell COVID-19 Research Consortium.  Presenting characteristics, comorbidities, and outcomes among 5700 patients hospitalized with COVID-19 in the New York City area.   JAMA. 2020;323(20):2052-2059. doi:10.1001/jama.2020.6775PubMedGoogle ScholarCrossref
If you are not a JN Learning subscriber, you can either:
Subscribe to JN Learning for one year
Buy this activity
jn-learning_Modal_Multimedia_LoginSubscribe_Purchase
Close
If you are not a JN Learning subscriber, you can either:
Subscribe to JN Learning for one year
Buy this activity
jn-learning_Modal_Multimedia_LoginSubscribe_Purchase
Close
With a personal account, you can:
  • Access free activities and track your credits
  • Personalize content alerts
  • Customize your interests
  • Fully personalize your learning experience
Education Center Collection Sign In Modal Right
Close

Name Your Search

Save Search
Close
With a personal account, you can:
  • Track your credits
  • Personalize content alerts
  • Customize your interests
  • Fully personalize your learning experience
jn-learning_Modal_SaveSearch_NoAccess_Purchase
Close

Lookup An Activity

or

Close

My Saved Searches

You currently have no searches saved.

Close

My Saved Courses

You currently have no courses saved.

Close
With a personal account, you can:
  • Access free activities and track your credits
  • Personalize content alerts
  • Customize your interests
  • Fully personalize your learning experience
Education Center Collection Sign In Modal Right
Close