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

Lucy Sun, Maggie Hymowitz, Howard D. Pomeranz

JAMA Ophthalmol. 2021;139(1):109-112. doi:10.1001/jamaophthalmol.2020.4988

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.

**Figure 1. Case 1: A Man in His Early 50s After 9 Sessions of 18-Hour Prone-Position Ventilation**

**Figure 2. Case 2: A Man in His Mid-40s After 4 Sessions of 18-Hour Prone-Position Ventilation**

**Figure 3. Case 2: A Man in His Mid-40s After 6 Sessions of 18-Hour Prone-Position Ventilation**

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.