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

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.

Systemic Capillary Leak Syndrome Secondary to Coronavirus Disease 2019.

Systemic capillary leak syndrome is a rare disorder characterized by dysfunctional inflammatory response, endothelial dysfunction, and extravasation of fluid from the vascular space to the interstitial space leading to shock, hemoconcentration, hypoalbuminemia, and subsequent organ failure. The condition may be idiopathic or secondary to an underlying cause, which can include viral infections. Here we describe a patient with acute coronavirus disease 2019 (COVID-19) infection who presented with hemoconcentration, shock, and hypoalbuminemia. The patient subsequently developed rhabdomyolysis and compartment syndrome of all four extremities, requiring fasciotomies. This is the first reported case of systemic capillary leak syndrome associated with COVID-19 infection. This case adds to the evolving spectrum of inflammatory effects associated with this viral infection.