key: cord-0734054-pes5784s
authors: Ekici Gok, Zarife; Gok, Abdullah; Acun Delen, Leman; Kasapoglu, Umut S.; Gurbuz, Esra; Mutlu, Kayhan
title: Evaluation of eye care and ocular findings in critically ill COVID‐19 patients
date: 2021-10-03
journal: Int J Clin Pract
DOI: 10.1111/ijcp.14909
sha: f8680fc9bdc5a82f0b1aa5f5b385855c3c0f8092
doc_id: 734054
cord_uid: pes5784s

OBJECTIVE: The current study aimed to evaluate eyecare needs along with ocular findings in patients treated in intensive care units because of Covid‐19 infection. MATERIALS AND METHODS: A total of 93 patients, 58 men and 35 women, who were under follow‐up and treatment in intensive care because of COVID‐19 infection from 1 January 2021 to 15 February 2021 were included in the study. Detailed eye examinations of the patients were performed with a portable handheld biomicroscope, direct and indirect ophthalmoscope. Cases requiring treatment for eye diseases were identified and treated. RESULTS: The mean patient age was 68.32 ± 9.97 years; 35 patients were followed up and treated with non‐invasive mechanical ventilation and 58 patients with invasive mechanical ventilation support. Mild, moderate, and severe chemosis was observed in 19 patients (20.4%), 10 patients (10.8%) and 4 patients (4.3%), respectively. Conjunctivitis (8.6%) was observed in eight patients. Corneal abrasion was present in seven patients (7.5%). Keratitis secondary to exposure keratopathy was observed in one patient. Eye care and medical treatment were initiated for these patients. We noted eight patients (8.6%) with retinal haemorrhage; however, to the best of our knowledge, these patients may show acute retinal involvement secondary to systemic diseases or have previous retinal findings other than Covid‐19 infection or treatments. CONCLUSION: Findings of ocular involvement because of COVID‐19 infection were detected in the present study. Retinal haemorrhages were detected in addition to the common findings in viral infections. Especially in patients supported with mechanical ventilation, the detection and treatment of conditions that require eye care for exposure keratopathy are very important for recovering from the disease and the quality of vision.

Although ocular findings such as conjunctivitis, chemosis, epiphora and conjunctival injection have been detected since the initial reports of Covid-19, it has also been reported that these findings may be the first sign of Covid-19 infection. 5 In various case reports, retinal haemorrhage and retinal vein occlusion have been shown as complications of the posterior segment associated with Covid. In a published report, patients without any systemic disease and decreased vision after the onset of Covid-19 infection and found to have unilateral or bilateral retinal vein occlusion were reported. The report suggested that there may be a vein occlusion associated with vasculitis and thromboembolism because of immune complex accumulation. 6, 7 In another report published, Paracentral Acute Middle Maculopathy and Acute Macular Neuroretinopathy were reported in a case of Covid-19 because of the hyper-reflective lesions detected in OCT as a result of decreased vision. 8 Since Covid-19 is a life-threatening infection, other organ interactions have not been fully determined, as many studies focus on the respiratory system to improve survival. Extra-pulmonary symptoms of SARS-Cov-2 should not be ignored, as they may be important causes of morbidity and a source of viral transmission. Therefore, the current study aimed to evaluate the ocular effects of infection and the treatments applied, especially in intensive care patients with severe disease, and to identify and treat patients who would require eye care.

In the current study, we included 93 patients who were being followed up and treated in the intensive care unit from 1 January 2021 to 15 Personal protective equipment was worn and precautions were taken before entering the patient rooms. The anterior segment findings such as cornea, conjunctiva, and eyelids were examined first with a portable handheld biomicroscope and direct ophthalmoscope for each patient. Subsequently, the eyes were dilated with 1% tropicamide, and retinal and optic nerve examinations were performed by the same ophthalmologist with an indirect ophthalmoscope and 28D lens. During the anterior segment examinations of the patients, conditions requiring eye care, especially in patients who were intubated and placed in the prone position, such as corneal epithelial defect, conjunctivitis and keratitis were determined. Intensive care personnel were also trained, and eye care and treatments were provided.

The sample size of the study was determined by Power Test with the power of each variable considered at least 80% and type 1 error taken as 5%. We checked whether the continuous measurements in the study were normally distributed or not with the Kolmogorov-Smirnov test (n > 50) and Skewness-Kurtosis tests. Parametric tests were applied because the measurements were normally distributed.

Descriptive statistics for continuous variables were expressed as mean, standard deviation, minimum and maximum. "Independent Ttest" was used to compare the measurements between the groups.

"Pearson correlation coefficients" were calculated to determine the relationships between measurements. Chi-square test was used to determine the relationship between categorical variables. In the calculations, the statistical significance level (a) was taken as 5% and the SPSS (IBM SPSS for Windows, ver. 24) statistics package program was used for analysis. 

Mean patient age was 68.32 ± 9.97 years, 35 patients were followed up and treated with non-invasive mechanical ventilation and 58 patients with invasive mechanical ventilation support (Table 1) .

Patients were treated in the hospital for an average of 7 days from the onset of Covid-19 symptoms. As a result of the clinical worsening, the patients were followed and treated in the intensive care unit, and ophthalmological examination was also performed in the intensive care unit. Ophthalmological examinations were performed after an average of 12.43 (2-30) days of admission to intensive care (Table 2) . It was observed in the files of the patients that no ocular symptoms were reported in any of the patients.

Patients who developed severe chemosis were those who were occasionally placed in the prone position for treatment. Severe keratitis because of lagophthalmos was detected in one patient, conjunctivitis with the purulent discharge was detected in one patient, and eye closure and drug treatment (moxifloxacin and artificial tear without preservative) were initiated. When these patients were examined for control purposes, improvement was observed in patients with corneal abrasion, but treatment responses could not be followed up in the patient with keratitis and purulent conjunctivitis considering that the patients were dead. In two of the cases with conjunctivitis, the PCR test was performed from conjunctival swabs to detect SARS-CoV-2, but a negative result was obtained. Although the main target of the SARS-CoV-2 virus is the respiratory tract, it is stated that it affects many other systems and that various symptoms are observed. 9 Furthermore, coronavirus has been shown to cause serious eye diseases such as retinal vasculitis, anterior uveitis, optic neuritis in animals, ocular symptoms in humans are rare and mild. 10 The retina is considered as an extension of the central nervous system (CNS), therefore involvement may occur not only in the optic nerve (optic neuritis) but also in the retina (retinitis) in neuroinflammatory conditions and infections of the CNS. 11 The CNS is protected from viruses by its multilayer barriers and the immune system, but viruses can affect the brain in various conditions such as direct brain damage, hypoxic damage, upregulated ACE-2 receptors and immunodeficiency. 12 It is well-known that ACE-2 receptors are widely distributed among many tissues and cell types, as well as in the conjunctiva. Some reports have shown that CoV-2 could potentially spread through direct or indirect contact with the mucous membranes of the eyes. 5 Wu et al 14 showed that the incidence of conjunctivitis and other ocular symptoms were higher in patients with severe pneumonia. In the present study, conjunctivitis was seen with a rate of 8.6%. The mechanism of how conjunctivitis occurs is still not fully understood.

It may be endothelial dysfunction, vasculitis or the host response of conjunctival vessels because of Covid-19 infection. 24 More than 15% of patients affected by the Covid-19 pandemic are hospitalised and treated, a significant portion of which will require mechanical ventilation. 25 Decrease in orbicular muscle tone because of neuromuscular blocking agents applied in patients under MV support and turning patients to the prone position, which is one of the treatment stages, increase the risk of exposure keratopathy in intensive care patients. 26 Exposure keratopathy can be seen in patients who are connected to mechanical ventilation, especially in intensive care, and it can lead to progressive vision loss by causing microbial keratitis and ocular surface scarring. 27 A guideline has been approved by The Royal College of Ophthalmologists (RCOphth) in collaboration with the Intensive Care

Association to prevent keratopathy in intensive care patients. It contains precautions that can be taken together with closing the eyelids. 26 Kam et al also suggested an eye care protocol in an eye care study in critically ill patients, emphasising that clinicians should evaluate the closure of the eyelids in terms of lagophthalmos. 28 To prevent the progression to keratopathy, eyelid closure and medical treatment was performed in patients in our intensive care unit with corneal epithelial defects seen in the first examinations during the examination phase. under mechanical ventilation support.

We observed retinal haemorrhage at a rate of 8.6%. We observed that Covid-19 infection can directly cause endothelitis, thromboembolism or retinal haemorrhage and cotton wool spots because of the treatments used. There was no significant difference in terms of systemic disease and laboratory parameters in patients with haemorrhage in the retina compared with those without haemorrhage.

None declared.

The authors have stated explicitly that there are no conflicts of interest in connection with this article. All authors reviewed and contributed in editing the manuscript.

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