A 78-year-old Caucasian woman, with a past medical history of non-insulin-dependent type 2 diabetes, arterial hypertension, dyslipidemia and obesity, was admitted to the intensive care unit (ICU) of our tertiary hospital with ARDS related to COVID-19 disease, with severe hypoxemic respiratory failure, requiring mechanical ventilation in prone position.
Relevant ophthalmic antecedents included bilateral senile corticonuclear cataracts extracted by large-incision extracapsular cataract surgery 13 years before, with a remaining area of scleral thinning at the incision site, in the right eye. The patient had completed a total of three sessions of 18-h prone-position mechanical ventilation over 4 days, by the time ophthalmological evaluation was requested because a thick subconjunctival hemorrhage was observed. There was no record of major eye trauma.
Bedside eye examination in the ICU revealed a considerable right peri-orbital edema and an extensive hemorrhagic chemosis, preventing complete eyelid closure (Fig. 1a and b). Intraocular pressure was impossible to assess, but globe hypotony was obvious by gentle digital palpation, and indirectly by the presence of multiple corneal folds. Anterior chamber structures were difficult to distinguish, but a superiorly deviated pupil and hyphema could be presumed. There was no red reflex. Left eye findings, in both the anterior and posterior segment, were unremarkable.
Upon suspicion of right globe rupture, an orbital computed tomography (CT) scan was performed. It showed a hazy and thickened eyeball outline, with internal structural disorganization, suggesting the presence of vitreous hemorrhage, and choroidal and retinal detachment (Fig. 2a). Contact B-scan ultrasonography was avoided at this time due to concern regarding iatrogenic damage.
A clinical diagnosis of occult right globe rupture was assumed.
Given the patient’s severe respiratory failure even with maximum ventilatory support, disqualifying her for eye surgery under general anesthesia, an interdisciplinary decision between intensivists and ophthalmologists favored a focus on life-saving measures. Attempts to reduce the frequency of prone were hindered by worsening of the oxygen saturation levels.
Lubricant drops and chloramphenicol-dexamethasone eye ointment were prescribed along with mechanical eyelid closure with hypoallergenic tape, and eye protection with a fox shield. Simultaneously, preventive protective cushioning around the fellow left eye was adopted to minimize the risk of ocular injury.
With the resolution of conjunctival edema and hemorrhage, subsequent ophthalmological evaluations showed the presence of an exteriorized intraocular lens (IOL) haptic, over the superior bulbar conjunctiva and cornea (Fig. 1c). The remainder of the IOL body was in the superior subconjunctival space (Fig. 1d). The diagnosis of a ruptured globe became unequivocal. There was no corneal staining with fluorescein dye, or signs of infection. By this time, B-scan ultrasonography corroborated the suspicion of vitreous hemorrhage, and choroidal and total retinal detachment (Fig. 2b).
The patient’s systemic condition progressively improved, and she was successfully extubated after 31 days in the ICU. Communication became possible, allowing visual acuity assessment. There was no light perception in the right eye, and the best-corrected visual acuity in the left was 20/25. The complex situation and the low visual potential of the right eye were explained to both the patient and her family, and the benefits and risks of the treatment and intervention options under consideration were discussed.
Consequently, ophthalmological surgery was undertaken. Following a more conservative approach, aiming to avoid a potential entry site for microorganisms, the exteriorized IOL haptic was cut, and the overlying conjunctiva was closed with an absorbable Vicryl 8-0 suture. After the procedure, the patient continued receiving antibiotic + corticosteroid ointment and drops.
After 55 days in the ICU, and able to maintain adequate oxygen saturation on room air, she was admitted to an inpatient rehabilitation care unit, where ophthalmological evaluations have been taking place regularly. One week after surgery, the patient was emotionally well and reported no pain. At the slit-lamp examination, the conjunctival suture was stable and there were no signs of infection. One month postoperatively, the Vicryl suture reabsorbed, and the remainder of the IOL haptic was fully covered by healthy conjunctiva (Fig. 3a and b).