Background
Non-arteritic ischaemic optic neuropathy (NAION) is a rare but harmful complication of prone positioning. Prone mechanical ventilation is a therapeutic strategy which has been used extensively during the COVID-19 pandemic to treat acutely hypoxemic patients with COVID-19 related acute respiratory distress syndrome (ARDS). Though a small number of cases of unilateral NAION have been reported in patients testing positive for the SARS-CoV-2 virus, we describe what is to our knowledge, the first reported case of bilateral NAION occurring in a patient proned extensively for the treatment of COVID-19 related ARDS. We consider the potential aetiological factors leading to NAION after prone mechanical ventilation in patients with COVID-19 and suggest strategies to protect against its development.
Case presentation
: We report a case of severe, irreversible, visual impairment secondary to bilateral anterior ION in a fifty-five-year-old male who underwent eight episodes of prone mechanical ventilation to treat COVID-19 related ARDS. Once weaned from his sedation he reported bilateral painless vision loss, and bedside ophthalmological assessment identified a reduced visual acuity of 3/30 unaided in the left eye and counting fingers in the right. Dilated indirect ophthalmoscopy revealed inferotemporal optic disc oedema with splinter haemorrhages in the right eye and mild disc oedema, temporal pallor, and nerve fibre layer haemorrhages inferiorly in the left eye. Humphrey visual field 24 − 2 testing confirmed a severely constricted visual field with macular sparing on the right and depressed inferonasal vision with preserved peripheral vision on the left eye. OCT disc imaging shortly after diagnosis revealed bilateral disc swelling and flame haemorrhages in the right eye.
Conclusions
NAION is a devastating, but preventable complication of prone positioning, which may pose significant risk of vision loss in patients with COVID-19 related ARDS.
This study supports previous evidence that LGP enhances the IOP-lowering success of VC/PVC. The advantages of LGP are that it is a minimally invasive clinic-based procedure with a low complication rate.
DESCRIPTIONA 15-year-old boy presented after being attacked by a 'Lightsaber' wielded by his friend. The device in question was a blue laser pointer (450 nm 8000 mW) reflected by his friend off a mirror-the beam caught the patient in the left eye for a mere 1 or 2 s. His vision dropped immediately and he presented the next day with a macular haemorrhage (figure 1) and a vision of 6/60. We treated via observation only and, fortunately, his vision improved slowly over the next 4 weeks: day 7, 6/36; day 14, 6/18 and day 30, 6/12. In the absence of any evidence for an active choroidal neovascular membrane, we felt that intravitreal antivascular endothelial growth factor therapy was not indicated.It is common knowledge that lasers can cause retinal injury, 1 but we would like to share these Figure 1 Fundus photos and optical coherence tomography images capturing the natural history of the foveal haemorrhage following the laser injury.
Aims: To explore the current roles, responsibilities and educational needs of ophthalmic specialist nurses (OSNs) in the UK. Method: A survey of 73 OSNs ranging from band 4 to band 8 was undertaken in May 2018. Findings: 73% of OSNs undertake more than one active role, with 59% involved in nurse-led clinics; 63% felt formal learning resources were limited, with 63% reporting training opportunities and 21% reporting time as major barriers to further training. More than 38% emphasised hands-on clinic-based teaching had a greater impact on their educational needs. Some 64% were assessed on their skills annually and 59% felt confident with their skill set. Conclusion: The Ophthalmic Common Clinical Competency Framework provides a curriculum and assessment tools for OSNs to use as a structure to maintain clinical skills and knowledge. Eye departments should use this as guidance to target learning needs and improve standards of care to meet the changing needs of society.
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