Purpose: Ocular complications are common in the critical care setting but are frequently missed due to the focus on life-saving organ support. The SARS-CoV-2 (COVID-19) pandemic has led to a surge in critical care capacity and prone positioning practices which may increase the risk of ocular complications. This article aims to review all ocular complications associated with prone positioning, with a focus on challenges posed by COVID-19. Materials and Methods: A literature review using keywords of “intensive care”, “critical care”, “eye care”, “ocular disorders”, “ophthalmic complications,” “coronavirus”, “COVID-19,” “prone” and “proning” was performed using the electronic databases of PUBMED, EMBASE and CINAHL. Results: The effects of prone positioning on improving respiratory outcomes in critically unwell patients are well established; however, there is a lack of literature regarding the effects of prone positioning on ocular complications in the critical care setting. Sight-threatening ophthalmic disorders potentiated by proning include ocular surface disease, acute angle closure, ischemic optic neuropathy, orbital compartment syndrome and vascular occlusions. Conclusions: COVID-19 patients may be more susceptible to ocular complications with increased proning practices and increasing demand on critical care staff. This review outlines these ocular complications with a focus on preventative and treatment measures to avoid devastating visual outcomes for the patient.

Fungal eye infections are rare. Trauma associated with contamination by vegetative material, contact lens wear and long term corticosteroid use are common risk factors. The aims of treatment are to preserve visual function, which depends on the rapid diagnosis and efficient administration of appropriate antifungal therapy. This necessitates a clinical suspicion of fungal aetiology and the taking of appropriate smears and cultures as early as possible to identify the fungal organism. Currently there are three main classes of drugs available for use in fungal eye infections: polyenes, azoles as derivatives of imidazoles, and 5-fluorocytosine. Of the polyenes, amphotericin B, natamycin and nystatin are of clinical ophthalmic use. Based on better pharmacokinetic profiles and spectra of antifungal activity, the triazoles are the agents of choice. Successful treatment of fungal keratitis depends on early initiation of specific therapy consisting of topically-applied antifungal agents since topical administration is most likely to provide the best opportunity for achieving therapeutic corneal levels. Hence, the molecular weight of the various antifungal agents is of importance since it influences their ability to penetrate the corneal epithelium. Systemic administration may be necessary for resistant fungal ulcers. For fungal endophthalmitis, to preserve visual function and eliminate the fungal pathogen, topical, systemic and possibly intraocular antifungal therapy is used, although some do not recommend use of systemic agents for exogenous endophthalmitis.

Cyclosporine cannot currently be considered as an effective sole agent in prophylaxis and treatment of allograft rejection, and corticosteroids therefore remain the gold standard choice of therapy. Further studies are required to refine the role of cyclosporine in modern corneal transplantation.

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The features and management of two adult patients with ophthalmoplegic migraine and longlasting sixth nerve palsies are described. Both had had previous shorter episodes of diplopia following migraine-like headaches. One recovered following an injection of botulinum toxin to the medial rectus of her affected eye 11 months after the onset of diplopia. The other patient had previously had surgery for a consecutive divergent squint and required further squint surgery to realign his eyes 1 year after the onset of his sixth nerve palsy. Both botulinum toxin and squint surgery may be useful in the management of longstanding sixth nerve palsy in patients with ophthalmoplegic migraine. The aetiology of ophthalmoplegic migraine is discussed.

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Purpose Dendritic cells (DCs) express the high-affinity receptor for IgE (FceRI) on their surface, which may enhance their ability to capture and internalize antigens for presentation to T-lymphocytes. The aim of this study was to determine if expression of FceRI þ DCs is increased in the conjunctivae of vernal keratoconjunctivitis (VKC) patients compared with those of normal controls. Methods Conjunctival biopsies were obtained from non-atopic and VKC patients. Double immunohistochemical staining was carried out using antibodies against FceRI and the CD1a antigen, a DC marker. The doublepositive cells were counted in five representative fields of view for each conjunctival sample. Results FceRI þ CD1a þ cells were present in significantly higher numbers in VKC conjunctivae compared with normal controls (mean cell count of 21.3 in VKC vs 5.0 in controls, Po0.005). In normal patients the FceRI-expressing DCs tended to be confined to the epithelial layer or the superficial substantia propria, but in the VKC samples these FceRI þ cells were mainly concentrated in the deeper substantia propria. Conclusions FceRI þ DC numbers are elevated in the conjunctivae of VKC patients, a finding consistent with the results of other studies focusing on atopic conditions. Elevated expression of FceRI on DCs would facilitate antigen presentation and enhance T-cell priming, thereby contributing to ocular symptoms.

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