Orbital-Conjunctival-Eyelid Hemorrhage-Hematoma due to Inappropriate use of FFP2/NK95 Facial Mask in COVID-19

Abstract

A non-traumatic or spontaneous orbital hemorrhage (NTOH) is usually caused by the presence of an orbital mass, an inflammation, an infection, a bleeding disorder or those called idiopathic. This entity usually affects elderly adults and some risk factors can be identified. The NTOH normally acts like a benign and self-limited process, but attending to its anatomical pattern, may need specific management. A 64-year-old male referred to us with sudden binocular double vision, without loss of visual acuity (VA) or pain immediately after fitting the FFP2/NK95 facial mask for air protection during the pandemic COVID-19. He presented sudden orbital-subconjunctival-eyelid cutaneous hemorrhage-hematoma with conjunctival protrusion from the palpebral fissure without proptosis. There was also limitation in adduction and a cutaneous hematoma in the inner third of the lower eyelid. After 48 hours, the diplopia had resolved and ocular motility was completely re-established with persistence of a massive hyposphagma. No radiological image test was performed due to the COVID-19 epidemiological situation, as the patient was in good systemic situation and it was not a vital emergency. The evolution was favorable with conservative treatment, cold application, and moisturizing eye drops. After 10 days, the bruising was almost completely gone. During the ongoing novel coronavirus disease (COVID-19) pandemic caused by the novel enveloped RNA virus named severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), face mask use has drastically increased among the healthcare professionals and the general population. The importance of this case lies in the new adverse effects caused by the misuse of mandatory face masks in the general population.

COVID-19: Update on Its Ocular Involvements, and Complications From Its Treatments and Vaccinations

“…Nevertheless, inappropriate use of masks can result in ocular complications. Nontraumatic orbital hemorrhage presented as sudden orbital-subconjunctival-eyelid cutaneous hemorrhage-hematoma with conjunctival protrusion from the palpebral fissure has been reported in the improper fitting of face mask whereby excessive pressure was exerted on the nasal bridge and lower eyelid 94 . Alternatively, unsuitable fitting with face masks in which exhaled air flows across the ocular surface could exacerbate tear film evaporation and predispose patients to the development of dry eye 95 …”

“…Nontraumatic orbital hemorrhage presented as sudden orbitalsubconjunctival-eyelid cutaneous hemorrhage-hematoma with conjunctival protrusion from the palpebral fissure has been reported in the improper fitting of face mask whereby excessive pressure was exerted on the nasal bridge and lower eyelid. 94 Alternatively, unsuitable fitting with face masks in which exhaled air flows across the ocular surface could exacerbate tear film evaporation and predispose patients to the development of dry eye. 95 At the beginning of the rapidly evolving pandemic, public fear and confusion regarding appropriate public health measures and behaviors to eliminate COVID-19 transmission have fuelled the dissemination of erroneous information and false beliefs.…”

A German AWMF’s S2e/realist synthesis and meta-narrative snapshot of craniomaxillofacial manifestations in COVID-19 patients: Rapid living update on 1 January 2021

“…The risk factors include ageing, hypertension, hyperlipidaemia, and taking antiplatelet and/or anticoagulant agents. (Level of Evidence 4) [ 52 ]. Spontaneous orbital emphysema may develop in relation to high positive end-expiratory pressure (PEEP) ventilation (Level of Evidence 4) [ [53] , [54] , [55] ], in a similar manner with our previous report on periorbital emphysema after nose blowing [ 56 ].…”