Proning related bilateral anterior ischaemic optic neuropathy in a patient with COVID-19 related acute respiratory distress syndrome

Abstract

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.

Nonarteritic Anterior Ischemic Optic Neuropathy following COVID-19 Vaccination: Consequence or Coincidence

“…Previous cases of NA-AION in the setting of COVID-19 infection were reported in the literature [ 7 – 9 ]. SARS-CoV-2 can cause significant inflammation resulting in hypercoagulability manifesting as pulmonary embolism, deep-vein thrombosis, ischemic strokes, or myocardial infarcts [ 7 ].…”

“Vision Loss” and COVID-19 Infection: A Systematic Review and Meta-Analysis

“…Finally, 29 studies were included in the systematic review [ 8 , 9 , 10 , 11 , 12 , 13 , 14 , 15 , 16 , 17 , 18 , 19 , 20 , 21 , 22 , 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , 35 , 36 ] and two in the meta-analysis [ 9 , 23 ]. The included studies provided data on the number of participants with “visual loss” developed during COVID-19, and the meta-analysis included two studies [ 9 , 23 ] with 288 COVID-19 patients.…”

“…The articles included in this systematic review were published between 28 April 2020 and 22 February 2022. We assessed two cross-sectional studies [ 9 , 23 ], twenty-four case reports [ 8 , 10 , 11 , 12 , 13 , 14 , 15 , 16 , 17 , 18 , 19 , 20 , 21 , 22 , 24 , 25 , 27 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , 36 ], and three case series [ 14 , 26 , 35 ]. The number of participants ranged from one (case reports) to 199 (cross-sectional studies), with 84 out 318 COVID-19 patients experiencing “visual loss”.…”

“…”Visual loss” in COVID-19 patients was reported in a few articles. Nonetheless, it has been observed that its onset may be due to viral neurotropism and indirect immunologic and neurovascular effects [ 8 , 9 , 10 , 11 , 12 , 13 , 14 , 15 , 16 , 17 , 18 , 19 , 20 , 21 , 22 , 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , 35 , 36 ].…”

Non-arteritic anterior ischemic optic neuropathy in COVID-19 infection – A case report

“… 2 Garcia B et al 14 55-year-old male with a history of high blood pressure, coronary stenting, and smoking bilateral NAION with left transverse sinus thrombosis with permanent vision loss Endothelial damage in arteries and veins caused in situ inflammation and occlusion of the short posterior ciliary arteries resulting in bilateral simultaneous NAION. 3 Clarke KM et al 15 55 year old Afro-Caribbean male with severe, irreversible, visual impairment with bilateral NAION in a patient with COVID 19 pneumonitis and hypoxemic respiratory failure requiring prolonged sedation and eight episodes of prone mechanical ventilation Prone positioning leading to alterations in IOP which precipitate nerve hypoperfusion 4 Tsukii R et al 16 55-year-old woman, who presented with a 4-day history of inferior visual field disturbance in the right eye 7 days after receiving the first dose of Pfizer-BioNTech COVID-19 vaccine. COVID-19 vaccination-related vasculopathy on the microvascular network of the optic nerve head.…”