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Year : 2022  |  Volume : 4  |  Issue : 1  |  Page : 28

Corneal perforation in a patient with COVID-19 pneumonia under helmet continuous positive airway pressure ventilation treatment

Department of Ophtalmology, Centro Hospitalar De Entre O Douro E Vouga, Santa Maria Da Feira, Portugal

Date of Submission01-Jan-2022
Date of Decision25-Feb-2022
Date of Acceptance07-Mar-2022
Date of Web Publication23-Jun-2022

Correspondence Address:
Maria Joao Matias
Department of Ophtalmology, Centro Hospitalar De Entre O Douro E Vouga, Rua Cândido Pinho, Santa Maria Da Feira
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/pajo.pajo_1_22

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Ocular surface complications secondary to continuous positive airway pressure (CPAP) machines have been previously reported such as ocular irritation, dry eye disease, lid laxity, and floppy eyelid syndrome. No severe ocular complications have been specified in the literature. We report a serious ocular complication in a patient under helmet CPAP (hCPAP). A 68-year-old male with COVID-19 pneumonia required ventilatory support with hCPAP. Following 5 days, the patient started complaining of ocular discomfort, purulent discharge in his left eye, and ocular dryness upon awakening. Ophthalmological examination showed no light perception in the left eye and slit-lamp biomicroscopy revealed atalamia, loss of corneal transparency with superior infiltrates, and a total epithelial defect with iris herniation and a central perforation. Considering the patient's progressive worsening clinical condition, with a painful blind eye, left evisceration was performed. It is important to be aware of possible ophthalmological complications related to ventilation since prompt diagnosis and treatment can avoid poor visual outcomes. In this clinical case, we faced a serious ocular complication following hCPAP ventilation.

Keywords: Continuous positive airway pressure, corneal perforation, COVID-19

How to cite this article:
Matias MJ, Ruao M, Costa J, Chibante-Pedro J, Almeida I. Corneal perforation in a patient with COVID-19 pneumonia under helmet continuous positive airway pressure ventilation treatment. Pan Am J Ophthalmol 2022;4:28

How to cite this URL:
Matias MJ, Ruao M, Costa J, Chibante-Pedro J, Almeida I. Corneal perforation in a patient with COVID-19 pneumonia under helmet continuous positive airway pressure ventilation treatment. Pan Am J Ophthalmol [serial online] 2022 [cited 2023 Mar 23];4:28. Available from: https://www.thepajo.org/text.asp?2022/4/1/28/347999

  Introduction Top

COVID-19 pandemic emerged in December 2019, causing lung complications such as pneumonia and in the most severe cases, acute respiratory distress syndrome.[1] Patients with severe COVID-19 pneumonia can develop hypoxemic acute respiratory failure requiring ventilatory support with the need for positive end-expiratory pressure.[2],[3]

Helmet continuous positive airway pressure (hCPAP) is a noninvasive type of ventilation, consisting of a transparent plastic hood that surrounds patient's head [Figure 1], which improves oxygenation, avoiding invasive mechanical ventilation in some selected patients.[3] Concerning ocular findings in patients using continuous positive airway pressure (CPAP), it has already been described some anterior segment complications, including dry ocular surface, chronic eye irritation, and ocular infection.[4] Such complications can be explained by eye barotrauma from the air blowing directly into the eyes, exposure to expired air from the mouth and nose with subsequent inoculation of bacteria, or from air passing from the nose to eyes by nasolacrimal duct, that can lead to ocular infections.[5],[6] In this article, we describe an ocular surface severe complication in one COVID-19 patient under hCPAP ventilation.
Figure 1: Patient with COVID-19 severe pneumoniae, admitted to intensive care unit, undergoing helmet continuous airway pressure ventilation

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  Case Report Top

A 68-year-old Caucasian male patient with a known history of chronic obstructive pulmonary disease presented to the emergency department complaining of fever, dry cough, asthenia, and myalgia for 2 weeks. Physical examination revealed cutaneous pallor, fever (temperature of 38.4°C), and oxygen saturation of 94% on room air. A chest X-ray showed bilateral hilar enlargement and right lung infiltrates; thorax computed tomography revealed irregular and peripheral ground-glass opacity lesions predominantly in the lower lobes. These findings suggested infection with SARS-CoV-2, which was confirmed by a positive real-time polymerase reaction test. The patient was hospitalized and started noninvasive ventilation with a nasal cannula. Five days later, he presented worsening symptoms including dyspnea at rest, polypnea, and a presumed hypoxemic acute respiratory failure. Considering this, hCPAP ventilatory treatment was started and 5 days after, the patient complained of ocular dryness upon awaking and an increasingly progressive burning sensation in both eyes. It was noted left eye redness and scant purulent discharge and empiric therapy were started with topical chloramphenicol drops four times a day in Internal Medicine Department. On the next day, hCPAP was stopped because the patient developed great intolerance to it. Due to lack of improvement of his ocular situation and external ocular appearance [Figure 2]a., it was requested evaluation by an ophthalmologist. When asked about previous ophthalmological history, the patient mentioned no previous ocular symptoms and a past normal ophthalmological exam 2 years before. The patient denied history of ocular trauma, even during hCPAP placing. He also noted ocular dryness upon awakening in the previous days, being increasingly difficult to tolerate hCPAP due to ocular discomfort and noise. Ophthalmological examination showed no light perception in the left eye and slit-lamp biomicroscopy revealed ciliary injection, chemosis, loss of corneal transparency with superior infiltrates, an almost total epithelial defect with central perforation and iris herniation, atalamia but no seidel [Figure 2]b. The right eye showed a superficial punctate keratitis and a reduced tear break-up time (TBUT). Owing to the patient's clinical condition, the left eye evisceration was performed.
Figure 2: (a) Ocular external appearance of patient's left eye that has motivated observation by an ophthalmologist showing conjunctival hyperemia, chemosis, and abundant purulent discharge. (b) Slit-lamp photograph showing ciliary injection, atalamia, loss of corneal transparency with central perforation, and iris herniation

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  Discussion Top

hCPAP is a type of noninvasive ventilation that is being used in COVID-19 patients with severe lung disease.[3] In this clinical case, we are toward an ocular severe complication in a COVID-19 patient under hCPAP ventilation that has never been described in previous studies. The dry eye seemed to be an important factor predisposing to corneal melting. In this clinical case, the patient clearly reported symptoms of dry eye after the placing of hCPAP and other causes of corneal melting were less likely to cause this clinical outcome. Ophthalmologic examination also showed signs of dry eye.

Literature comprises a few cases reports on ocular surface complications due to CPAP.[6] Hayirci et al. reported that CPAP therapy increased ocular irritation, tear evaporation, and squamous metaplasia of conjunctiva in patients with obstructive sleep apnea, revealing increased Schirmer 1 score and decreased TBUT.[6] Concerning CPAP mask, Stauffer et al. reported a case of bacterial conjunctivitis, Ely and Khorfan described a case of unilateral periorbital edema and Fayers et al. reported reactivation of recurrent corneal ulceration.[6] However, no such complications were found among patients under hCPAP in a large study evaluating this interface.[7] Comparing hCPAP to face mask, it seems that the first is associated with less eye irritation, being better tolerated since air leaks are localized around the neck, reducing eye barotrauma.[8],[9]

It is essential to alert health-care workers to be aware of possible ocular complications of CPAP therapy, monitoring symptoms of ocular irritation and infection. When a patient is started on CPAP ventilation, corneal drying should be prevented with preservative-free artificial teardrops or bedtime gels. Given the increase in hospital admissions of patients with COVID-19, it is likely the number of ocular complications due to ventilation will increase.

However, further studies are needed to clarify the ocular effects of hCPAP in patients with and without preexisting ocular disease.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Fan E, Beitler JR, Brochard L, Calfee CS, Ferguson ND, Slutsky AS, et al. COVID-19-associated acute respiratory distress syndrome: Is a different approach to management warranted? Lancet Respir Med 2020;8:816-21.  Back to cited text no. 1
Ogawa F, Kato H, Nakajima K, Nakagawa T, Matsumura R, Oi Y, et al. Therapeutic strategy for severe COVID-19 pneumonia from clinical experience. Eur J Inflamm 2020;18:1-10.  Back to cited text no. 2
Aliberti S, Radovanovic D, Billi F, Sotgiu G, Costanzo M, Pilocane T, et al. Helmet CPAP treatment in patients with COVID-19 pneumonia: A multicentre cohort study. Eur Respir J 2020;56:2001935.  Back to cited text no. 3
Harrison W, Pence N, Kovacich S. Anterior segment complications secondary to continuous positive airway pressure machine treatment in patients with obstructive sleep apnea. Optometry 2007;78:352-5.  Back to cited text no. 4
Karaca EE, Akçam HT, Uzun F, Özdek Ş, Ulukavak Çiftçi T. Evaluation of ocular surface health in patients with obstructive sleep apnea syndrome. Turk J Ophthalmol 2016;46:104-8.  Back to cited text no. 5
Hayirci E, Yagci A, Palamar M, Basoglu OK, Veral A. The effect of continuous positive airway pressure treatment for obstructive sleep apnea syndrome on the ocular surface. Cornea 2012;31:604-8.  Back to cited text no. 6
Rali AS, Howard C, Miller R, Morgan CK, Mejia D, Sabo J, et al. Helmet CPAP revisited in COVID-19 pneumonia: A case series. Can J Respir Ther 2020;56:32-4.  Back to cited text no. 7
Esquinas Rodriguez AM, Papadakos PJ, Carron M, Cosentini R, Chiumello D. Clinical review: Helmet and non-invasive mechanical ventilation in critically ill patients. Crit Care 2013;17:223.  Back to cited text no. 8
Longhini F, Bruni A, Garofalo E, Navalesi P, Grasselli G, Cosentini R, et al. Helmet continuous positive airway pressure and prone positioning: A proposal for an early management of COVID-19 patients. Pulmonology 2020;26:186-91.  Back to cited text no. 9


  [Figure 1], [Figure 2]


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