Orbital Compartment Syndrome Following Extracorporeal Support

Posterior Segment Findings in Patients on Extracorporeal Membrane Oxygenation

Purpose:

Extracorporeal membrane oxygenation (ECMO) is an established treatment modality for critically ill patients with cardiopulmonary failure, yet little is known of the ocular pathology in this population. The aim of this study is to characterize the posterior segment findings of ECMO patients.

Methods:

This study is a retrospective analysis of 20 ECMO patients evaluated by ophthalmology from September 2012 to May 2019 at a level 1 trauma center. Comprehensive examinations assessed for intraocular pathology. Demographic data, exam findings, and mortality were analyzed.

Results:

The sample size consisted of 20 patients; a majority were male (75%), and mean age was 37.4 years (interquartile range, 26.75-50 years). All patients received ECMO for care of acute respiratory distress syndrome (ARDS). Average duration of ECMO therapy was 9.6 ± 6.5 days. Eleven (55%) patients had acute retinal pathology, including Purtscher-like retinopathy (20%), intraocular hemorrhage (50%), and septic chorioretinitis (bacterial or fungal, 10%). Location of hemorrhage included the retina (40%), vitreous (30%), and optic disc (15%). Sixty percent (n = 12) of patients were unable to provide a subjective history on initial assessment. Ultimately, 5 out of 20 patients (25%) died of systemic illness during their hospital stay.

Conclusion:

This study demonstrates high rates of retinal pathology, most commonly vitreous and/or retinal hemorrhage alongside a Purtscher-like retinopathy. This is likely secondary to complications of anticoagulation, microthrombi, septicemia, and hemodynamic instability. We found a mortality rate slightly lower than that of prior ECMO studies. Prospective studies with pre-ECMO and post-ECMO fundus photography is warranted for better understanding of these medically complex patients.

Orbital Compartment Syndrome Following Major Burn Resuscitation: A Case Series and Survey of Practice Patterns

Orbital compartment syndrome (OCS) is a rare but devastating complication of over-resuscitation in burn patients that may lead to permanent visual loss. The purpose of this study was to 1) present a series of burn patients with OCS and 2) survey practice patterns of monitoring intra-ocular pressure (IOP) during burn resuscitation. Cases of OCS at two American Burn Association (ABA)-verified burn centers were retrospectively reviewed. Patients were included if they 1) required lateral canthotomy/cantholysis for elevated IOPs or 2) developed blindness on admission unrelated to any other ocular pathology. Data were collected on demographics, burn characteristics, fluid administration, ophthalmologic findings, and complications. An eight-item electronic survey was distributed by email through the ABA to all physician members. Twelve patients with OCS were identified, with a mean age of 47.8 ± 12.4 years and TBSA of 63.7 ± 18.6%. Mean fluid resuscitation at 24 hours was 4.9 ± 1.6 ml/kg/%TBSA or 0.29 ± 0.06 liter/kg. Eight patients underwent canthotomy/cantholysis for OCS, whereas four were later found to have visual loss. A total of 83 (14%) ABA physicians responded to the survey. IOP was routinely measured by 23% of respondents during acute burn resuscitation. OCS appears to have developed despite a relatively low 24-hour ml/kg/% burn resuscitation volume, but with a relatively higher cumulative (liter/kg) fluid volume. Their survey found that monitoring of IOP during burn resuscitation is not routinely performed by the majority of providers. Taken together, the present study suggests clinical guidelines to recognize this complication of over-resuscitation.