Covid-19 Lockdown And Eye Injury: A Case Series From Jordan

To report 4 cases of traumatic eye injury that resulted in ruptured globes presented to the ophthalmology ER at our tertiary center during COVID-19 associated lockdown in Jordan. All the involved eyes shared a history of previous penetrating keratoplasty and were the worst seeing eyes in each patient. They also shared the same form of rupture that involved large wound dehiscence and associated with extrusion of the lens (crystalline or artificial) through the wound at the time of trauma. Also, to compare the percentage of open globe injuries /total number of emergency cases presented during the lockdown with the percentage of open globe injuries /total number of emergency cases presented during the corresponding period in the previous year.

We describe the mechanism, place and timing of trauma for each eye. We also describe the clinical presentations and findings in each eye. We also compare the number of globe injury cases presented to the ophthalmology ER during the COVID-19 associated lockdown to the number of globe injury cases presented in the corresponding period of the preceding year. We describe possible causes for the higher likelihood for globe injuries in visually compromised eyes during COVID-19 lockdown.

Four cases of ruptured globe injuries presented to the ER department during the 2^nd, 3^rd, 4^th and 6^th weeks of the two-month period of COVID-19 strict lockdown that started in March 17^th of 2020. The 1st and 2nd cases were for a 25-year-old male patient and 48-year-old female patient who presented after 1 hour of direct trauma in the house (falling down and walking into a wall). Both had a history of keratoconus and a previous PK for the involved eye, and both were phakic. Examination showed a VA of LP and HM respectively and a wound dehiscence of about half of the donor host junction and aphakia for both eyes. The 3rd case was for an 8-year-old female patient with a left eye previous rupture that resulted in a scarred cornea and cataract. PK with phaco and IOL was performed 2 years prior to presentation. She had a history of falling down 2 hours prior to presentation. Upon examination, VA was HM in the left eye, wound dehiscence temporally from 11 to 4 o’clock, aphakia, and vitreous was seen to be incarcerated in the wound. The 4th case was for a 42-year-old female with history of keratoconus and a PK performed for the right eye 15 years ago. The trauma was with a closet door 2 hours prior to presentation. VA was HM and slit lamp exam showed a donor-host wound dehiscence of about six clock hours involving the superior half of the PK. The percentage of globe injuries/ total ocular emergencies was significantly higher than the previous year (P=0.0005).

We believe the lockdown could have resulted in higher risk of eye trauma in visually compromised patients. This may be due to the psychological impact of the lockdown, and/or as a direct effect of staying within a limited space inside the house for a long period of time. As a consequence of the structural weakness of eyes with previous PKs, these eyes were more likely to present with wound dehiscence and more severe damage that required urgent surgical interventions. Four cases of ruptured globe, all of which were in a form of large wound dehiscence and lens extrusion in eyes with previous PKs, and all presenting in one center within five weeks during the period of lockdown, represent an extremely unusual scenario that deserves reporting.