COVID-19 Lockdown and Eye Injury: A Case Series from Jordan

Figures & data

Figure 1 Picture of the eye at presentation in the first case showing dehiscence of the superior two thirds of the donor tissue from the host with eversion of the donor tissue downward resulting in the endothelial part of the graft facing away from the globe.

Figure 2 B-scan ultrasonography of the eye for the first case one day post-operatively showing vitreous hemorrhage and complete retinal detachment.

Figure 3 Slit lamp picture of the eye for the fourth case one week post-operatively showing seven 10/0 nylon stitches securing the area of donor-host junction dehiscence superiorly and a large iridodialysis superiorly and superionasally.

Table 1 Summary of Clinical Scenarios for Patients Who Presented with Eye Injury Resulting in Ruptured Globe at KAUH During COVID-19 Lockdown in Jordan

	Patient 1	Patient 2	Patient 3	Patient 4
Patient’s Profile	25 Years, Male	48 Years, Female	8 Years, Female	42 Years, Female
PMH	Free	Essential HT	Free	Free
POH	1. KC OU. 2. Corneal hydrops OD. 3. PK OD 7 months prior to presentation.	1. KC OU 2. PK OS 12 years ago 3. Advanced steroid-response glaucoma OS	1. Ruptured globe OS with primary repair 2 years ago. 2. Traumatic cataract OS with Phaco+PCIOL 2 years ago. 3. PK OS 4 months ago	1. KC OU 2. PK OD 15 years ago. 3. Patient stated VA was always better in the left eye than in the right one.
Last eye exam prior to presentation	1. VA: 0.2 OD, 0.7 OS. 2. Clear graft OD 3. Phakic OU	1. VA: 0.3 OD, CF 1m OS. 2. RAPD OS. 3. Clear graft OS. 3. Phakic OU 4. Cupped disc OS.	1. VA: 1.0 OD, 0.1 OS. 2. Clear graft OS 3. Pseudophakia OS	Not Available, the patient was not a regular patient in our department.
Involved eye in the trauma	OD	OS	OS	OD
Mechanism of trauma	Tripped and fell down in the house on the right side of the body with a direct hit to the right side of the face.	Direct hit to the left side of her face from a wall while walking in the house.	Falling from bed while sleeping	Direct hit from a closet door when the patient opened it.
Clinical exam at presentation and injury description	1. VA: LP OD, 0.7 OS. 2. RAPD OD 3. Dehiscence of the superior two thirds of the donor tissues from the host with eversion of the donor tissue downward. 4. Lens extrusion/Aphakia 5. Vitreous prolapse 6. Total RD 7. VH	1. VA: 0.3 OD, HM OS 2. RAPD OS 3. Dehiscence of the inferior half of the donor-host junction. 4. Lens extrusion/Aphakia. 5. Vitreous prolapse and incarceration in the wound.	1. VA: 1.0 OD, HM OS 2. No RAPD 3. Donor-host wound dehiscence temporally from 11 to 4 o’clock. 4. IOL was expelled outside the wound, and the PC was disrupted. 5. Vitreous prolapse and incarceration in the wound	1. VA: HM OD, 0.7 OS. 2. No RAPD 3. Donor-host wound dehiscence of about six clock hours superiorly. 4. Iris prolapse 5. Vitreous prolapse 6. Total Hyphema 7. Lens extrusion/Aphakia 8. Iridodialysis
Surgery performed	Primary wound repair with anterior vitrectomy	Primary wound repair with anterior vitrectomy	Primary wound repair with anterior vitrectomy	Primary wound repair with anterior vitrectomy and AC washout, some prolapsing iris tissue was cut and removed.
Postoperative last exam of the involved eye	1. VA: LP 2. RAPD 3. Corneal edema/secondary graft failure. 4. Aphakia 5. Total RD	1. VA: CF. 2. RAPD 3. Corneal edema/secondary graft failure. 4. Aphakia 5. Subtotal disc cupping	1. VA: CF 3 meters 2. Clear graft 3. Aphakia	1. VA: 0.1 2. Clear graft 3. Iridodialyis superiorly and superionasally. 4. Aphakia 5. Minimal VH
Future plan	1. PPV with RD repair. 2. Iris fixation IOL implantation 3. PK 4. Temporary keratoprosthesis to be used intraoperatively. 5. Patient was notified the uncertainty of the surgical outcome.	1. PK 2. Iris fixation IOL implantation 3. Patient chose to wait for the time being	Iris fixation IOL implantation	1. Iridodialysis repair 2. Secondary scleral fixation IOL implantation.

Abbreviations: KC, keratoconus. OU, both eyes. OD, right eye; OS, left eye; PK, penetrating keratoplasty; VA, visual acuity; LP, light perception; RAPD, relative afferent pupillary defect; RD, retinal detachment; PPV, pars plana vitrectomy; IOL, intra-ocular lens; HT, hypertension; CF, counting fingers; HM, hand motion; Phaco, phacoemulsification; PCIOL, posterior chamber intra-ocular lens; VH, vitreous hemorrhage.

Table 2 Number of Total Ocular Emergencies and Open Globe Injuries Presented to the ER at KAUH During the Lockdown

Total Cases of Open Globe Injuries	Open Globe Injuries in Eyes with History of PK	Inside-Home Open Globe Injuries	Total Number of Ocular Emergencies	Percentage of Open Globe Injuries to the Total Ocular Emergencies
4	4	4	34	12%

Abbreviations: ER, emergency room. PK, penetrating keratoplasty. KAUH, King Abdullah University Hospital.

Table 3 Number of Open Globe Injuries Presented to the ER at KAUH in the Year Preceding the Lockdown and p values when Compared to the Period of Lockdown

Total Number of Open Globe Injuries	Open Globe Injuries in Eyes with History of PK	Inside-Home Open Globe Injuries	P value for Difference Between the Rate of Open Globe Injuries During the Strict Lockdown Period and the Year Preceding it	P value for the Difference Between the Rate of Open Globe Injuries in Eyes with Previous PKs During the Strict Lockdown Period and the Year Preceding it	P value for the Difference Between the Rate of Inside-Home Open Globe Injuries During the Strict Lockdown Period and the Year Preceding it
11	1	3	0.3	0.007	0.03

Abbreviations: ER, emergency room. PK, penetrating keratoplasty. KAUH, King Abdullah University Hospital.

Table 4 Number of Total Ocular Emergencies and Open Globe Injuries Presented to the ER at KAUH During the Corresponding Period of the Previous Year and p value When Compared to the Period of Lockdown

Total Cases of Open Globe Injuries	Total Number of Ocular Emergencies	Percentage of Open Globe Injuries to the Total Ocular Emergencies	P value for the Difference Between the Rate of Open Globe Injuries to the Total Ophthalmology Emergency Cases During the Lockdown Compared to the Corresponding Period of the Last Year.
1	288	0.3%	0.0005

Abbreviations: ER, emergency room. PK, penetrating keratoplasty. KAUH, King Abdullah University Hospital.