A 32 y.o. male is in the ICU. He is intubated, on pressors, and profoundly hypoxic

what do you notice in his sclera?

What condition causes it?

Our patient had tache noire; a black stain on the cornea in the perimortem or post mortem period. This is a kind of exposure keratopathy in the setting of sedation or severe illness. This drying of the ocular surface can cause corneal ulceration or even perforation. This is most commonly found after death but has been reported in critically ill patients as in our case.  Our patient died of his leukemia and complications of treatment including ARDS.  He was negative for COVID.

tache noire in a patient with sepsis and multiorgan system failure

the same patient on the next day treated with lubricants and eye patching

RANDOM EYE FINDINGS IN CRITICALLY ILL/CARDIAC ARREST PATIENTS

1.Eye pressure decreases with time after death exponentially. This coincides  with clouding of the cornea.

2.Pupils dilate after cardiac arrest.  This is thought to be lack of perfusion to the midbrain causing pupil constriction mechanisms to be inactive. A study of brain dead patients whose organs were being harvested found that since the iris is perfused through vessels arising from the external carotid, the midbrain autonomic reflexes would be absent but the sympathetic innervation of the dilator muscles of the iris would be active after brain death. After the aorta was cross clamped; prior to harvest , the pupils still dilated(without therefore, any effect of the midbrain) due to sympathetics. Hypoxia is also needed to activate the sympathetic effect and it lasts only briefly, since anoxia eventually causes sympathetic neurons to cease firing.

3.Pupils return to mid position 3-20 minutes after death.

4.Acute anoxia causes pupillary constriction until asystole occurs or the cardiac output is reduced by more than 70%, at which point pupils dilate.

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