A clear view: the way forward for eye care on ICU. Intensive care units

Neglected ocular surface care in critical care medicine: An observational study

AIM

To study the prevalence of lagophthalmos and its related complications among the unconscious patients admitted in the intensive care units (ICU)/wards of a tertiary care centre.

METHODS

Cross-sectional observational study.

RESULTS

A total of 87 unconscious patients were included. 44 were children and 43 were adults. The overall median age of patients was 16 years (range: 9 days- 85 years). 53/87 (60.91%) showed signs of lagophthalmos, among which 56.60% (30/53) were children and 43.40% (23/53) were adults. There was no significant difference in the exposure patterns between children and adults (p = 0.25). Exposure related manifestations (conjunctival/corneal) were found in 49/87 patients (56.32%). The most common conjunctival manifestation was chemosis, occurring in 28/53 patients (52.83%). Corneal exposure was seen in 31/53 patients (58.49%), of which fragile epithelium was the commonest finding (32.08%). Only 17/31 (54.83%) cornea exposed eyes were taped, of which 15 were sub-optimal. 6 patients were unnecessarily taped. Signs of infection were noted in 8/53 eyes (15.09%).

CONCLUSION

Optimal eye care in unconscious patients can avert the development of exposure-related complications and subsequent ocular morbidity. Adoption and implementation of systematic protocols can help improve the standard of care.

Development and validation of an eye care educational programme for intensive care unit nurses

AIMS AND OBJECTIVES

To develop and validate an eye care educational programme for intensive care unit nurses.

BACKGROUND

Eye care guidelines and protocols have been developed for increasing eye care implementation in intensive care units. However, the guidelines lack consistency in assessment or intervention methodology.

DESIGN

This was a one-sample pre/postprogramme evaluation study design for testing the effects of the eye care educational programme, developed for and applied to intensive care unit nurses, on their levels of knowledge and awareness.

METHODS

The eye care educational programme was developed based on literature review and survey of educational needs. Thirty intensive care unit nurses served as subjects for the study.

RESULTS

The levels of eye care-related knowledge, awareness and practice were enhanced following the implementation of the educational programme. Moreover, satisfaction with the educational programme was high.

CONCLUSION

It is necessary to intensify eye care education aimed at new nurses who are inexperienced in intensive care unit nursing and provide continuing education on the latest eye care methods and information to experienced nurses.

RELEVANCE TO CLINICAL PRACTICE

The eye care educational programme developed in this study can be used as a strategy to periodically assess the eye status of patients and facilitate the appropriate eye care.

Making a Difference in Eye Care of the Critically Ill Patients

Ocular surface disorders are frequently encountered in patients under sedation and paralyzed patients in intensive care units (ICUs). In the ICUs, treatment is usually focused on the management of organ failures, and eye care becomes a side issue. As a result, ophthalmological complications do occur (incidence ranges from 3.6% to 60%) and are frequently overlooked in this setting. To identify the best available evidence in providing the best eye care to prevent exposure keratopathy, a literature review was performed. The databases of PUBMED, COCHRAN, and EMBASE library were searched. We only looked at higher quality articles. Among various eye care measures that have been advocated to prevent exposure keratopathy, the most effective is the application of polyethylene covers. Early diagnosis and effective treatment will help prevent microbial keratitis and visual loss.

Incidence and risk factors of corneal epithelial defects in mechanically ventilated children

OBJECTIVE

To determine the incidence of corneal defects and the main risk factors in children exposed to mechanical ventilation (MV) in the pediatric intensive care unit between March 28 and November 4, 2001.

METHODS

A cohort study where characteristics of 53 children exposed to MV were evaluated and risk factors relating to the occurrence of corneal defects were identified. Patients' corneas were evaluated on a daily basis using a fluorescein test and a portable slit lamp. Risk ratios and 95% confidence intervals were calculated. A multiple logistic regression analysis was performed using a nonconditional model. The model selects variables that maintain associations with corneal defects at a 5% level of significance. The variables with the highest predictive value were identified.

RESULTS

Twenty-five percent of children exposed to MV developed corneal defects. From this percent, almost 54% of the defects occurred in both eyes, and 46% in the left eye alone. Most defects (69%) were detected within the first week of MV, and a large number were detected within the first 48 hours (46% of cases). In those children who exhibited failure of at least one organ in addition to the lungs, 43% developed defects. Among the children who died, 44% showed corneal defects. After adjusting for potential confounding variables in the multivariate analysis, the maintenance of opened eyes and sepsis remained as prognostic factors for corneal defects.

CONCLUSIONS

A high incidence (25%) of corneal defects was found in children exposed to MV, as is also observed with adult patients. The main risk factors associated with corneal defects were the maintenance of opened eyes and the presence of sepsis.

Screening for ocular surface disease in the intensive care unit

PURPOSE

Ventilated patients in the intensive care unit (ICU) often develop exposure keratopathy. This predisposes to the development of bacterial keratitis, which in ICU is often bilateral, with a high risk of perforation. As regular examinations of all ventilated patients by ophthalmologists would be impractical, the purpose of this study was to assess whether ICU staff can screen reliably for keratopathy.

METHODS

A prospective study was performed in a general adult ICU. Twice each week, two junior ICU doctors examined the lid position and ocular surface of all patients who had been continuously sedated for more than 24 h, using fluorescein and a pen torch with a blue filter. An ophthalmologist performed similar examinations using a portable slit lamp.

RESULTS

A total of 48 ocular examinations were performed in 18 patients. Exposure keratopathy was found by the ophthalmologist in 37.5% of examinations and by ICU doctors in 31.3% of examinations. ICU doctors had a sensitivity of 77.8% and a specificity of 96.7% in detecting keratopathy, when compared with the findings of the ophthalmologist. All cases missed by ICU doctors had punctate erosions of less than 5% of the corneal surface. Keratopathy was significantly commoner in patients with incomplete lid closure than in patients with closed lids (70.0 vs 28.9%; two-tailed Fisher's exact test P=0.027).

CONCLUSIONS

ICU staff can perform screening examinations for exposure keratopathy with reasonable sensitivity and specificity. Regular screening by ICU staff would facilitate appropriate treatment of exposure keratopathy and promote earlier identification of cases of keratitis.

A randomised controlled study of the efficacy of hypromellose and Lacri-Lube combination versus polyethylene/Cling wrap to prevent corneal epithelial breakdown in the semiconscious intensive care patient

OBJECTIVE

To compare the efficacy of two forms of eye care (hypromellose and Lacri-Lube combination vs polyethylene/Cling wrap covers) for intensive care patients.

DESIGN

Randomised-controlled trial.

SETTING

University affiliated, tertiary referral hospital.

PATIENTS AND PARTICIPANTS

One hundred ten patients with a reduced or absent blink reflex were followed through until they regained consciousness, were discharged from the facility during study enrolment, died or developed a positive corneal ulcer or eye infection.

INTERVENTIONS

All patients received standard eye cleansing every 2 h. In addition to this, group one ( n=60) received a treatment combining hypromellose drops and Lacri-Lube (HL) to each eye every 2 h. Group two ( n=50) had polyethylene covers only placed over the eye to create a moisture chamber.

MEASUREMENTS AND RESULTS

Corneal ulceration was determined using corneal fluorescein stains and mobile slit lamp evaluation, performed daily. No patients had corneal ulceration in the polyethylene cover group, but 4 patients had corneal ulceration in the HL group.

CONCLUSIONS

Polyethylene covers are as effective as HL in reducing the incidence of corneal damage in intensive care patients.