Prevalence and Risk Factors of Exposure Keratopathy Across Different Intensive Care Units

Prevalence and risk factors of exposure keratopathy among critically ill patients: A systematic review and meta-analysis

AIMS

To identify the incidence, prevalence and risk factors of exposure keratopathy (EK) among critically ill patients.

DESIGN

Systematic review and meta-analysis, in accordance with the PRISMA 2020 Statement.

METHODS

The Cochrane Library, PubMed, Embase, Web of Science, Cumulative Index to Nursing and Allied Health Literature (CINAHL), China Knowledge Resource Integrated Database (CNKI), Chinese Biomedical Database (CBM), Weipu Database (VIP) and WanFang Database were systematically searched from inception to June 2022. Observational studies that reported EK among paediatric and adult critically ill patients were screened and included original articles based on the inclusion criteria. Two reviewers independently completed data extraction and quality assessments. Subgroup analysis investigated potential causes of heterogeneity.

RESULTS

Of the 4508 studies identified, 23 studies involving 3519 subjects were included. The pooled prevalence of EK was 34.0%, and the pooled incidence rate of EK was 23.0%. Risk factors associated with EK in critically ill patients included lagophthalmos, chemosis, eye blinks <5 times per minute, mechanical ventilation, sedation, lower Glasgow Coma Scale (GCS) score and higher Acute Physiology and Chronic Health Evaluation (APACHE) II score.

CONCLUSION

This review shows that EK rates are high in critically ill patients and are influenced by multiple factors. Medical staff should pay more attention to EK in critically ill patients, conduct professional evaluations and implement targeted eye care protocols to reduce its occurrence.

IMPLICATIONS FOR PRACTICE

This study shows the frequency of and multiple risk factors for EK in critically ill patients, which provides evidence-based guidance for nurses to evaluate the risk of EK in critically ill patients and take appropriate precautions to reduce the risk.

PROTOCOL REGISTRATION

The protocol was registered in PROSPERO (https://www.crd.york.ac.uk/prospero/) (CRD42022346964).

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution.

Causal validation of the risk for corneal injury in critically ill adults

BACKGROUND

The validity of a nursing diagnosis depends on a continuous investigation process in different populations to provide clinical evidence. The risk for corneal injury nursing diagnosis was approved in 2013 and only reviewed in 2017, demonstrating the need to perform a clinical validation to improve it.

AIM

To perform a causal validation of the risk for corneal injury nursing diagnosis in critically ill adults.

STUDY DESIGN

A prospective cohort study was performed in two intensive critical care units in Northern Brazil with adults aged over 18 years without corneal injury at admission. The patients were evaluated for 10 days, using a data collection tool composed of risk factors for the risk for corneal injury nursing diagnosis. The independent variables were described through absolute and relative frequency. The accuracy measures and risk factors were identified through Cox regression, considering a 95% confidence interval.

RESULTS

The nurses assessed 209 critically ill adults and identified that 76.0% of them presented the risk for corneal injury nursing diagnosis, with 16.3% developing a corneal injury, all having previously presented the risk for corneal injury nursing diagnosis. The risk factors identified were eyeball exposure (hazard ratio: 1.78; 95% CI: 1.27-2.51), Glasgow score < 6 (hazard ratio: 1.73; 95% CI: 1.15-2.60) and periorbital oedema (hazard ratio: 1.43; 95% CI: 1.03-1.99), with these factors showing high specificity, and the mechanical ventilation variable, showing high sensitivity, with ROC curve of .86.

CONCLUSION

Eyeball exposure, Glasgow score < 6 and periorbital oedema are the risk factors of the risk for corneal injury nursing diagnosis, in critically ill adults. These risk factors guide nursing interventions. This causal validation can improve the risk for corneal injury nursing diagnosis levels of evidence in the NANDA International Taxonomy.

RELEVANCE TO CLINICAL PRACTICE

It is necessary to guide nursing interventions for critically ill adults with lowered level of consciousness and corneal exposure for the prevention of corneal injury.

Nursing interventions to prevent corneal injury in critically ill sedated and mechanically ventilated patients: A systematic review of interventions

OBJECTIVE

To identify the effectiveness of interventions to prevent corneal injury in critically ill, sedated, and mechanically ventilated patients.

RESEARCH METHODOLOGY

A systematic review of intervention studies was conducted in the following electronic databases: Cumulative Index to Nursing and Allied Health Literature, Cochrane Central Register of Controlled Trials, Embase, Latin American and Caribbean Literature in Health Sciences, LIVIVO, PubMed, Scopus and Web of Science, and reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. Study selection and data extraction were performed by two independent reviewers. Quality assessment of the randomized and non-randomized studies was performed using the Risk of Bias (RoB 2.0) and ROBINS-I Cochrane tools, respectively, and the Newcastle-Ottawa Scale for cohort studies. The certainty of the evidence was assessed according to the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system.

RESULTS

15 studies were included. Meta-analysis showed that the risk of corneal injury in the lubricants group was 66% lower (RR = 0.34; 95 %CI: 0.13-0.92) than in the eye-taping group. The risk of corneal injury in the polyethylene chamber was 68% lower than in the eye ointment group (RR = 0.32; 95 %CI 0.07-1.44). The risk of bias was low in most of the studies included and the certainty of the evidence was evaluated.

CONCLUSIONS

The most effective interventions to prevent corneal injury in critically ill sedated mechanically ventilated, who have compromised blinking and eyelid closing mechanisms, are ocular lubrication, preferably gel or ointment, and protection of the corneas with a polyethylene chamber.

IMPLICATIONS FOR CLINICAL PRACTICE

Critically ill, sedated, and mechanically ventilated patients who have compromised blinking and eyelid closing mechanisms must receive interventions to prevent corneal injury. Ocular lubrication, preferably gel or ointment, and protection of the corneas with a polyethylene chamber were the most effective interventions to prevent corneal injury in critically ill, sedated, and mechanically ventilated patients. A polyethylene chamber must be made commercially available for critically ill, sedated, and mechanically ventilated patients.

[Anterior eye segment damage in coronavirus infection (COVID-19)]

Conjunctivitis may appear as the first symptom of the coronavirus infection (COVID-19). In isolated cases, the lesion of the conjunctiva evokes a systemic infectious process. Currently, the conjunctiva is not considered as an area of long-term reproduction of coronavirus, and its damage is caused by hyperproduction of pro-inflammatory cytokines (especially IL-6); development of iridocyclitis and keratoconjunctivitis is also possible. Most often, local corticosteroids are used to treat these processes, although their use requires caution due to the risk of activating secondary infection (herpetic bacterial, fungal), which often develops as a result of immunodeficiency caused both by COVID-19 and the massive corticosteroid and antibiotic therapy employed when the course of the disease is severe. The severe condition of patients, the lung ventilation, and the prone position all contribute to corneal erosions, exposure keratopathy, pseudomonas aeruginosa keratitis and angle-closure glaucoma attacks. The risk of transmission of coronavirus infection during keratoplasty is estimated as minimal.

Risk for corneal injury in intensive care unit patients: A cohort study

AIM

To identify the incidence and risk factors for corneal injury amongst critically ill patients.

METHOD

A prospective cohort study with adult patients from one intensive care unit in Northern Brazil. Logistic regression was performed to predict the risk factors associated with corneal injury.

RESULTS

Data from 149 patients revealed 18.8% (28/149) corneal injuries. Factors independently associated with corneal injury were patients with eyeball exposure (OR: 27.31; 95% CI: 3.50-212.78); lagophthalmos (OR: 17.15; 95% CI: 5.78-50.85); chemosis (OR: 7.39; 95% CI: 2.28-23.97), periorbital oedema (OR: 7.99; 95% CI: 2.19-29.13) and hospitalisation >7-days (OR: 11.96; 95% CI: 3.27-43.66) had a significantly higher risk of developing corneal injury in this ICU.

CONCLUSION

Corneal injury was a common complication amongst critically ill patients and was associated with altered physiological function of the eyes such as exposure, lagophthalmos, chemosis and periorbital oedema. This study suggests introduction of a corneal injury prevention protocol for nursing and adding lagophthalmos and chemosis to the NANDA-I Taxonomy, thus contributing to the assessment and monitoring for the risk for corneal injury in critically ill patients.

Ocular surface manifestations of coronavirus disease 2019 (COVID-19): A systematic review and meta-analysis

Purpose

This study was performed to determine the occurrence of ocular surface manifestations in patients diagnosed with coronavirus disease 2019 (COVID-19) due to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2).

Methods

A systematic search of electronic databases i.e. PubMed, Web of Science, CINAHL, OVID and Google scholar was performed using a comprehensive search strategy. The searches were current through 31st May 2020. Pooled data from cross-sectional studies was used for meta-analysis and a narrative synthesis was conducted for studies where a meta-analysis was not feasible.

Results

A total of 16 studies reporting 2347 confirmed COVID-19 cases were included. Pooled data showed that 11.64% of COVID-19 patients had ocular surface manifestations. Ocular pain (31.2%), discharge (19.2%), redness (10.8%), and follicular conjunctivitis (7.7%) were the main features. 6.9% patients with ocular manifestations had severe pneumonia. Viral RNA was detected from the ocular specimens in 3.5% patients.

Conclusion

The most common reported ocular presentations of COVID-19 included ocular pain, redness, discharge, and follicular conjunctivitis. A small proportion of patients had viral RNA in their conjunctival/tear samples. The available studies show significant publication bias and heterogeneity. Prospective studies with methodical collection and data reporting are needed for evaluation of ocular involvement in COVID-19.

Repetitive magnetic stimulation protects corneal epithelium in a rabbit model of short-term exposure keratopathy

PURPOSE

To investigate the effect of repetitive magnetic stimulation (RMS) on corneal epithelial permeability in a rabbit model of exposure keratopathy.

METHODS

61 female New Zealand White (NZW) rabbits were treated on one eye with repetitive magnetic stimulation (RMS) at a frequency of 20 Hz for 15 min. The other eye was untreated. Rabbit eyes were kept open for 2 h to induce acute corneal desiccation. The extent of fluorescein corneal staining was evaluated using EpiView software and the concentration of fluorescein in the anterior chamber was determined by a fluorometer. Safety was evaluated by electroretinogram, spectral domain optical coherence tomography (SD-OCT) and histopathology. Expression pattern of corneal cell markers was determined by immunofluorescence.

RESULTS

A significant decrease in fluorescein concentration in the anterior chamber (54 ± 8.4 ng/ml vs. 146.5 ± 18.6 ng/ml, p = 0.000001) and in corneal surface fluorescein staining score (1.7 ± 0.2 vs. 4.6 ± 0.6, p = 0.00001) was obtained in RMS-treated eyes compared with control eyes, respectively. RMS treatment reduced by nearly 4 fold the percentage of corneal area with epithelial erosions by anterior segment SD-OCT. The therapeutic effect was maintained for at least 3 months. Increased expression of epithelial tight junction protein Zo-1 was observed in treated eyes. SD-OCT and histopathology analysis revealed no pathological changes in the treated or non-treated eyes.

CONCLUSIONS

RMS treatment decreases epithelial corneal erosions in a rabbit model of exposure keratopathy, with no indication of pathological changes. RMS may present a novel treatment for protection of corneal epithelium from desiccation.

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.