Ocular surface bacterial colonisation in sedated intensive care unit patients

Glaucoma and the Human Microbiome

PURPOSE OF REVIEW

To explore a view of the human microbiome as an interconnected, functional, dynamic system that may be linked to the pathogenesis and progression of glaucoma.

METHODS

A literature review was undertaken that included publications from 1966 to 2023.

RESULTS

Bacterial lipopolysaccharides (LPS) activate toll-like receptors (TLR) and mediate the human immune response. The LPS-TLR4 pathway is a potential avenue for the ocular, gut, and oral microbiomes to interface and/or influence ocular disease. Studies of gut dysbiosis have shown that alterations in the healthy microbiota can predispose the host to immune-mediated inflammatory and neurodegenerative conditions, while oral and ocular surface dysbiosis has been correlated with glaucoma. While developmental exposure to commensal microflora has shown to be necessary for the autoimmune and neurodegenerative responses to elevated intraocular pressure to take place, commensal bacterial products like short-chain fatty acids have regulatory effects protective against glaucoma.

SUMMARY

Alterations to human microbiotas have been associated with changes in intestinal permeability, gene regulation, immune cell differentiation, and neural functioning, which may predispose the host to glaucoma. Select microbes have been highlighted for their potential contributions to glaucoma disease progression or protection, raising the potential for microbiota-based treatment modalities. Current topical glaucoma treatments may disrupt the ocular surface microbiota, potentially having ramifications on host health. Further study of the relationships between human microbiome and glaucoma is needed.

Nursing strategies for the mechanically ventilated patient

The goal of this manuscript is to provide a comprehensive and multi-disciplinary review of the best nursing practices of caring for mechanically ventilated patients. By reviewing human medicine literature, the authors will extrapolate procedures that have been found to be most effective in reducing the risk of mechanical ventilation (MV) complications. Paired with review of the current standards in veterinary medicine, the authors will compile the best practice information on mechanically ventilated patient care, which will serve as a detailed resource for the veterinary nursing staff. Written from a nursing standpoint, this manuscript aims to consolidate the nursing assessment of a mechanically ventilated patient, addressing both systemic and physical changes that may be encountered during hospitalization. The goal of this review article is to present information that encourages a proactive approach to nursing care by focusing on understanding the effects of polypharmacy, hemodynamic changes associated with MV, complications of recumbent patient care, and sources of hospital acquired infections. When applied in conjunction with the more technical aspects of MV, this manuscript will allow veterinary technicians involved in these cases to understand the dynamic challenges that mechanically ventilated patients present, provide guidance to mitigate risk, address issues quickly and effectively, and create an up-to date standard of practice that can be implemented.

Comparison of Conjunctival Sac Microbiome between Low and High Myopic Eyes

Microbial communities played a vital role in maintaining homeostasis of ocular surface. However, no studies explored the myopia-associated conjunctiva microbiota changes until now. In this study, conjunctival sac swab specimens were collected from 12 eyes of low myopia (LM), and 14 eyes of high myopia (HM) patients. The V3-V4 region of the 16S rRNA gene was amplified and then sequenced. Statistical analysis was performed to investigate differences in the taxonomy and diversity between two groups. Compared to LM, higher Ocular Surface Disease Index (OSDI) scores were observed in HM group. The Shannon index of the HM was lower than that of the LM group (P = 0.017). Principle coordinate analysis and Partial Least Squares Discrimination Analysis showed distinct microbiome composition between two groups. At the phylum level, there were higher relative abundances of Proteobacteria (68.27% vs 38.51%) and lower abundances of Actinobacteria (3.71% vs 9.19%) in HM, compared to LM group (P = 0.031, 0.010, respectively). At the genus level, the abundances of Acinetobacter in HM (18.16%) were significantly higher than the LM (6.52%) group (P = 0.011). Actinobacteria levels were negatively correlated with the myopic spherical equivalent and OSDI scores. Moreover, positive correlations were found between Proteobacteria levels and OSDI scores, Acinetobacter levels were positively correlated with myopic spherical equivalent and OSDI scores. In conclusion, HM Patients have bacterial microbiota imbalance in the conjunctival sac, compared with LM patients. Proteobacteria, Actinobacteria, Acinetobacter may play roles in the HM associated ocular surface irritation.

Conjunctival sac microbiome in anophthalmic patients: Flora diversity and the impact of ocular prosthesis materials

Purpose

To explore the changes of bacterial flora in anophthalmic patients wearing ocular prosthesis (OP) and the microbiome diversity in conditions of different OP materials.

Methods

A cross-sectional clinical study was conducted, involving 19 OP patients and 23 healthy subjects. Samples were collected from the upper, lower palpebral, caruncle, and fornix conjunctiva. 16S rRNA sequencing was applied to identify the bacterial flora in the samples. The eye comfort of each OP patient was determined by a questionnaire. In addition, demographics information of each participant was also collected.

Results

The diversity and richness of ocular flora in OP patients were significantly higher than that in healthy subjects. The results of flora species analysis also indicated that in OP patients, pathogenic microorganisms such as Escherichia Shigella and Fusobacterium increased significantly, while the resident flora of Lactobacillus and Lactococcus decreased significantly. Within the self-comparison of OP patients, compared with Polymethyl Methacrylate (PMMA), prosthetic material of glass will lead to the increased colonization of opportunistic pathogens such as Alcaligenes, Dermabacter and Spirochaetes, while gender and age have no significant impact on ocular flora.

Conclusions

The ocular flora of OP patients was significantly different from that of healthy people. Abundant colonization of pathogenic microorganisms may have an important potential relationship with eye discomfort and eye diseases of OP patients. PMMA, as an artificial eye material, demonstrated potential advantages in reducing the colonization of opportunistic pathogens.

Analysis of Conjunctival Sac Microbiome in Dry Eye Patients With and Without Sjögren's Syndrome

Purpose

To analyze the conjunctival sac microbial communities in patients with Sjögren's syndrome-associated dry eyes (SSDE) and non-Sjögren's syndrome-associated dry eyes (NSSDE), compared with normal controls (NC).

Methods

Conjunctival sac swab samples from 23 eyes of SSDE, 36 eyes of NSSDE, and 39 eyes of NC were collected. The V3–V4 region of the 16S ribosomal RNA (rRNA) gene high-throughput sequencing was performed on an Illumina MiSeq platform and analyzed using Quantitative Insights Into Microbial Ecology (QIIME). Alpha diversity was employed to analyze microbiome diversity through Chao1 and Shannon indexes. Beta diversity was demonstrated by the principal coordinates analysis (PCoA) and Partial Least Squares Discrimination Analysis (PLS-DA). The relative abundance was bioinformatically analyzed at the phylum and genus levels.

Results

The alpha diversity was lower in patients with dry eye disease (Shannon index: NC vs. SSDE: P = 0.020, NC vs. NSSDE: P = 0.029). The beta diversity showed divergent microbiome composition in different groups (NC vs. SSDE: P = 0.001, NC vs. NSSDE: P = 0.001, NSSDE vs. SSDE: P = 0.005). The top 5 abundant phyla were Firmicutes, Proteobacteria, Actinobacteriota, Bacteroidota, and Cyanobacteria in all three groups. The top five abundant genera included Acinetobacter, Staphylococcus, Bacillus, Corynebacterium, and Clostridium_sensu_stricto_1. The relative microbiome abundance was different between groups. The Firmicutes/Bacteroidetes (F/B) ratio was 6.42, 7.31, and 9.71 in the NC, NSSDE, and SSDE groups, respectively (NC vs. SSDE: P = 0.038, NC vs. NSSDE: P = 0.991, SSDE vs. NSSDE: P = 0.048).

Conclusion

The diversity of conjunctival sac microbiome in patients with NSSDE and SSDE was diminished compared with NC. The main microbiome at the phylum and genus level were similar between groups, but the relative abundance had variations. The Firmicutes/Bacteroidetes ratio was higher in the SSDE group.

Effect of Polyethylene Cover for Preventing Corneal Injury in Critically Ill Patients: A Meta-Analysis

Objective

Polyethylene cover has been proved to be an effective method in protecting corneal, but its advantage compared to other conventional methods is still unclear. Our study is aimed at assessing clinical effects of polyethylene cover versus other methods in the prevention of corneal injury for critically ill patients.

Methods

We searched randomized controlled trials comparing polyethylene cover versus other methods for critically ill patients through the databases of PubMed, Embase, Web of Science, and China National Knowledge database. Forest plots and funnel plots were also performed on the included articles. Results were expressed as risk ratio (RR) with 95% confidence intervals.

Results

Eight studies were eventually identified. The incidence of corneal injury in the polyethylene cover group was lower than that in the eye drops group (RR = 0.24, 95% CI (0.12, 0.45), P < 0.0001) but had no significant difference when compared to the eye gel group (RR = 0.42, 95% CI (0.13, 1.34), P = 0.14) and the eye ointment group (RR = −0.61, 95% CI (0.23, 1.59), P = 0.31).

Conclusion

This study showed that polyethylene cover, eye gel, and eye ointment had an equal effect for preventing corneal injury in critically ill patients, and the effect of eye drops was relatively low. However, there were other intervention methods that had not been compared due to the small number of articles; further studies should be performed to assess which method was the best practice method.

[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 Factors of Eye Complications in Patients Treated in the Intensive Care Unit

In critically ill patients, normal eye protection mechanisms, such as tear production, blinking, and keeping the eye closed, are impaired. In addition, many other factors related to patients' severe condition and treatment contribute to ocular surface disease. Reducing risk factors and proper eye care can have a significant impact on incidences of eye complications and patient quality of life after discharge from the intensive care unit (ICU). The aim of the study was to determine risk factors for ocular complication, especially those related to nursing care. The study was conducted in the ICU of a university hospital. Methods for estimating and analyzing medical records were used. The patient's evaluation sheet covering 12 categories of risk factors for eye complications was worked out. The study group included 76 patients (34 patients with injuries and 42 without injuries). The Shapiro-Wilk test, the Spearman's rank correlation test, the Mann-Whitney U test and the Friedman's ANOVA test were used. The level of significance was set at α = 0.05. The most important risk factors for eye complications in the study group were: lagophthalmos (p < 0.001), sedation (p < 0.01), use of some cardiological drugs and antibiotics (p < 0.01), mechanical ventilation (p < 0.05), use of an open suctioning system (p < 0.01), presence of injuries (p < 0.01) including craniofacial trauma (p < 0.001), high level of care intensity (p < 0.01), failure to follow eye care protocol (p < 0.001), length of hospitalization at the ICU (p < 0.001), and the frequency of ophthalmological consultations (p < 0.001). There was no correlation between the incidence of these complications and the age and gender of the patients. The exposure of critically ill patients to eye complications was high. It is necessary to disseminate protocols and guidelines for eye care in ICU patients to reduce the risk factors.

Study of Conjunctival Microbial Flora in Patients of Intensive Care Unit

Purpose

The objective of the study was to evaluate the type of conjunctival microbial flora in intensive care unit patients and their antimicrobial sensitivity pattern.

Methods

A total of 272 samples (conjunctival swabs) were taken from patients in various intensive care units and sent for culture and sensitivity. An ocular examination was done to look for lagophthalmos, conjunctival discharge, exposure keratitis, and corneal perforation.

Results

Majority (82.1%) of the samples showed at least one microbial isolate while 29 (10.7%) samples showed multiple microbial growth. The most common microbes were coagulase negative Staphylococcus spp. (41.5% of isolates), diphtheroids (11.0% of isolates), and Staphylococcus aureus (9.6% of isolates) which are the usual commensals of the ocular surface. Of the other microbes isolated, Pseudomonas aeruginosa (4.0%) was the most common. Eighty-four percent isolates of coagulase negative Staphylococcus sp., 81.8% isolates of diphtheroids and 100% isolates of Staphylococcus aureus were penicillin resistant. All isolates of Enterococcus fecalis were sensitive only to vancomycin. Two hundred and twenty eyes (80.9%) had varying degrees of lagophthalmos. Nineteen (7.0%) had severe corneal exposure changes leading to infectious corneal ulcer and perforation in all of them.

Conclusions

The isolates in patients of intensive care units were no different from the normal conjunctival flora though few pathogenic organisms such as Pseudomonas aeruginosa and Acinetobacter sp. were also isolated. Most of the isolates were penicillin resistant. This knowledge will help take appropriate prophylactic measures to contain ocular infections in the intensive care units.

Impact of COVID-19 at the Ocular Level: A Citation Network Study

BACKGROUND

The main objective of this study was to use citation networks to analyze the relationship between different publications on the impact of COVID-19 at an ocular level and their authors. Furthermore, the different research areas will be identified, and the most cited publication will be determined.

MATERIALS AND METHODS

The publications were searched within the Web of Science database, using "ocular", "SARS-CoV-2", "ophthalmology", "eyesight", and "COVID-19" as keywords for the period between January 2020 and January 2021. The Citation Network Explorer and the CiteSpace software were used to analyze the different publications.

RESULTS

A total of 389 publications with 890 citations generated on the web were found. It must be highlighted that July was the month with the largest number of publications. The most cited ones were "Characteristics of Ocular Findings of Patients with Coronavirus Disease 2019 (COVID-19) in Hubei Province, China" by Wu et al., which was published in May 2020. Three groups covering the different research areas in this field were found using the clustering functions: ocular manifestations, teleophthalmology, and personal protective equipment.

CONCLUSIONS

The citation network has shown a comprehensive and objective analysis of the main studies on the impact of COVID-19 in ocular disease.

Ophthalmic manifestations in the COVID-19 clinical spectrum

Purpose

The aim of this study was to determine the frequency and various types of ophthalmic manifestation of patients with COVID-19.

Methods

This is a prospective observational study conducted on patients with SARS-Co-V-2 infection, at a dedicated tertiary COVID-19 hospital in South India from April 1 to July 31, 2020. At the time of their admission to the COVID hospital, demographic data such as name, age, sex was recorded. A thorough history regarding the onset, duration, progression, nature of symptoms and its associated factors, medication history, treatment history were elicited and documented. Ocular examination was performed under torchlight by an ophthalmologist posted for COVID duty. Further investigations including imaging were sought for, depending on clinical indications. Serial follow-up examinations of all patients were carried out every 72 hours or when patients complained of any ocular symptoms whichever earlier, until discharge. All relevant data were compiled and statistically analyzed.

Results

A total of 2742 patients were examined. Of them, 1461 (53.28%) were males and 1281 (46.72%) were females. The mean age (±SD) was 39.46 ± 17.63 years. None of the patients in our study had any ocular symptoms or signs as the presenting complaint at the time of their admission. On subsequent follow-up, only 20 (0.72%) developed ocular manifestations, of which 19 (95%) had features suggestive of Bilateral viral conjunctivitis. However, 1 (5%) patient had orbital cellulitis secondary to pansinusitis.

Conclusion

Ophthalmic manifestations in the clinical spectrum of COVID-19 infection are uncommon and unlikely to be the presenting clinical impression. However, it has broadened our view to a wider spectrum of COVID-19 presentations enhancing our clinical acumen for staunch detection of COVID-19 suspects in our daily practice, augmenting early diagnosis and management and also break the chain of transmission for the greater good of humanity.

Ocular surface characteristics and colonization in a burn center: A prospective cohort study

We aimed to evaluate the characteristics and colonization by pathogenic microorganisms of the ocular surface in patients in a burn center and to determine their association with sedation, mechanical ventilation, and periocular burn. We prospectively evaluated 40 patients during an eight-month period. Five evaluations where performed, at baseline and weekly on four more occasions or until hospital discharge or death. On each visit, we assessed periocular burn, lid position, Bell's phenomenon, Schirmer's test, presence of chemosis, conjunctival hyperemia, and exposure keratopathy; conjunctival fornix swabs were taken for microbiology culture. Also, we documented the level of sedation, mechanical ventilation status, and systemic and ocular treatment. Absent Bell's phenomenon and chemosis were significantly different at baseline in patients under mechanical ventilation, sedation, and in those with periocular burn. The cumulative incidence of exposure keratopathy was 22.5% and the cumulative incidence of ocular surface colonization by pathogenic microorganisms was 32.5%. Both outcomes were associated with mechanical ventilation and periocular burn. The most frequent pathogenic microorganisms in the ocular surface were Candida parapsilosis, Acinetobacter baumanii, and Pseudomonas aeuroginosa. We did not observe any case of persistent epithelial defect, infectious keratitis, corneal perforation or corneal opacity in this cohort. Results from our study may benefit future patients by allowing better risk stratification and treatment strategies for the ocular surface care in burn units.

MLST-Based Analysis and Antimicrobial Resistance of Staphylococcus epidermidis from Cases of Sheep Mastitis in Greece

Staphylococcus epidermidis is an important causal agent of ovine mastitis. A literature search indicated a lack of systematic studies of causal agents of the infection by using multi-locus sequence typing (MLST). The objectives were to analyse MLST-based data and evaluate the antimicrobial resistance of S. epidermidis isolates from ovine mastitis in Greece. The database included 1593 isolates from 46 countries: 1215 of human, 195 of environmental and 134 of animal origin, distributed into 949 sequence types (STs) and cumulatively with 450 alleles therein. Among mastitis isolates, bovine isolates were distributed into 36 different STs and ovine ones into 15 STs. The 33 isolates from ovine mastitis in Greece were in 15 different STs, 6 of these (ST677, ST678, ST700, ST 709, ST710, ST711) assigned for the first time; in addition, 5 alleles (65 for arcC, 59 for aroE, 56 and 57 for gtr and 48 for tpiA) were identified for the first time. The spanning tree of these isolates included 15 nodes and 14 edges (i.e., branches). Among these isolates, 19 showed resistance to antimicrobial agents (tetracycline, penicillin, fucidic adic, erythromycin, clindamycin, cefoxitin). Resistance-related genes (tetK, tetT, msrA, tetM, tetS, ermC, mecA) were detected. There was no association between STs and resistance to antimicrobial agents. Isolates with antimicrobial resistance were recovered more often from flocks where hand-milking was practised.

Descemetocele and bilateral, severe Pseudomonas keratitis in an intensive care unit patient with Graves' orbitopathy: A case report

RATIONALE

Exposure keratopathy (EK) is common among intensive care unit (ICU) patients, especially those under sedation and with incomplete eyelid closure. EK can be mild punctate epithelial erosions exhibiting spontaneous recovery; rarely, severe complications including bacterial ulcers causing corneal perforation or opacity could occur. We describe a patient with pre-existing Graves' orbitopathy (GO) who developed bilateral, rapidly progressing bacterial keratitis due to EK with secondary aerosol inoculation from respiratory pathogens in ICU.

PATIENT CONCERNS

A 49-year-old intubated and sedated woman who underwent urgent craniotomy was admitted to ICU. The ophthalmology department was consulted for progressive chemosis. History of poorly controlled GO was revealed based on external ocular signs, including proptosis with lid retraction, and careful ophthalmological history taking. After 2 days of ICU admission, slit lamp examination revealed large inferior corneal epithelial defects and dellen (OU). Despite prescribing gentamicin ointment and lubricants, purulent discharge with corneal infiltration and thinning (OU) was observed 2 days later. Owing to a characteristic Pseudomonas odor from her endotracheal tube, corneal and endotracheal sputum cultures were obtained, which revealed Pseudomonas aeruginosa infection.

DIAGNOSIS

Pseudomonas keratitis secondary to EK INTERVENTIONS:: Topical fortified anti-Pseudomonas antibiotic eye drops with temporary tarsorrhaphy and lubricants OUTCOMES:: Despite multiple treatments, she developed enlarging descemetocele in the left eye with severe corneal stromal destruction and severe visual impairment due to central corneal scar formation in the right eye. After 2 months, the descemetocele ruptured owing to generalized tonic-clonic seizures after cranioplasty. Therefore, she underwent urgent penetrating keratoplasty in the left eye.

LESSONS

GO increases ocular surface inflammation and exposure, which may exacerbate EK and subsequent complication risks. Careful monitoring and aggressive treatment through appropriate eye care regimen are required in these patients.

Ocular Complications in the Prone Position in the Critical Care Setting: The COVID-19 Pandemic

PURPOSE

Ocular complications are common in the critical care setting but are frequently missed due to the focus on life-saving organ support. The SARS-CoV-2 (COVID-19) pandemic has led to a surge in critical care capacity and prone positioning practices which may increase the risk of ocular complications. This article aims to review all ocular complications associated with prone positioning, with a focus on challenges posed by COVID-19.

MATERIALS AND METHODS

A literature review using keywords of "intensive care", "critical care", "eye care", "ocular disorders", "ophthalmic complications," "coronavirus", "COVID-19," "prone" and "proning" was performed using the electronic databases of PUBMED, EMBASE and CINAHL.

RESULTS

The effects of prone positioning on improving respiratory outcomes in critically unwell patients are well established; however, there is a lack of literature regarding the effects of prone positioning on ocular complications in the critical care setting. Sight-threatening ophthalmic disorders potentiated by proning include ocular surface disease, acute angle closure, ischemic optic neuropathy, orbital compartment syndrome and vascular occlusions.

CONCLUSIONS

COVID-19 patients may be more susceptible to ocular complications with increased proning practices and increasing demand on critical care staff. This review outlines these ocular complications with a focus on preventative and treatment measures to avoid devastating visual outcomes for the patient.

Ophthalmology in Critical Care

Ophthalmic disease encountered in the intensive care unit (ICU) has a wide spectrum of prevalence and severity. Prolonged exposure of the cornea is common and preventable. Trauma, glaucoma, infection, vascular disease, and burns are among the potential causes of vision loss. Patients are predisposed to ocular complications by the ICU environment and critical illness itself. Critically ill patients require prioritization of life-sustaining interventions, and less emphasis is placed on ophthalmic disease, leading to missed opportunities for vision-saving intervention. It is therefore imperative for intensivists, nurses, and other providers to have an increased awareness and understanding of the broad range of ocular conditions potentially seen in the ICU.

Ocular Findings in COVID-19 Patients: A Review of Direct Manifestations and Indirect Effects on the Eye

The novel pandemic coronavirus disease 2019 (COVID-19), caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has challenged the medical community. While diagnostic and therapeutic efforts have been focused on respiratory complications of the disease, several ocular implications have also emerged. SARS-CoV-2 RNA has been found in tears of the infected patients, and reports suggest that the ocular surface could serve as a portal of entry and a reservoir for viral transmission. Clinically, COVID-19 has been associated with mild conjunctivitis, which can be the first and only symptom of the disease. Subtle retinal changes like hyperreflective lesions in the inner layers on optical coherence tomography (OCT), cotton-wool spots, and microhemorrhages have also been reported. In addition, COVID-19 has been associated with an increased incidence of systemic diseases like diabetes mellitus and Kawasaki disease, which are particularly relevant for ophthalmologists due to their potentially severe ocular manifestations. Several treatment strategies are currently under investigation for COVID-19, but none of them have been proved to be safe and effective to date. Intensive care unit patients, due to risk factors like invasive mechanical ventilation, prone position, and multiresistant bacterial exposure, may develop ocular complications like ocular surface disorders, secondary infections, and less frequently acute ischemic optic neuropathy and intraocular pressure elevation. Among the array of drugs that have shown positive results, the use of hydroxychloroquine and chloroquine has raised a concern due to their well-known retinal toxic effects. However, the risk of retinal toxicity with short-term high-dose use of antimalarials is still unknown. Ocular side effects have also been reported with other investigational drugs like lopinavir-ritonavir, interferons, and interleukin-1 and interleukin-6 inhibitors. The aim of this review was to summarize ophthalmological implications of SARS-CoV-2 infection to serve as a reference for eye care and other physicians for prompt diagnosis and management.

Effect of polyethylene cover on the treatment of exposure keratopathy in ICU

BACKGROUND

Exposure keratopathy may lead to serious complications such as microbial keratitis, corneal perforation, and visual impairment if not treated.

AIM

To compare the effect of carbomer eye drops when used alone and in combination with polyethylene covers in the healing of exposure keratopathy.

METHODS

A single blind randomized-controlled trial (RCT) in two intensive care units (ICUs) was carried out in a university hospital in Western Turkey between September 2011 and December 2012. The control group received only carbomer, eye drops while the intervention group received both carbomer eye drops and polyethylene covers. The primary outcome was the decrease or absence of corneal damage, which refers to healing. Corneal damage was followed up with a fluorescein dye test (decrease/absence of the corneal staining) by the same ophthalmologist for 10 days.

RESULTS

A total of 43 corneas in 24 patients were studied. Corneal epithelial defects decreased in the intervention group by day 2 and progressed or remained unchanged in the control group every day (P = .001). Patient characteristics did not affect the grade ranges of corneal staining in the groups except for level of consciousness.

CONCLUSION

Carbomer eye drops, when used in combination with polyethylene covers, were effective in managing exposure keratopathy.

RELEVANCE TO CLINICAL PRACTICE

Corneal damage and further ocular complications can be reduced with the utilization of polyethylene covers in nursing care and treatment.

Eye care in the intensive care unit during the COVID-19 pandemic

Ocular complications in critical care patients are common. There has been a surge in intensive care admissions following the COVID-19 outbreak. The management of COVID-19 exposes patients to a number of specific risk factors for developing ocular complications, which include non-invasive ventilation, mechanical ventilation and prone positioning. Consequently, it is likely that there will be an increase in the number of ocular complications secondary to the management of COVID-19 patients in the intensive care unit setting, and these complications could lead to permanent visual loss and blindness. Increased awareness of eye care in the intensive care unit setting is therefore vital to help prevent visual loss and maintain quality of life for patients recovering from COVID-19.

Eye care in the intensive care unit

Ocular surface disease is common in the intensive care population with 20-42% of patients developing corneal epithelial defects. The ocular surface is normally protected by the ability to produce tears, to blink and to close the eyes with rest or sleep. All of these mechanisms can be disrupted in the intensive care population, increasing the risk of developing ocular surface disease. Despite the scale of the problem, eye-care protocols are commonly not instigated and documentation of eye care is often poor. This review details the risk factors for developing ocular surface disease. It also provides evidence-based guidance on protecting the eyes in vulnerable patients, identifying diseases affecting the eye in intensive care patients and delivering the best treatment to the eye. There is growing evidence that adherence to a correctly performed eye-care guideline prevents the majority of corneal problems encountered in the intensive care unit.

Distribution and Diversity of Ocular Microbial Communities in Diabetic Patients Compared with Healthy Subjects

PURPOSE

The aim of this study was to identify differences in the major (core vs. variable) microbial genera of human subjects with and without diabetes.

METHODS

Bacterial 16S rRNA genes obtained from conjunctival swabs of 19 healthy subjects and 30 diabetic patients were sequenced using the Illumina MiSeq platform, and the sequencing data were analyzed using QIIME 1.9.1. To elucidate the microbial diversity in the ocular surface (OS), test programs from various bioinformatics domains were used.

RESULTS

Diversity index and rarefaction analysis showed that the microbial community of the diabetic patients was more diverse than that of the healthy subjects. Proteobacteria, Firmicutes, Actinobacteria, Cyanobacteria and Bacteroidetes were the dominant taxa present in the OS, and there was a significant difference in the relative abundance of the bacterial phyla between the diabetic patients and control subjects. Proteobacteria were more abundant in the diabetic group, whereas Firmicutes was more abundant in the control group. Analysis of bacterial taxa at the genus level showed that the core microbiome of diabetic patients comprised Acinetobacter, Burkholderia, Sphingomonas, and Ralstonia, whereas that of the controls comprised Bradyrhizobiaceae, Staphylococcus, Corynebacterium, Pseudomonas, Novosphingobium, Neisseriaceae, and Acinetobacter.

CONCLUSIONS

There was a significant difference in the microbial community composition between diabetic patients and healthy subjects. A high abundance of Acinetobacter in the OS of diabetic patients may arise from the unique characteristics of the OS compared with those of other organ surfaces.

Intensive Care Nurses' Views and Practices for Eye Care: An International Comparison

Eye care is an important area of critical care. However, lack of eye care studies is a common issue across the globe. The aim of this study is to determine the views and practices of intensive care unit (ICU) nurses on eye care in Turkey and Palestine. This descriptive study was conducted using a self-administrated questionnaire. The data were collected from 111 nurses in nine kinds of ICUs in two education hospital. Normal saline (75.9%) was the most commonly reported solution for eye hygiene among the Palestinian nurses, and gauze soaked in normal saline or sterile water (64.3%) were the most frequently used supplies by the Turkish nurses. Although both Palestinian and Turkish ICU nurses took some precautions to prevent eye complications in critical patients, there were some gaps and insufficiencies in the eye care of ICU patients. There is a need for continuing training in this area.

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.

[Purulent corneal ulcers: etiology, pathogenesis, classification]

Advanced purulent corneal ulcer, as well as abscess, is a serious vision-threatening condition notable for its fulminant course and possible loss of the eye due to endophthalmitis. Its leading causes, pathogenesis, and classifications are described and analyzed in this paper.

Moisture chamber versus lubrication for corneal protection in critically ill patients: a meta-analysis

PURPOSE

Critically ill patients in the intensive care unit are at increased risk of exposure keratopathy. There is limited evidence available to make the best choice of eye care modality. This meta-analysis aimed to evaluate the effect of moisture chamber compared with lubrication for corneal protection in critically ill patients.

METHODS

Studies were identified through PubMed, Embase, The Cochrane Library, and complementary manual searches, up to May 31, 2014. Randomized controlled trials of critically ill patients in the intensive care unit comparing moisture chamber with lubrication and evaluating risk of corneal damage were included.

RESULTS

Seven trials were included. The pooled analysis showed that the use of moisture chambers resulted in a reduction of the incidence of corneal damage [risk ratio (RR), 0.27; 95% confidence interval (CI): 0.11-0.67; P = 0.005]. In 1 subgroup analysis, there was a significant difference between the use of moisture chambers and lubricating drops, and the moisture chamber group had a decreased incidence of corneal damage (RR, 0.13; 95% CI: 0.05-0.35; P < 0.0001). In the other subgroup analysis, no statistically significant difference was observed between the use of moisture chambers and lubricating ointments (RR, 0.81; 95% CI: 0.51-1.29; P = 0.38). The overall quality of evidence was low.

CONCLUSIONS

The use of moisture chambers is associated with more effective corneal protection compared with lubrication. The analytic result is limited by serious risk of bias and imprecision.

Acinetobacter junii as an aetiological agent of corneal ulcer

Rods of the Acinetobacter genus are present mainly in the external environment (e.g. water, soil) and in animals, while in humans they may comprise physiological flora. The main pathogenic species is Acinetobacter baumannii complex, which constitutes a common cause of nosocomial infections, particularly in patients with underlying diseases and risk factors (e.g. prior broad-spectrum antibiotic therapy, malignancy, central venous catheter, mechanical ventilation); however, infections of the eye caused by strains of Acinetobacter spp. are very rare. We report a unique case of community-acquired corneal ulcer caused by Acinetobacter non-baumannii (possibly A. junii), in a patient with no risk factors identified. The case highlights the need for obtaining a sample from the cornea for bacteriological culture in the case of suspected ophthalmic infection as identification of the pathogen, and assessment of its susceptibility profile enables proper antibiotic therapy, improves the outcome and may constitute an eyesight-saving management.

Virulence properties of multidrug resistant ocular isolates of Acinetobacter baumannii

PURPOSE

Acinetobacter (A.) baumannii is an opportunistic pathogen and has been reported as a causative agent of ocular infections. The aim of this study is to identify virulence properties (biofilm formation, adhesion, invasion and cytotoxicity) and antibiotic resistance among A. baumannii isolates recovered from the eye.

MATERIALS AND METHODS

The Microscan Walk-Away®, an automated bacterial identification and susceptibility testing system was used to determine antibiotic resistance. Clonal relatedness was assessed by Pulsed-field gel electrophoresis (PFGE) and plasmid profile analysis. Conjugation experiments were carried out to determine the transfer of antibiotic resistance genes and PCR was used to confirm gene transfer. Virulence properties of the isolates were determined by biofilm formation using crystal violet and immunofluorescence staining, adherence and internalization using cultured corneal epithelial cells, and cytotoxicity by TUNEL-staining and LDH release assays.

RESULTS

All ocular isolates (n = 12) exhibited multidrug resistant (MDR) phenotype and one of the isolate (AB12) was resistant to 18 antibiotics (β-lactam, aminoglycosides, tetracycline, chloramphenicol and quinolones). The plasmid profile analysis showed the presence of multiple plasmids in each isolate and a total of 10 different profiles were observed. However, PFGE analysis was more discriminatory which revealed 12 distinct genotypes. Antibiotic resistance (tetracycline and quinolone) was transferable from the isolate AB12 to a recipient Escherichia coli J53. Ten isolates were strong biofilm producers and the remaining two (AB5 and AB7) were moderate producers. All isolates demonstrated adherence and invasive properties towards HCECs. A similar trend was observed in their ability to cause cell death and toxicity.

CONCLUSIONS

Our results indicate that ocular isolates of A. baumannii are biofilm producers and adherent and invasive to corneal epithelium, a first step in the pathogenesis of ocular infection. In addition, they demonstrated plasmid-mediated transfer of MDR traits making them a reservoir of resistance genes at ocular surface.

Ocular surface disorders in intensive care unit patients

Patients in intensive care units (ICU) are at increased risk of corneal abrasions and infectious keratitis due to poor eyelid closure, decreased blink reflex, and increased exposure to pathogenic microorganisms. The aim of this retrospective study was to evaluate the ocular surface problems in patients who stayed in ICU more than 7 days and were consulted by an ophthalmologist. There were 26 men and 14 women with a mean age of 40.1 ± 18.15 years (range 17–74 years). Conjunctiva hyperemia, mucopurulent or purulent secretion, corneal staining, and corneal filaments were observed in 56.25%, 36.25%, 15%, and 5% of the eyes, respectively. Keratitis was observed in 4 patients (10%) who were treated successfully with topical antibiotics. Mean Schirmers test results were 7.6 ± 5.7 mm/5 min (median 6.5 mm/5 min) in the right, and 7.9 ± 6.3 mm/5 min (median 7 mm/5 min) in the left eyes. Schirmers test results were <5 mm/5 min in 40% of the subjects. The parameters did not show statistically significant difference according to mechanical ventilation, sedation, and use of inotropes. As ICU patients are more susceptible to develop dry eye, keratopathy, and ocular infections, they should be consulted by an ophthalmologist for early diagnosis of ocular surface disorders.