Eye care for critically ill adults

Ocular surface disease (OSD), due to superficial corneal exposure, has been reported to occur in up to 60% of critically ill patients (1-3). Eye care is an important aspect of the nursing management of critically ill patients, especially for those patients whose ocular protective mechanisms may be compromised (4). Dryness of the cornea and disruption to corneal epithelial surface lining may result in sequelae of corneal abrasion, erosion, infection, ulceration, scarring, rupture or blindness (5). The intensive care patient is at increased risk for any of these events due to having a co-existing compromised immune response and being exposed to environmental factors and pathogens (6). Additionally, for the critically ill patient, lagophthalmos or incomplete eyelid closure is thought to be the primary mechanism underlying the development of this condition (7-10).

Read the Eye care for critically ill adults guideline.

Eye care for critically ill adults guideline

Resources

Purpose and outcomes

The purpose of this guideline is to inform intensive care practice related to the provision of eye care for critically ill patients. The underlying aim of the guideline is to minimise the prevalence of ocular surface disorders in this group of patients.

Projected outcomes for this guideline include:

  • facilitation of the diffusion of evidence-based eye care recommendations into clinical eye care practice
  • to support the early detection of eye disease, timely referral for conditions, and systematic delivery of eye toilet and treatment
  • improvement of patient quality of care by routinely addressing iatrogenic ophthalmologic issues, ensuring that on discharge from the unit, visual compromise is not added to existing co morbidities (5).

Scope

Guideline development addresses clinical practices aimed at maintaining/optimising the eye health of critically ill adults nursed in intensive care units (ICUs) in NSW. In particular, practice recommendations are most relevant for patients at increased risk for iatrogenic ophthalmological complications due to a compromise in level of consciousness and/or impaired ability to control eye opening and closure. Guideline development has been based on the assumption that readers possess a working knowledge of anatomy and physiology of the eye.

Target clinicians

This guideline is for the use of all intensive care clinicians, especially for clinicians responsible for the care of any patient in whom protection of the ocular surface cannot be achieved by independent complete eyelid closure. Clinicians who use this guideline must ensure they have a working knowledge of anatomy and physiology of the eye, as well as of ocular protective mechanisms that may become compromised during episodes of critical illness and treatment.

Guideline development

This guideline is a revision of 2007 Eye Care Clinical Practice Guideline (11) . A guideline development network (GDN) group was formed in November 2011 to review the original guideline, and the primary authors undertook an updated literature review (see Appendix 1 2012 literature review in full guideline document). The available research was evaluated against the designations of levels of evidence stipulated by the National Health and Medical Research Council (NHMRC) (12). Provisional recommendations based on the available evidence were developed and revised by GDN members. Subsequent to this, the revised guideline was written and the revised clinical practice guideline (CPG) sent to the GDN members who assigned their level of agreement with recommendation statements. The guideline narrative was also revised based on group feedback. Due to the delay in publishing the guideline another search was undertaken covering literature published between1/1/2012-8/7/2013. Because no controlled studies were identified no changes were made to the guideline

Practice recommendations

Section

Recommendation statement

Grading

Patient assessment

1.

Eye health assessment should be part of routine patient physical assessment practice and be performed on admission and then routinely at the beginning of the new nursing shift. The initial assessment should include input from the patients’ family to identify pre-admission ocular conditions and treatment and to identify the need for ophthalmology review.

D

2.

Admission and ongoing assessment should include, but is not limited to the following:

  • risk factors for OSD
  • ability for patient to maintain complete eyelid closure
  • evaluation of eye and eyelid cleanliness
  • corneal dryness or discolouration
  • eye care interventions, and
  • effectiveness of eye care interventions.

C

3.

An assessment by intensive care medical staff should be undertaken when the following are found:

  • signs of infection
  • patients with red eyes and/or general sepsis
  • cornea that is dull and cloudy, or with white lines or spots visible.

C

4.

Where red eyes are identified, with or without exudate, bilateral swabs for culture should be taken.

C

Interventions

5.

Eyelid closure should be maintained to protect the eyes of intensive care patients who are unable to independently maintain complete lid closure.

B

6.

All patients should receive regular eye cleaning to remove debris, secretions, dried ointment and/or other ocular medications.

D

7.

For all patients with, or at risk of lagopthalmos, second hourly eye care must be undertaken to prevent drying of ocular epithelial surfaces, and reduce the risk of infection. Interventions include:

  • cleaning of the eye (with saline soaked gauze)
  • closure of the eyelid by use of either
    • ocular lubricant, or
    • creation of a moisture chamber by use of polyethylene wrap

The frequency of eye cleansing should vary with the frequency of eye intervention required.

C

Consensus

8.

If eyelid closure cannot be maintained passively then mechanical taping methods should be used to close the eye.

C

Consensus

9.

If eye infection is suspected, consideration should be given to commencing broad-spectrum topical antibiotic treatment until the result of swabs are available.

D

10.

Clinicians should take care to ensure that patient eyes are not exposed to aspirates during tracheal or oropharyngeal suction procedures.

D

11.

Medical Officers should assess the patient for iatrogenic ophthalmologic complications (at the micro epithelial level) at least weekly in intensive care patients with a length of stay greater than seven days using readily available practical methods.

D

12.

Patients should be referred for specialist ophthalmological consultation where

  • clinical practices fail to achieve sustained eyelid  closure within 24 hours and/or
  • when iatrogenic ophthalmologic complications are  identified, or
  • patient response to treatment is limited.

C

Consensus

Infection prevention

13.

Clinicians are to undertake a risk assessment to identity the risk of contamination and mucosal or conjunctival splash injuries when caring for patients PPE (including goggles/face shield/gloves and gown/apron) as per NSW 2007 Infection Prevention control policy should be worn according to the risk assessment.

PD2007_036

14.

Clinicians are to adhere to the Five Moments of Hand Hygiene (13).

PD2010_058

15.

Equipment for eye care must be kept in its own container separate from other patient hygiene equipment. These containers should be passed through ward cleaning procedures on a regular basis.

D

Work health and safety

16.

Occupational health and safety principles must be followed including:

  • use of personal protective equipment, and
  • ergonomic use of equipment, such as appropriate bed height for staff when treating patients.

C

Consensus

Governance

17.

Eye care interventions should be included as part of a comprehensive patient care plan.

C

Consensus

18.

All ICUs must ensure clinical staff are competent in the delivery of appropriate eye care.

D

19.

All clinical staff must maintain contemporaneous documentation of eye health and interventions. A flowchart, checklist or check box tool is suggested, which should be completed on shift handover for this purpose.

D

20.

All ICUs should monitor the effectiveness of eye care delivered by monitoring for iatrogenic ophthalmological complications. This could include:

  • review of adverse events as reported
  • audit of practice
  • review of ICU eye consults
  • review of health of donated corneas
  • point prevalence studies.

D

Grading of recommendations

Grade of recommendation Description

A

Body of evidence can be trusted to guide evidence

B

Body of evidence can be trusted to guide practice in most situations

C

Body of evidence provides some support for recommendation/s but care should be taken in its application

D

Body of evidence is weak and recommendation must be applied with caution

Consensus

Consensus was set as a median of ≥ 7

Grades A–D are based on NHMRC grades (14)

References

  1. Imanaka H, Taenaka N, Nakamura J, Aoyama K, Hosotani H. Ocular surface disorders in the critically ill. Anaesthesia Analg. 1997;85:343-6.
  2. Bates J, Dwyer R, O'Toole L, Kevin L, O'Hegarty N, Logan P. Corneal protection in critically ill patients: a randomized controlled trial of three methods. Clinical Intensive Care. 2004;15(1):23-6.
  3. Mehta A, Jiandani P, Desai M. Ocular Lesions in Disseminated Candidiasis. Associations of Physicans India. 2007 July 2007;55:483-5.
  4. Konno R. Eye Care: (ICU): Clinician Information. JBI. 2011.
  5. Lightman S. Eye Care for Patients in ITU. 2005.
  6. Rosenberg JB, Eisen LA. Eye care in the intensive care unit: Narrative review and meta-analysis. Crit Care. 2008;36(12):3151-5.
  7. So HM, Lee CC, Leung AK, Lim JM, Chan CS, Yan WW. Comparing the effectiveness of polyethylene covers (Gladwrap) with lanolin (Duratears) eye ointment to prevent corneal abrasions in critically ill patients: a randomized controlled study. Int J Nurs Stud. 2008 Nov;45(11):1565-71. PubMed PMID: 18394624. Epub 2008/04/09. eng.
  8. Sivasankar S, Jasper S, Simon S, Jacob P, John G, Raju R. Eye care in ICU 2006 [cited 2012 18th January]. Available from: http:www.criticalcarenews.com.
  9. Desalu I, Akinsola F, Adekola O, Akinbami O, Kushimo O, Adefule-Ositelu A. Ocular Surface Disorders in Intensive Care Unit Patients In a Sub-Saharan Teaching Hospital. The Internet Journal of Emergency and Intensive Care Medicine. 2008;11(1).
  10. Guler EK, Eser I, Egrilmez S. Effectiveness of polyethylene covers versus carbomer drops (Viscotears) to prevent dry eye syndrome in the critically ill. Journal of Clinical Nursing. 2010 17 August 2010(20):1916-22.
  11. Marshall A, Elliott R, Rolls K, Schacht S, Boyle M. Eyecare in the critically ill: Clinical practice guideline. ACCCN (Australian College of Critical Care Nurses). 2008;21:97-109.
  12. NHMRC. A guide to the development, evaluation and implementation of clinical practice guidelines: Australian Federal Government;  [updated 199930 March 2009].
  13. Clinical Safety QaG. Hand Hygiene Policy. In: Health Do, editor. Sydney: NSW Department of Health; 2010.
  14. Hillier S, Grimmer-Somers K, Merlin T, Middleton P, Salisbury J, Tooher R, et al. FORM: an Australian method for formulating and grading recommendations in evidence-based clinical guidelines. BMC Medical Research Methodology. 2011;11:23. PubMed PMID: 21356039.

Glossary

Bacterial keratitis

Inflammation of the cornea secondary to bacterial infection

Chemosis

Swelling of the conjunctiva, often preventing eyelid closure.

CI

Confidence interval

CNC

Clinical nurse consultant

CNS

Clinical nurse specialist

CONSORT

Consolidated Standards on Reporting Trials

Corneal abrasions

Superficial disruption to corneal epithelial lining. Common conditions may be secondary to foreign body or contact lens use.

Corneal erosion

Small/punctate or changes/break in the corneal epithelium creating a breach in the defence mechanisms of the cornea, leaving it vulnerable to pathogenic organisms. Left untreated, corneal erosion may result in ulceration and scarring and compromised vision.

CPG

Clinical practice guideline

Dry Eye

Lack of normal eye tear film and lubrication. Corneal defences are compromised due to lack of IgA and other immune mediators.

ETT

Endotracheal tube

EVP

External validation panel

Exposure keratitis/

Inflammation of the cornea, either sterile or microbial, may result in epithelial breakdown.

Filamentary keratitis

A condition caused by the formation of epithelial filaments of varying size and length, attached at one or both ends of the cornea. Patients often experience a foreign body sensation, grittiness, discomfort, photophobia, eyelid twitching, increased blinking or pain.

GCS

Glasgow Coma Scale

GDN

Guideline development network

GOR

Grading of recommendations

HDU

High dependency unit

Hypopyon

An accumulation of pus in the anterior chamber of the eye

ICC

Intensive care collaborative

ICC-CDC

Intensive care collaborative – consensus development conference

ICCMU

NSW Intensive Care Coordination and Monitoring Unit

ICU

Intensive care unit includes all types of units designated as such in NSW. May include units currently designated as ICU, HDU, critical care units

Injection

Conjunctival redness

Keratopathy

Ocular surface breach predisposing to corneal infection, inclusive of any corneal disease, dysfunction or abnormality.

Lagophthalmos

The inability to close or poor closure of the eyelids.

Microbial keratitis

Inflammation of the cornea secondary to bacterial, viral or fungal infection. May result in corneal ulceration and perforation.

Neurotrophic keratopathy

A degenerative disease characterised by decreased corneal sensitivity and poor corneal healing. This disease leaves the cornea susceptible to injury and decreases reflex tearing. Epithelial breakdown can lead to ulceration, infection, and perforation secondary to poor healing.

NHMRC

National Health and Medical Research Council

Ocular Surface Disease (OSD)

General term covering conditions of superficial corneal exposure. These may range from micro/punctuate lesions to larger geographical defects de-epitheliazing the cornea.

OR

Odds ratio

PICO

Population intervention comparison outcome

Punctate epithelial keratopathy

Micro epithelial defects to the corneal surface

RCT

Randomised control trial

SR

Systematic review

Disclaimer

The information on this page is general in nature and cannot reflect individual patient variation. It reflects Australian intensive care practice, which may differ from that in other countries. It is intended as a supplement to the more specific information provided by the doctors and nurses caring for your loved one. ICNSW attests to the accuracy of the information contained here but takes no responsibility for how it may apply to an individual patient. Please refer to the full disclaimer.