Eye care - Interventions

Section

Recommendation statement

Grade of recommendation

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

Incomplete eye closure (lagopthalmos) has been identified as strongly contributing to the development of iatrogenic ocular surface disorders (OSD) (1-7). The vulnerability of ICU patients to lagopthalmos has been attributed to a number of factors including reduced level of consciousness, tracheal intubation, prolonged sedation, paralysis, prolonged mechanical ventilation and PEEP. Medical conditions with significant metabolic derangement and positive fluid balances also contribute (3, 4, 7-15). Exposure of the eye due to inadequate lid closure may lead to drying of the conjunctival and corneal epithelium, and trigger a cascade of infection and corneal erosion resulting in permanent corneal scarring and visual loss (16). Early identification of incomplete eyelid closure by regular assessment of eyelid position (Figure 5), provides a strategy for early intervention to close and protect the eyes. However, while the underlying principle of the eye care CPG is to ensure eye lid closure, this strategy is based on consensus opinion that treatable causes for lagopthalmos have first been identified and addressed.

Various methods have been used to provide protective barriers and moisture to the corneal surface. Evidence supporting practice however has been inconsistent, due to variations in definitions and methodologies used. Study outcomes on the effectiveness of interventions used should therefore be viewed with caution. Regardless, support exists for the use of lubricants in all unconscious or heavily sedated patients (5) as lubricants have been found to decrease the risk of corneal dehydration and infection (8). The literature also supports the use of lubricants over eye drops, as ointment has been shown to provide longer lasting eye moisture, and require less frequent installation (17). Lubricants have been found to be better than passive eyelid closure in reducing the incidence of corneal erosion (17, 18), less effective than mechanical eye covers (except Geliperm) to reduce corneal breakdown (7, 19, 20), and less effective than polyethylene cover moisture chamber to reduce the incidence of exposure keratopathy (18, 21, 22). Other studies have found efficiency with the use of either polyethylene covers or lubricants to decrease the incidence of corneal breakdown (22). Combination use of 1.27cm Duratears ointment with polyethylene covers has been shown to result in a low incidence of OSD (5.3% - 6.8%)(17, 22), and Micropore edging has additionally been used with polyethylene covers in order to create a better seal (21, 22). Research using swimming goggles as a moisture chamber and changed 12/24 has proved inconclusive in reducing the incidence of OSD (7). While a meta-analysis (14) supports the use of moisture chambers over the use of lubricants, these findings have been based on studies with a moderate to high risk of bias.

For patients unable to maintain eyelid closure independently, interventions to cover the eye and to maintain corneal moisture (Appendix 7 Clinical practice effective in preventing iatrogenic opthalmological complications)) appear to reduce the incidence of eye complications (7, 14, 17, 19, 21-24). These interventions include the use of either passive or mechanical means to obtain complete lid closure (5, 17, 18). Mechanical eye covers have been advocated as a strategy to minimise the risk of eye infection in cases of respiratory infection and wherein open tracheal suction techniques may be in use (8, 9, 25). These covers have been advocated for use in combination with eye ointment (18, 21, 22, 26), paraffin gauze, dressing and tape (20). All interventions include the use of regular eye hygiene. Eye cleaning with saline soaked gauze 2/24 – 4/24 to remove exudate, debris or dried ocular medications (5, 20, 24, 26) has evidence-based support. However, while the use of normal saline over sterile water remains debatable (5, 20-22), agreement exists on the need to promote patient comfort and healing by frequently cleaning the eyes with eye care interventions utilised.

Moisture chamber

clear moisture chambers over eyes of a dummy
Image courtesy RNSH ICU Eye Care Guideline

Given the limited success at protecting and supporting ocular epithelial integrity associated with moisture chambers, mechanical covers, and passive eye closure, additional mechanical means of eye closure by taping with Micropore has also been suggested (7, 20). The proviso with this recommendation is that extreme care should be taken to prevent injury because the tissues surrounding the eyes are delicate and inadvertent application of tape to the cornea may cause damage (11, 27).

To summarise, available evidence lends support to routine eye hygiene for all patients, and eyelid cleansing if lids are unclean (24, 28). Eye lubricants, eye covers and eye taping have been found to either decrease the incidence or the severity of OSD once apparent (7, 24, 28). Furthermore, that incomplete eyelid closure is indicative of a need for eye hygiene, eye lubricant and eye covers, with the exception of the use of Geliperm (6, 20, 24).

Eliminating lagopthalmos and ocular surface exposure has been shown to be essential for the prevention of microbial colonisation and infection (29). Signs of infection may include redness, pain or discharge (20), lid and conjunctival swelling with hyperaemia, lid margin crusting or corneal clouding (6, 13). Suspicion of infection, medical review and subsequent to obtaining bilateral eye swabs for culture (20), and medical consideration for ophthalmologic referral, consideration should also be given to the use of a broad-spectrum antibiotic until the result of eye swabs become available. Two antibiotics have been cited in the literature for interim use in this situation: gentamycin, for use when respiratory pathogen involvement is suspected (13), or otherwise, a chloramphenicol prescription (3).

The frequency for medical assessment of iatrogenic ocular surface disease in ICU patients cited in the literature varies. This has ranged from weekly (5) to more frequent examination especially with symptomatic patients (6, 20). Regardless, timely specialist referral is recommended for symptomatic patients, or for patients in whom treatment response is limited, or the adopted interventions do not achieve the goal of eyelid closure (5, 13, 20).

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 (30)

References

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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.