Patient assessment

Section

Recommendation statement

Grade of recommendation

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

A limited numbers of studies have focussed on eye care assessment for the adult intensive care patient. Research areas have ranged from identifying risk factors for lagopthalmos (1), risk factors for OSD (1, 2) and studies on eyelid cleanliness and corneal dryness (2, 3). Consensus support is given to a comprehensive patient history and assessment on admission and at regular intervals (3, 4) such as at shift handover as an essential component of clinical care. These recommendations are based on existing findings that critical illness, pre-existing conditions and intensive care treatment all contribute to an increased risk of iatrogenic eye complications for the critically ill adult.

To ensure that all-important information is obtained, and in keeping with good clinical practice, clinicians should approach family members for information regarding the patient’s medical and surgical history. This history should include ocular conditions and treatment on admission, in order to assess the risks of and early recognition of OSD (4). Highly effective eye regimes may be compromised by interruption to treatment. On admission, previous eye injury or surgery, the presence of an artificial lens, a history of cataracts, glaucoma and any other pre-existing eye treatment and medications, such as anticholinergic drops, should be elicited (5, 6).

A number of studies have focussed on the role of critical illness, pre-existing conditions and the treatment environment of intensive care as factors contributing to iatrogenic risk for eye complications. Critical illness commonly presents with a range of conditions potentially affecting ocular defence mechanisms. The following medical conditions have been investigated: immunosuppression (1), sepsis and trauma (7, 8), multi-organ failure (8, 9), burns (5), Guillian Barre Syndrome (10), myasthenia gravis (11), collagen disease and diabetes (6), neurological presentations (12, 13), and ocular conditions arising due to various complications of systemic disease (13, 14). Pre-existing eye conditions also place this population of adult intensive care patients at greater risk, especially if interruption to existing treatment regimes were to occur by virtue of admission to the intensive care unit (15).

The patient treatment process within the intensive care environment may also create barriers to ocular health and integrity of eye function. The use of sedation and neuromuscular blockade has been identified as a precursor to lagopthalmos (16, 17), and this relationship has been shown to strengthen with an increased length of ICU stay (7, 16, 18) and an increased length in ventilation time (7, 8, 19). Unconscious patients are vulnerable to eye injury and infection due to inadequate lid closure and epithelial exposure (1, 6). This may lead to drying of the conjunctiva and corneal epithelium, infection, permanent corneal scarring and visual loss (2, 3). In the ICU environment, other risks for eye infection and corneal disruption arise from respiratory pathogens (8, 20, 21), high gas flow, CPAP, the use of tracheal or oropharyngeal open suction (19), copious secretions, patient positioning (for example proning) (6) and cross infection from other body infective surface wounds (19, 21).

Risk factors for ocular surface disorders

Risk factor

Level of risk

Overview of evidence

References

Lagopthalmos

Probably
highly significant

2 x RCT

1 x Prospective cohort

1 x Observational

1 x Retrospective case control

1 x Narrative review

(16, 17)

(22)

(8)

(23)

(6)

Length of sedation/use of neuromuscular blockade

Probably significant

1 x RCT

2 x Observational

2 x Clinical practice guideline

1 x Narrative review

([36)

(7, 8)

(3, 4)

(6)

Length of stay

Probably a function of critical illness

2 x RCT

1 x Observational

(16, 18)

(7)

Length of ventilation

Probably a function of critical illness

2 x Observational

1 x Narrative review and meta-analysis

(7, 8)

(19)

Medical conditions

Possibly a risk

1 x RCT

2 x Observational

1 x Narrative review

(17)

(7, 8)

(6)

Respiratory pathogens

Possibly a risk

1 x Narrative review and Meta-analysis

1 x Narrative review

(19)

(6)

Clinical practice highlights that early recognition of signs and symptoms of ocular surface disease and early treatment improves resolution of these conditions (15). Initially on admission, and routinely regularly thereafter, such as at shift handover, recommendation is made that all patients should be assessed for risk factors, the ability to maintain eyelid closure, in addition to assessment for signs and symptoms of eye infection and disease (1, 21). A bright light (using a pen torch) should be used for eye examination, looking for signs of infection or disease, conjunctival swelling, dullness, cloudiness, whiteness or spotting of the cornea. New findings should initiate the administration of additional lubricant in the short term and trigger a medical alert for ophthalmologic review (15). Where red eyes are found, with or without exudate, a swab and culture of both eyes should routinely be conducted, and a medical review completed. Development of a red eye in a septic patient should be addressed as an ocular emergency, as the patient’s visual capacity may deteriorate within hours, and may be dependent on the need for rapid intervention (15). Frequency of ocular assessment and eye care interventions used should routinely be documented in a care plan that is regularly reviewed and updated. Results of patient assessment and evaluation of the effectiveness of interventions should also be documented at least each nursing shift.

Method of eyelid taping

taped eyelid

It is important to ensure that the eye lids are opposed correctly so that the eye lashes are not able to scratch the eye. Image source (15).

Figure 5: Grading lagaopthalmos

Grade 1: Eyes completely closed
""

Grade 2: Eyes open - sclera or conjunctiva visible
""

Grade 3: Eyes open - cornea visible
""

Opthalmology abnormalities

Chemosis
Figure 6: Chemosis

Corneal abrasion
Figure 7: Corneal abrasion

Allergic conjunctivitis
Figure 8: Allergic conjunctivitis

Marginal keratitis
Figure 9: Marginal keratitis

Viral conjunctivitis
Figure 10: Viral conjunctivitis

Bacterial ulcer
Figure 11: Bacterial ulcer

Bacterial conjunctivitis
Figure 12: Bacterial conjunctivitis

Red eye in septic patient
Figure13: Red eye in septic patient

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 (24)

References

  1. 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.
  2. Laight SE. The efficacy of eye care for ventilated patients:  outline of an experimental comparative research pilot study. Intensive and Critical Care Nursing. 1996;12:16-22.
  3. Yi WY. Evidence-based Eye Protocol for ICU Patients with Altered Level of Consciousness: University of Hong Kong; 2009.
  4. Konno R. Eye Care: (ICU): Clinician Information. JBI. 2011.
  5. Smith SB, Coffee T, Yowler C, Steinemann TI. Risk Factors for Ophthalmic Complications in Patients with burns. Journal of Burn Care & Research. 2010;31(6):911-7.
  6. Ramirez F, Ibarra S, Varon J, Tang R. The Neglected Eye: Ophthalmological Issues in the Intensive Care Unit. Crit Care & Shock. 2008;11:72-82.
  7. Mela E, Drimtzias E, Christofidou M, Filos K, Anastassiou E, Gartaganis S. Ocular surface bacterial colonization in sedated intensive care unit patients. Anaesth Intensive Care. 2010;38:190-3. Epub
  8. 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).
  9. Imanaka H, Taenaka N, Nakamura J, Aoyama K, Hosotani H. Ocular surface disorders in the critically ill. Anaesthesia Analg. 1997;85:343-6.
  10. Vriesendorp F. Clinical features and diagnosis of Guillain-Barre syndrome in adults. Up to Date Online. 2012;2012.
  11. Pelak V, Quan D. Ocular myasthenia gravis. UpToDate Online. 2011;2012.
  12. Kam K, Hayes M, Joshi N. Ocular Care and complications in the critically ill. Trends in Anaesthesia and Critical Care. 2011 (1):257-62.
  13. Klig J. Opthalmologic Complications of Systemic Disease. Emerg med Clin N Am. 2008;26(2008):217-31.
  14. Mehta A, Jiandani P, Desai M. Ocular Lesions in Disseminated Candidiasis. Associations of Physicans India. 2007 July 2007;55:483-5.
  15. Lightman S. Eye Care for Patients in ITU. 2005.
  16. 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.
  17. 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.
  18. 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.
  19. Rosenberg JB, Eisen LA. Eye care in the intensive care unit: Narrative review and meta-analysis. Crit Care. 2008;36(12):3151-5.
  20. Mercieca F, Suresh P, Morton A, Tullo A. Ocular surface disease in intensive care unit patients. Eye. 1999;13:231-6.
  21. Parkin B, Turner A, Moore E, Cook S. Bacterial keratitis in the critically ill. British Journal of Ophthalmology. 1997;81:1060-3.
  22. Jammal H, Khader Y, Shihadeh W, Ababneh L, AlJizawi G, AlQasem A. Exposure keratopathy in sedated and ventilated patients. Journal of Critical Care. 2012;27(6):537-41.
  23. Oh EG, Lee WH, Yoo JS, Kim SS, Ko IS, Chu SH, et al. Factors related to incidence of eye disorders in Korean patients at intensive care units. Journal of Clinical Nursing. 2008;18:29-35.
  24. 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.

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.