Incidence, risk factors and impact of protocolised care on exposure keratopathy in critically ill adults: a two-phase prospective cohort study

The effect of polyethylene cover intervention on ocular surface disorder of intensive care unit patients: a systematic review and meta-analysis

BACKGROUND

Polyethylene covers have been proven to be effective in protecting the eyes in patients with decreased or disappeared blink reflexes, but their advantages compared to other conventional methods are still unclear. This systematic review and meta-analysis study aimed to elucidate the impact of polyethylene covers in the prevention of ocular surface disease (OSD) in patients admitted to the intensive care unit (ICU).

METHODS

We searched the Scopus, PubMed, Web of Science, and Cochrane Central Register of Controlled Trials (CENTRAL) databases to identify randomized controlled trial studies. This study followed the PRISMA guidelines and used the Cochrane Collaboration tool to assess the risk of bias.

RESULTS

The findings were expressed as risk ratio (RR) with 95% confidence intervals. The incidence of OSD in the polyethylene cover group was lower than that in the eye drops group (RR = 0.27; 95% CI (0.07, 1.09), P = 0.07) and adhesive tape group (RR = 0.11, 95%CI (0.04, 0.31), P < 0:0001) but the polyethylene cover group showed no significant difference compared to the eye gel group (RR = 0.79, 95%CI (0.18, 3.51), P = 0.76) and the eye ointment group (RR = 0.85; 95% CI (0.36, 1.99), P = 0.71).

CONCLUSION

This study showed that polyethylene covers, eye gels, and eye ointments had an equal effect on preventing OSD in ICU patients, and eye drops and adhesive tapes were relatively less effective. However, other intervention methods had not been compared due to the small number of articles. Hence, further studies should assess the available methods to choose the best practical method.

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.

Early detection of ocular lesions in critically ill children: Testing an ocular assessment scale

OBJECTIVE

There is scarcity of data on the incidence and factors associated with the occurrence of ocular lesions in critically ill children. The objective was to test the applicability and utility of an ocular assessment scale and to identify risk factors of ocular lesions.

DESIGN

Prospective observational study.

SETTING

A tertiary care medical-surgical Paediatric Intensive Care Unit.

SAMPLE

194 children without previous ocular disease who stayed in the Paediatric Intensive Care Unit for more than 48 h.

INTERVENTIONS

An ocular lesions risk scale was designed including risk factors lagophthalmos, eye dryness, conjunctival hyperemia, slow blinking, intubation, sedation, relaxation, face mask and hemodynamic instability. Patients were classified as high-, medium-, and low-risk patients. Corneal lesions were examined by fluorescein staining according to their risk and were confirmed by an ophthalmologist.

RESULTS

76 patients were examined with fluorescein staining. Thirty-two ocular lesions were detected by nursing staff, 26 confirmed by the ophthalmologist. 53.6% of the high-risk patients developed a corneal lesion. Univariate analysis revealed an association between ocular damage and all factors included in the scale, except for face mask. In the multivariate analysis, ocular lesions were associated with lagophthalmos, hyperemia, invasive mechanical ventilation and inotropic support.

CONCLUSIONS

The scale was useful to detect corneal lesions in critically ill children. The identification of risk factors will enable the development of measures to reduce the incidence of ocular lesions.

RELEVANCE FOR CLINICAL PRACTICE

A new, non-validated scale allowed staff to detect eye injuries, study this problem and improve future prevention.

The effect of eye care protocol on the prevention of ocular surface disorders in patients admitted to intensive care unit

Eye care is one of the most critical tasks of intensive care unit (ICU) nurses. Patients in this unit are exposed to potential ocular problems due to critical conditions. This study aimed to establish a new eye care protocol for preventing ocular surface disorders in patients admitted to ICU. This was a clinical trial study performed on patients admitted to ICU in 2019. The data gathering tools included the demographic questionnaire, the Schirmer test for dry eye, fluorescein staining and slit lamp manual for examining corneal ulcers, and slit lamp manual to check keratitis and conjunctivitis. A type of eye care protocol was performed on the patient's eyes. After five consecutive days of executing the protocol, the data were analyzed using SPSS software version 18. The use of eye care protocol reduced the risk of keratitis (P=0.027), conjunctivitis (P=0.012), eye dryness (P=0.001), and corneal ulcer (P=0.003) in patients admitted to ICU in the intervention group compared to the control group. Ophthalmology protocols reduced the incidence of keratitis, conjunctivitis, dry eye, and corneal ulcers in ICU patients. Therefore, using this method in ICU patients can improve nursing care.

The Effects of Passive Blinking on Exposure Keratopathy among Patients in Intensive Care Units

Background

Patients in Intensive Care Units (ICUs) are at risk of eye disorders such as Exposure keratopathy (EK) due to impaired blinking and incomplete eye closure. The aim of this study was to assess the effects of passive blinking exercise (PBE) on EK among patients in ICUs.

Materials and Methods

This single-blind, randomized, clinical trial was conducted in 2017. The study participants included 51 patients purposively recruited from the three ICUs of Valiasr Teaching Hospital, Arak, Iran. Through coin tossing, one eye of each participant was randomly allocated to the intervention group and the other to the control group. The eye in the control group received routine eye care, whereas the eye in the intervention group received routine eye care and PBE for a week. EK prevalence and severity were assessed daily for 7 consecutive days using fluorescein eye staining papers and an ophthalmoscope with a cobalt blue filter.

Results

The study groups did not significantly differ from each other in terms of the baseline prevalence and severity of EK. After the intervention, the prevalence of EK (χ ² = 13.44, df = 1, p < 0.001) and the prevalence of grade II EK (χ ² = 8.33, df = 1, p = 0.003) in the intervention group were significantly lower than the control group.

Conclusions

PBE is effective in significantly reducing EK prevalence and severity among patients in ICUs. Therefore, critical care nurses are recommended to use PBE for EK prevention and management.

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.

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.

Incidence and related factors of surface eye disorders in traumatic intensive care unit patients in Iran

BACKGROUND

Intensive care unit (ICU) patients are exposed to several surface eye disorders ranged from minor complications like corneal dryness to more serious ones such as corneal perforation and blindness. This study is then to assess the incidence of the ocular complications and related factors.

MATERIALS AND METHODS

During a prospective cross sectional study in a general adult ICU, ocular complications of the patients were assessed by an ophthalmologist. Data were analyzed using descriptive analysis. A P-value of ≤0.05 was considered significant.

RESULTS

Out of 155 patients, 130 cases (260 eyes) were covered during the study period, 2016-2017. The most common complications among the patients included dry eye and corneal abrasion (25.8%) followed by conjunctivitis (25%). The mean time of occurrence for dryness and corneal abrasion was 4±2.93 days after admission to the ICU. Lower Glasgow coma scale (GCS) and longer hospital stay were significantly associated with ocular complications in the ICU (P<0.05).

CONCLUSION

Eye surface complications are commonplace in critically ill patients admitted in the ICU. Dry eye, corneal abrasion, and conjunctivitis have been revealed as the most prevalent complications in this study. Lower GCS and longer stay in the ICU predisposed the cases to these complications. Efficient eye care protocol and training the ICU staff are both recommended to reduce complication rates as such.

Comparative efficacy of various preventive methods for exposure keratopathy among critically ill patients: A network meta-analysis of randomized controlled trials

BACKGROUND

There is a wide variety of preventive methods currently available for the treatment of exposure keratopathy. Because of a lack of evidence from head-to-head randomized controlled trials (RCTs), the relative effects of these preventive methods in exposure keratopathy patients remain unclear. The purpose of our study is to carry out a network meta-analysis comparing the efficacy of different methods for the prevention of exposure keratopathy and rank these nursing methods for practical consideration.

METHODS

A literature search was performed of the MEDLINE (PubMed), EMBASE, Web of Science, China National Knowledge Infrastructure Library (CNKI), China Science and Technology Journal Database (Weipu), WanFang Database and China Biology Medicine disc. Two authors independently extracted data from each included RCTs according to a predesigned Excel spreadsheet and assessed the methodological quality of included RCTs using the Cochrane risk of bias tool. Data was analyzed using the R (V.3.6.2) and the Stata (V.15.0).

RESULTS

21 RCTs involving 2022 patients and evaluating 11 preventive methods were included. Rankings based on posterior probabilities revealed that artificial tear ointment might be the best way to prevent exposure keratopathy (35%), polyethylene covers might be the second-best (31%), swimming goggles might be the third-best (21%), foam dressing might be the fourth-best (18%).

CONCLUSIONS

This network meta-analysis indicated that artificial tear ointment, polyethylene covers, swimming goggles and foam dressing might be selected for the prevention of exposure keratopathy in intensive care unit patients, which is important in future research. Although evidence is scant, more attention should be paid to head-to-head comparisons of the most commonly used prevention methods in this field.

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.

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

PURPOSE

To determine the prevalence and risk factors of exposure keratopathy (EK) across different intensive care units (ICU) at Columbia University Medical Center, including the Pediatric ICU (PICU), Medical ICU (MICU), and Neurologic ICU (NICU).

METHODS

In this prospective cohort study, 65 patients were examined daily during their admission in the PICU (27 patients), MICU (15 patients), and NICU (23 patients). Data on eyelid position, conjunctival and corneal changes, Bell's and blink reflexes, medications, Glasgow Coma Scale rating, and ventilation type were collected.

RESULTS

Overall EK percentages were as follows: PICU 19%, MICU 60%, and NICU 48%. The prevalence of EK was lowest in the PICU (P = 0.013). Factors associated with EK were lagophthalmos (P < 0.001), an absent Bell's reflex (P = 0.003), an absent blink reflex (P < 0.001), conjunctival injection (P < 0.001), a low Glasgow Coma Scale score (P < 0.001), intubation (P < 0.001), surgery before examination (P < 0.001), dialysis (P = 0.002), and administration of opioid (P < 0.001), sedative (P < 0.001), and neuromuscular blocking medications (P = 0.006).

CONCLUSIONS

This is the first study to examine the rates and risk factors of EK across different ICU settings. The prevalence of EK was lowest in the PICU, which may partly be explained by the increased number of PICU patients receiving noninvasive ventilation and the absence of conjunctival chemosis.

The importance of protocol-based eye care in the paediatric intensive care unit

Eye care is a fundamental aspect of personal hygiene that should not be neglected in a critically ill child. This article informs nursing care by linking theory to practice, based on a systematic search and critical review of the literature. It explores the significance of evidence related to the eye care of a ventilated child and considers the role of the children's nurse as an agent for change in developing an eye care protocol for use in the paediatric intensive care unit.

Periorbital lesions in severely burned patients

PURPOSE

This study aimed to characterize the injuries involving periorbital region in our severely burned patients.

METHOD

A 2 years retrospective study was conducted with a total of 210 severe burns admissions. Periorbital burn injuries (all produced in association with facial injuries) were encountered in 126 patients, representing the study group that was further analyzed for multiple parameters: demographics, mechanism of injury, TBSA (total body surface area), burn depth, inhalation injury, need for intubation and mechanical ventilation. The presence and severity of ocular injuries were also evaluated.

RESULTS

Analyzing our study group (n=126), we observed the presence of multiple negative prognosis factors: elderly patients, extensive burns, deep burns affecting functional areas, unfavorable mechanism (electric, chemical or explosions), inhalation injuries, need for intubation and mechanical ventilation, leading to severe morbidity and high mortality level. Ocular injuries were encountered in 37 patients (30 primary and 7 secondary lesions). The predominance of primary ocular lesions is explained trough high severity burns encountered in our patients with high mortality and lack of long-term clinical observations.

CONCLUSION

The clinical outcome for periorbital burn injuries depends on patient characteristics, etiology, burn extension and depth, associated lesions, infectious risk and the quality of the treatment applied. Presence of ocular injuries in various severity degrees impose an adequate evaluation and specialized treatment, being associated with important morbidity. In severely burned patients, it is mandatory to apply preventive measures to avoid ocular complications. If exposure keratopathy is detected, prompt ophthalmologic treatment is essential to avoid functional impairment including loss of vision. Abbreviations: TBSA = total body surface area, MSOF = multisystem organ failure, OCS = orbital compartment syndrome, AION = anterior ischemic optic neuropathy.