Making a Difference in Eye Care of the Critically Ill Patients

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.

Bedside assessment of ophthalmic manifestations in neurocritical care: A study in Southern India

PURPOSE

This study aimed to investigate the incidence of Ocular Surface Disorders (OSDs), including Dry Eye Disease, Chemosis, and Exposure Keratitis, among patients admitted to the Neurocritical Care Unit (NCC). Additionally, we sought to assess the correlation between these OSDs, the length of hospitalization at NCC, and the Glasgow Coma Score (GCS). The heightened risk of OSD development in the NCC environment, coupled with pre-existing neurological impairments, can lead to conditions like dry eye disease, chemosis, corneal abrasions, and infectious keratitis, ultimately resulting in corneal opacities and perforations that significantly impact visual acuity and overall quality of life.

METHODS

In this observational cross-sectional study, we examined the ocular health of all patients admitted to an NCC unit from February to May 2022. We assessed the presence of Conjunctivitis, chemosis, Keratitis, and Dry Eyes in relation to the duration of stay at NCC, GCS, lagophthalmos, adherence to the prescribed eye care protocol in NCC, and the use of mechanical ventilation. Our study comprised one hundred subjects over a four-month period, with a mean age of 51.92 ± 18.73 years (ranging from 17 to 89), including 70% males and 30% females (gender ratio of 2.33).

RESULTS

Our findings revealed that 26 eyes (13%) exhibited Conjunctival Hyperemia, 23 eyes (11.5%) displayed Chemosis, and severe dry eye was prevalent in 41 (20.5%) eyes. A statistically significant association was observed between GCS (p-value <0.001) and Keratitis (p-value 0.0035) with dry eyes (Chi-Square Test). Notably, the incidence of dry eyes was significantly higher among patients with a prolonged stay of ≥10 days (p-value 0.003).

CONCLUSIONS

Patients admitted to Neurocritical Care Units necessitate meticulous eye care and structured protocols to mitigate the risk of long-term ocular complications such as exposure keratitis. Given their heightened susceptibility to these conditions, proactive measures are imperative to ensure optimal ocular health among NCC patients.

Prevalence and risk factors of exposure keratopathy among critically ill patients: A systematic review and meta-analysis

AIMS

To identify the incidence, prevalence and risk factors of exposure keratopathy (EK) among critically ill patients.

DESIGN

Systematic review and meta-analysis, in accordance with the PRISMA 2020 Statement.

METHODS

The Cochrane Library, PubMed, Embase, Web of Science, Cumulative Index to Nursing and Allied Health Literature (CINAHL), China Knowledge Resource Integrated Database (CNKI), Chinese Biomedical Database (CBM), Weipu Database (VIP) and WanFang Database were systematically searched from inception to June 2022. Observational studies that reported EK among paediatric and adult critically ill patients were screened and included original articles based on the inclusion criteria. Two reviewers independently completed data extraction and quality assessments. Subgroup analysis investigated potential causes of heterogeneity.

RESULTS

Of the 4508 studies identified, 23 studies involving 3519 subjects were included. The pooled prevalence of EK was 34.0%, and the pooled incidence rate of EK was 23.0%. Risk factors associated with EK in critically ill patients included lagophthalmos, chemosis, eye blinks <5 times per minute, mechanical ventilation, sedation, lower Glasgow Coma Scale (GCS) score and higher Acute Physiology and Chronic Health Evaluation (APACHE) II score.

CONCLUSION

This review shows that EK rates are high in critically ill patients and are influenced by multiple factors. Medical staff should pay more attention to EK in critically ill patients, conduct professional evaluations and implement targeted eye care protocols to reduce its occurrence.

IMPLICATIONS FOR PRACTICE

This study shows the frequency of and multiple risk factors for EK in critically ill patients, which provides evidence-based guidance for nurses to evaluate the risk of EK in critically ill patients and take appropriate precautions to reduce the risk.

PROTOCOL REGISTRATION

The protocol was registered in PROSPERO (https://www.crd.york.ac.uk/prospero/) (CRD42022346964).

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution.

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.

Nursing interventions to prevent corneal injury in critically ill sedated and mechanically ventilated patients: A systematic review of interventions

OBJECTIVE

To identify the effectiveness of interventions to prevent corneal injury in critically ill, sedated, and mechanically ventilated patients.

RESEARCH METHODOLOGY

A systematic review of intervention studies was conducted in the following electronic databases: Cumulative Index to Nursing and Allied Health Literature, Cochrane Central Register of Controlled Trials, Embase, Latin American and Caribbean Literature in Health Sciences, LIVIVO, PubMed, Scopus and Web of Science, and reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. Study selection and data extraction were performed by two independent reviewers. Quality assessment of the randomized and non-randomized studies was performed using the Risk of Bias (RoB 2.0) and ROBINS-I Cochrane tools, respectively, and the Newcastle-Ottawa Scale for cohort studies. The certainty of the evidence was assessed according to the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system.

RESULTS

15 studies were included. Meta-analysis showed that the risk of corneal injury in the lubricants group was 66% lower (RR = 0.34; 95 %CI: 0.13-0.92) than in the eye-taping group. The risk of corneal injury in the polyethylene chamber was 68% lower than in the eye ointment group (RR = 0.32; 95 %CI 0.07-1.44). The risk of bias was low in most of the studies included and the certainty of the evidence was evaluated.

CONCLUSIONS

The most effective interventions to prevent corneal injury in critically ill sedated mechanically ventilated, who have compromised blinking and eyelid closing mechanisms, are ocular lubrication, preferably gel or ointment, and protection of the corneas with a polyethylene chamber.

IMPLICATIONS FOR CLINICAL PRACTICE

Critically ill, sedated, and mechanically ventilated patients who have compromised blinking and eyelid closing mechanisms must receive interventions to prevent corneal injury. Ocular lubrication, preferably gel or ointment, and protection of the corneas with a polyethylene chamber were the most effective interventions to prevent corneal injury in critically ill, sedated, and mechanically ventilated patients. A polyethylene chamber must be made commercially available for critically ill, sedated, and mechanically ventilated patients.

Nurses' perceptions of critically ill patients' eye care: a qualitative study in Iran

BACKGROUND

Despite the high prevalence of ocular complications in patients admitted to the intensive care unit (ICU), eye care, as an important component of the care plan, has not received much attention from nurses. To improve the quality of eye care, the challenges and concerns of ICU nurses should be studied deeply. Thus, the present study aimed at exploring the challenges faced by ICU nurses in taking care of patients admitted to the ICU.

METHODS

The present conventional qualitative content analysis study was carried out on 11 nurses and 3 head nurses selected purposefully by observing the maximum variation. The data were collected through face-to-face, in-depth, and semi-structured interviews. All data were recorded, transcribed, and analyzed using the conventional content analysis method proposed by Graneheim and Lundman (Nurse Educ Today 24:105-12, 2004). The Max Q Data software 2020 was run to record the interviews and extract codes from the transcriptions.

RESULTS

The participants' mean age was 37.14 ± 6.41 years and their average work experience in ICU was 10.29 ± 7.63 years. The core category that emerged from data analysis was "the lack of an evidence-based approach", which was subdivided into five categories: "education, the missing link", "nurses' inadequate professional competence", "unsafe nursing care", "organizational requirements", and "difficulty in eye care evaluation".

CONCLUSION

Evidence-based practice plays a minor role in the field of eye care in Iran, despite its critical importance. Thus, the Ministry of Health and Medical Education of Iran is recommended to adapt the clinical guidelines so that more attention is paid to this field.

Predictors of Nurses' Practice of Eye Care for Patients in Intensive Care Units

Introduction

Taking care of patients' eyes is an important nursing skill. Nurses must be capable of providing a standard assessment of the eye and vision as well as necessary care such as eye cleaning. Intensive care unit (ICU) nurses typically focus on life-threatening issues while giving little attention to other serious issues. The purpose of this study was to assess predictors of nurses' practice of eye care for patients in ICUs in the West Bank.

Method

A cross-sectional study was conducted with all ICU nurses from West Bank hospitals. The researchers developed a self-administered questionnaire to collect data.

Results

One hundred and fifty-two nurses participated in this study. The findings revealed that the mean age of nurses was 31.2 (SD  =  7.5) years. The analysis revealed that only 0.7% had a good knowledge level, 7.2% had a fair knowledge level, and 25.7% had a good practice level of eye care for patients in an ICU. Knowledge of patients' eye care in the ICU, as well as an eye care protocol or policy for unconscious patients, was found to be significant predictors of practice (p < .001).

Conclusion

The study confirmed that the nurses had poor knowledge and inadequate practice of eye care for patients in the ICU. Also, the study confirmed that a nurse's knowledge of patients' eye care in the ICU and an eye care protocol or policy for unconscious patients were significant predictors of practice.

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.

The Effect of Three Eye Care Methods on the Severity of Lagophthalmos in Intensive Care Patients: A Randomized Controlled Clinical Trial

Background

Patients admitted to intensive care units are exposed to a variety of eye injuries such as lagophthalmos, which can lead to blindness. There is conflicting evidence regarding the effectiveness of different eye protection methods, and evaluations are ongoing. Therefore, this study was performed to compare the effect of “polyethylene cover,” “polyethylene cover plus artificial tear drops,” and “polyethylene cover plus Lubratex eye ointment” on the severity of lagophthalmos.

Methods

A total of 156 patients connected to ventilators were included in this clinical trial using the convenience sampling method. They were randomly divided into three groups: “polyethylene cover,” polyethylene cover plus artificial tear drops,” and “polyethylene cover plus Lubratex eye ointment.” In each group, one eye was regarded as control and the other eye as intervention. The control eye received routine interventions, including washing with normal saline. The eyes were examined daily by an ophthalmologist for 5 days for the occurrence of lagophthalmos.

Results

There was no statistically significant difference in the severity of lagophthalmos among the three groups “polyethylene cover,” “polyethylene cover plus artificial tear drop,” and “polyethylene cover plus Lubratex eye ointment.” However, clinically the severity of lagophthalmos was lower in the “polyethylene cover plus artificial tear drops” group than in the other two groups.

Conclusion

The results showed that the combination of polyethylene cover and artificial tears drops can be clinically effective in reducing the severity of lagophthalmos. Therefore, the use of this method is recommended for patients admitted to the intensive care unit. Similar studies are recommended.

The effect of implementation of evidence-based eye care protocol for patients in the intensive care units on superficial eye disorders

Background

Superficial eye disorders are one of the most common complications of improper eye care in intensive care units that can lead to corneal ulcers and permanent eye damage. The aim of this study was to determine the effect of the implementation of eye care protocol on the incidence of infection and superficial eye disorders in patients admitted to intensive care units.

Methods

This study was a cross-over clinical trial that was performed on 32 patients admitted to the intensive care unit with reduced or no blink reflex following loss of consciousness or receiving sedatives. The eye of the test group received eye care according to the protocol and the eye of the control group received the routine care of the ward. The data collection form included demographic and clinical information and the clinical score scale of superficial eye disorders, which were completed in 7 days for both eyes. Data analysis was performed by McNemar and Cochran tests with a 95 % confidence interval.

Results

In the study of superficial eye disorders, the frequency of dacryorrhea and hyperemia was not significantly different in the second to seventh days in the control and test eyes (P < 0.05). The frequency of xerophthalmia was not significantly different between the control and the test eyes on the second to third days (P < 0.05), but there was a significant difference on the fourth, fifth, sixth, and seventh days (P = 0.0001). Also, the frequency of corneal opacity was not significantly different in the second and third days (P < 0.05), but in the fourth (P < 0.05), fifth, sixth, and seventh days, this difference was significant (P = 0.0001).

Conclusions

Based on the results, although the implementation of eye care protocol has been able to have a significant effect on reducing ocular complications and problems, routine eye care in the intensive care unit also has clinical effectiveness. Therefore, in order to prevent and completely eliminate eye disorders in the intensive care unit, more evidence and research are needed.

Trial registration

The trial was retrospectively registered on https://en.irct.ir/trial/43493 on 13 November 2019 (13.11.2019) with registration number [IRCT20140307016870N5].

Supplementary Information

The online version contains supplementary material available at 10.1186/s12886-021-02034-x.

Influence of Face Masks on the Use of Contact Lenses

BACKGROUND

The COVID-19 epidemic is largely controlled by the use of face masks. The use of a face mask has been indicated as a strong cause of dry eye, although it is not yet described in the literature. This study aims to compare the impact of the use of masks on the visual quality of patients. The symptoms in the human eye intensified during the pandemic versus the symptoms before the pandemic, in a Portuguese population.

METHODS

A fifteen-question questionnaire was conducted to find out what changes occurred in the use of soft contact lenses during the pandemic in relation to the use of masks. Statistical analysis was performed with SPSS 27.0 software (SPSS Inc., Chicago, IL, USA).

RESULTS

The use of contact lenses decreased compared with before the pandemic (p < 0.001). The number of hours of wear decreased significantly compared with before the pandemic (p < 0.001). The sensation of dry eyes was found to be worse in those using monthly replacement contact lenses (p = 0.034), and the need to remove contact lenses was more frequent in women (p = 0.026) after using a mask.

CONCLUSIONS

Mask use increases dry eye symptoms in contact lens wearers, negatively impacting visual quality.

Polyethylene eye-cover versus artificial teardrops in the prevention of ocular surface diseases in comatose patients: A prospective multicenter randomized triple-blinded three-arm clinical trial

Background

Polyethylene covers are claimed to be useful in preventing ocular surface diseases (OSD); however, evidence of their clinical efficacy is limited. This clinical trial aimed to compare the use of polyethylene eye covers and artificial teardrops versus normal saline on the incidence and severity of OSD in comatose patients.

Methods

Of 90 eligible patients randomly assigned to three treatment groups, 79 patients completed the study, In group A, patients (n = 25) received artificial teardrops for left and normal saline for right eyes, in group B (n = 29) polyethylene covers for left and normal saline for right eyes, and in group C (n = 25) polyethylene covers for left and artificial teardrops for right eyes. As the patients were comatose, their blinding did not applicable, and a blinded observer evaluated the patients’ eyes based on the Corneal Fluorescein Staining Pattern. The blinded analyzer analyzed collected data by SPSS-16 software at a 95% confidential level.

Results

The OSDs were observed in 65 (41.14%) out of 158 eyes examined. The artificial teardrop was more effective than the normal saline in group A, polyethylene eye cover was more useful than the normal saline in group B, and polyethylene eye cover was more effective than the artificial teardrop in group C in reducing the incidence of OSD (p< 0.01). Polyethylene eye covers had the most impact on reducing the severity of the OSD compared to the other interventions (p< .001).

Conclusions

Polyethylene eye covers significantly reduced the incidence and severity of OSD. Using polyethylene cover is suggested as a safe, effective, and accessible eye care intervention for preventing OSD in comatose patients.

Trial registration

(IRCT201609129014N115), Iranian Registry of Clinical Trials.

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.

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.

Effect of Training Eye Care Clinical Guideline for ICU Patients on Clinical Competence of Eye Care in Nurses

Introduction

Sight is one of the most important and vital human senses. Lack of proper eye care (EC) in anesthetized patients can lead to serious ocular complications and even vision loss. Insufficient knowledge, attitude, and skills of nurses are considered as a barrier to providing EC in the intensive care unit (ICU). The aim of the present study was to determine the effect of training EC clinical practice guidelines for ICU patients on nurses' knowledge, attitude, and practice of EC.

Methods

This was an interventional study with a pre-post design performed on 60 ICU nurses. For the experimental group, EC clinical guideline training was performed for anesthetized patients in three sessions. The data collection tool included nurses' clinical competence of the EC questionnaire with a possible score range of 0-86. This tool consists of three domains, including knowledge (0-18), attitude (0-28), and practice (0-40), which was completed in a self-assessment manner before and three months after the training program. Data analysis was carried out using SPSS16. Findings. The mean scores of knowledge, attitude, and practice after the intervention in the experimental and control groups were 15.03 ± 2.72 and 11.11 ± 3.50, 25.65 ± 3.47 and 22.07 ± 3.08, and 33.88 ± 4.14 and 28.5 ± 55.08, respectively, which were statistically significant (P ≤ 0.001). Also, the total score of clinical competence of EC after the intervention in the experimental and control groups was 74.56 ± 7.93 and 61.74 ± 9.66, which showed a significant difference (P ≤ 0.001).

Conclusion

Training nurses based on EC clinical guidelines for anesthetized patients can improve the knowledge, attitude, and practice of ICU nurses. Evidence-based EC practice requires continuous training based on clinical guidelines and EC practice monitoring by nursing managers according to EC clinical guideline for an anesthetized patient.

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.

COVID-19: Ocular Manifestations and the APAO Prevention Guidelines for Ophthalmic Practices

The World Health Organization declared the Coronavirus Disease 2019 (COVID-19) caused by Severe Acute Respiratory Syndrome Coronavirus 2 a "Pandemic" on March 11, 2020. As of June 1, 2020, Severe Acute Respiratory Syndrome Coronavirus 2 has infected >6.2 million people and caused >372,000 deaths, including many health care personnel. It is highly infectious and ophthalmologists are at a higher risk of the infection due to a number of reasons including the proximity between doctors and patients during ocular examinations, microaerosols generated by the noncontact tonometer, tears as a potential source of infection, and some COVID-19 cases present with conjunctivitis. This article describes the ocular manifestations of COVID-19 and the APAO guidelines in mitigating the risks of contracting and/or spreading COVID-19 in ophthalmic practices.

Ocular microvascular changes in patients with sepsis: a prospective observational study

Background

The aim of the study was to detect differences in the conjunctival microcirculation between septic patients and healthy subjects and to evaluate the course of conjunctival and retinal microvasculature in survivors and non-survivors over a 24-h period of time.

Methods

This single-center prospective observational study was performed in mixed ICU in a tertiary teaching hospital. We included patients with sepsis or septic shock within the first 24 h after ICU admission. Conjunctival imaging, using an IDF video microscope, and retinal imaging, using portable digital fundus camera, as well as systemic hemodynamic measurements, were performed at three time points: at baseline, 6 h and 24 h. Baseline conjunctival microcirculatory parameters were compared with healthy controls.

Results

A total of 48 patients were included in the final assessment and analysis. Median APACHE II and SOFA scores were 16[12–21] and 10[7–12], respectively. Forty-four (92%) patients were in septic shock, 48 (100%) required mechanical ventilation. 19 (40%) patients were discharged alive from the intensive care unit. We found significant reductions in all microcirculatory parameters in the conjunctiva when comparing septic and healthy subjects. In addition, we observed a significant lower microvascular flow index (MFI) of small conjunctival vessels during all three time points in non-survivors compared with survivors. However, retinal arteriolar vessels were not different between survivors and non-survivors.

Conclusions

Conjunctival microvascular blood flow was altered in septic patients. In the 24-h observation period conjunctival small vessels had a significantly higher MFI, but no difference in retinal arteriolar diameter in survivors in comparison with non-survivors.

Trial registration NCT04214743, https://www.clinicaltrials.gov. Date of registration: 31 December 2019 – Retrospectively registered, https://clinicaltrials.gov/ct2/show/NCT04214743

Clinical indicators of dry eye severity nursing outcome in intensive care unit

Objective:

to verify the extent of impairment of the clinical indicators of the nursing outcome Dry Eye Severity in patients admitted to the Intensive Care Unit.

Method:

cross-sectional, descriptive study developed with 206 patients. Based on the result listed, six indicators of the Classification of Nursing Results were evaluated with a questionnaire containing clinical variables and the Likert scale of the Classification of Nursing Results with constructed definitions, which varies from more impaired to non-impaired. The data were analyzed using descriptive and inferential statistics.

Results:

the decrease in lacrimal production and the presence of redness in the conjunctiva were more impaired. The other indicators were more frequent for the absence of impairment: incomplete eyelid closure 81% (167), excessive tearing 95.1%(196), excessive mucous secretion 78.7% (162) and decreased blinking mechanism 50.5% (104). The clinical characteristics of hospitalization for neurological disorders, invasive mechanical ventilation, chemosis, use of sedatives, vasoconstrictors, benzodiazepines, antibiotics and corticosteroids interfered in the impairment of the dry eye severity.

Conclusion:

the result indicators show that the clinical characteristics of patients in the intensive care unit interfere in the impairment and in the dry eyes severity. According to these results, the importance of assistance directed to the prevention of eye diseases is emphasized.

Neglected ocular surface care in critical care medicine: An observational study

AIM

To study the prevalence of lagophthalmos and its related complications among the unconscious patients admitted in the intensive care units (ICU)/wards of a tertiary care centre.

METHODS

Cross-sectional observational study.

RESULTS

A total of 87 unconscious patients were included. 44 were children and 43 were adults. The overall median age of patients was 16 years (range: 9 days- 85 years). 53/87 (60.91%) showed signs of lagophthalmos, among which 56.60% (30/53) were children and 43.40% (23/53) were adults. There was no significant difference in the exposure patterns between children and adults (p = 0.25). Exposure related manifestations (conjunctival/corneal) were found in 49/87 patients (56.32%). The most common conjunctival manifestation was chemosis, occurring in 28/53 patients (52.83%). Corneal exposure was seen in 31/53 patients (58.49%), of which fragile epithelium was the commonest finding (32.08%). Only 17/31 (54.83%) cornea exposed eyes were taped, of which 15 were sub-optimal. 6 patients were unnecessarily taped. Signs of infection were noted in 8/53 eyes (15.09%).

CONCLUSION

Optimal eye care in unconscious patients can avert the development of exposure-related complications and subsequent ocular morbidity. Adoption and implementation of systematic protocols can help improve the standard of care.

Predictive clinical factors for ocular dryness in patients admitted to the Intensive Care Unit

OBJECTIVE

To evaluate the predictive clinical factors for ocular dryness and for the nursing diagnosis Risk for dry eye in the ocular surface of hospitalized adult patients in an intensive care unit.

METHOD

A cross-sectional study was conducted between January and July 2016, with 206 patients (412 eyes). An inference about the presence of the diagnosis in the evaluated patients was performed by diagnostic nurses. The descriptive and inferential statistics subsidized the data analysis.

RESULTS

47.6% of the patients presented Risk for dry eye, and 52.4% were already diagnosed with ocular dryness. Statistical differences between the ocular dryness diagnosis in the right eye with hyperemia, mucous secretion, eyelid edema and lagophthalmia were identified. In addition, statistical differences were observed between hyperemia and eyelid edema with Risk for dry eye in the left eye and with the nursing diagnosis Risk for dry eye.

CONCLUSION

Hyperemia, mucous secretion, eyelid edema and lagophthalmia are the predictive clinical factors for the nursing diagnosis Risk for dry eye and also of ocular dryness in the intensive care unit environment which deserve special attention in the preventive evaluation.

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.

Effectiveness of Nursing Interventions to Prevent Dry Eye in Critically Ill Patients

BACKGROUND

Critically ill patients are susceptible to the development of dry eye. Few studies have been conducted on how to best prevent and treat this condition.

OBJECTIVE

To compare the effectiveness of 2 nursing interventions in preventing dry eye in adult intensive care unit patients: liquid artificial tears (Lacribell; Latinofarma) and artificial tears gel (Vidisic Gel; Bausch and Lomb).

METHODS

In this randomized controlled trial, 140 participants were randomly assigned to 1 of 2 treatment groups: a liquid artificial tears group (n = 70) and an artificial tears gel group (n = 70). The study inclusion criteria were as follows: admission to the intensive care unit, age of 18 years or older, no diagnosis of dry eye at admission, receipt of mechanical ventilation, blink rate of less than 5 times per minute, and a score of 7 or less on the Glasgow Coma Scale. On 5 consecutive days, a single researcher who was unaware of the treatment assignment assessed the participants' eyes using the fluorescein eye stain test and the Schirmer test for dry eye.

RESULTS

Dry eye developed in 21% of participants who received liquid artificial tears versus 9% of participants who received artificial tears gel (P = .04).

CONCLUSIONS

In this study, artificial tears gel was superior to liquid artificial tears in preventing the development of dry eye. These results may help nurses deliver evidence-based eye care aimed at reducing the risk of dry eye in critically ill patients.

Knowledge and practice patterns of Intensive Care Unit nurses towards eye care in Chhattisgarh state

Purpose

The aim of the study was to present the level of knowledge and practice patterns regarding exposure keratopathy in mechanically ventilated patients among Intensive Care Unit (ICU) nurses in Chhattisgarh state.

Methods

A previously validated semi-structured questionnaire was administered in the ICU of six multispecialty hospitals in Chhattisgarh in 2014-2015. Demography included age, gender, level of education, and months of working in ICU. Most of the questions dealt with frequency of eyelid closure assessment, frequency of cleaning of eyes with saline gauze, using a protocol-based approach for eye care, and documentation of ophthalmic complications. Common barriers to delivery of eye care such as shortage of time and too much writing tasks were also inquired.

Results

Our study included 120 nurses. They worked for mean 22.9 ± 17.8 months in ICU. Knowledge about high risk of exposure keratopathy in ventilated patient was present in 93% (78%; 95% confidence interval [CI]) nurses. Only six nurses (5%) followed a strict protocol for eye care, 52 nurses (43%) checked for eyelid closure in the ventilated patients, and 58 (48%) cleaned the eyes frequently. Those who were aware of exposure keratopathy checked eyelid closure (73% vs. 48%) and cleaned eyes with saline gauze more frequently (24% vs. 4%). Nurses in cardiac ICU were significantly lesser aware of exposure complications compared to medical ICU nurses (40% reduction in awareness, 95% CI = 0.37-0.98, P = 0.04).

Conclusion

Although there is high awareness, practice patterns of ICU nurses were less than desired. Educational initiatives should focus on weaknesses in knowledge and practice noted to improve eye care of patients in ICU.

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

Background

Exposure keratopathy (EK) has a high incidence in critically ill patients. We aimed to determine the rate of EK in patients admitted to our intensive care unit (ICU), identify risk factors for developing EK and ascertain the effectiveness of a protocol to prevent EK.

Methods

We undertook a two-phase prospective cohort single-centre study in a general adult ICU. The first phase of the study was observational. In the second phase of the study an eye care protocol was introduced. Daily ophthalmic assessment was carried out using a portable slit lamp. We also recorded Acute Physiology and Chronic Health Evaluation II score, daily Sequential Organ Failure Assessment score, mechanical ventilation, Richmond Agitation-Sedation Scale, and level of eye care. Student’s t test and χ² statistics were used for simple analysis of continuous data and categorical data, respectively. Binary logistic regression was used to analyse the relationship between EK (yes/no), as the dependent variable, and multiple independent variables, calculating unadjusted and adjusted odds ratios.

Results

We studied 371 patients. In the first phase, the overall rate of EK was 21% but the rate in mechanically ventilated patients was 56%; χ² (1, N = 257) = 80.8, p < 0.001. Adjusted odds ratios (AOR) for development of EK were 28.6 (8.19–43.37), 13.0 (3.16–54.38) and 1.2 (1.03–1.33) with incomplete eye closure, mechanical ventilation, and higher SOFA score, respectively. Following the introduction of the protocol in the second phase, the overall rate of EK reduced to 2.6% (three cases); χ² (1, N = 371) = 18.6, p < 0.001. Compliance with the protocol was 97%.

Conclusions

EK is common in critically ill patients, and is associated with mechanical ventilation and incomplete eye closure. A simple protocol substantially reduces the incidence of EK and is easily achieved in clinical practice.

Exposure keratopathy: Incidence, risk factors and impact of protocolised care on exposure keratopathy in critically ill adults. J Crit Care. 2018;44:413-418. [PMID: 29353117 DOI: 10.1016/j.jcrc.2017.11.031]

PURPOSE

We aimed to determine the rate of exposure keratopathy (EK) in critically ill patients, identify risk factors for developing EK and ascertain the effectiveness of a protocol to prevent EK.

MATERIALS AND METHODS

We undertook a two-phase prospective cohort study in a general adult ICU with first-phase being observational and an eye care protocol was introduced in the second-phase. Daily ophthalmic assessment was carried out along with recording of various risk factors.

RESULTS

We studied 371 patients. In the first phase, the overall rate of EK was 21% but the rate in mechanically ventilated patients was 56%; χ² (1, N=257)=80.8, p<0.001. Adjusted odds ratios (AOR) for development of EK was 28.6 (8.19-43.37), 13.0 (3.16-54.38) and 1.2 (1.03-1.33) with incomplete eye closure, mechanical ventilation, and higher sequential organ failure assessment score respectively. Following the introduction of the protocol, the overall rate of EK reduced to 2.6% (3 cases); χ² (1, N=371)=18.6, p<0.001.

CONCLUSIONS

EK is common in critically ill patients and a simple protocol substantially reduces the incidence of EK and is easily achieved in clinical practice.

Nurses can play an active role in the early diagnosis of exposure keratopathy in intensive care patients

AIM

This study was conducted in order to determine nurses' ability to diagnose exposure keratopathy reliably in the early stage in intensive care patients.

METHODS

This methodological and descriptive study was carried out between 2011 and 2012 in the Neurology and Anesthesiology and Reanimation Intensive Care Units of a teaching hospital in western Turkey. The sample consisted of 4354 ocular assessments in 156 corneas of 78 patients. A patient identification form and a fluorescein test patient tracking chart were used in the data collection. The corneas of the patients were checked by a fluorescein dye test by the same nurse and ophthalmologist.

RESULTS

The mean age of the patients was 59 ± 15.5 years and 47.4% of them were female. The consistency between the nurse and the ophthalmologist was almost perfect in terms of determining the presence of exposure keratopathy, characteristics, and the grade of corneal staining. Exposure keratopathy was detected at a rate of 2% by the ophthalmologist. A significant relationship was found between the presence of lagophthalmos and the development of exposure keratopathy. A positive correlation was found between the grade of corneal staining and the degree of the eyelid position of the patients and the duration of mechanical ventilation therapy.

CONCLUSION

After eye care and assessment training, intensive care nurses can play an effective role in detecting early-stage exposure keratopathy in intensive care patients.

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.