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This guideline is intended for healthcare professionals caring for patients within the Paediatric Intensive Care Unit at the Royal Hospital for Children, Glasgow.
Whilst ocular conditions may alter between different ages, this basic ocular management guidance applies for all children from neonates to teenagers. There are some important age related considerations at the end of the guideline
Medical, nursing and allied professionals caring for patients in PICU.
Most inpatient referrals can be sent via trakcare:
For more urgent referrals, or for advice, please contact 85808 Monday to Friday 9am – 5pm, except on Wednesday afternoons. For Wednesday after 1pm or out of hours, please contact ophthalmology on-call via switchboard.
Patients in intensive care are at risk of developing corneal defects as normal ocular defence mechanisms are challenged [1-7]. Sedatives and paralysis interfere with eyelid closure . Passive closure may occur, but is often incomplete . Lack of blinking fails to renew the tear film leading to the potential retention of micro-organisms. Mechanical ventilation encourages venous stasis and fluid retention, leading to conjunctival chemosis . Capillary leak and fluid shifts associated with sepsis similarly cause conjunctival chemosis . The exposed cornea becomes dry, and small defects may develop . Keratitis occurs if micro-organisms adhere to the damaged corneal surface [10,11]. Corneal defects are painful and a source of agitation, as well as being potentially blinding.
The proposed algorithm uses eyelid position and whether the patient is lying prone or not to guide treatment and been made considering guidance from the Royal College of Ophthalmologists . A randomized controlled trial comparing ocular lubricant to passive eye closure, found lubricant to be favourable . When lubricant was compared to eye taping or covering there was no significant difference between the treatments .
We have selected lubricants with/without taping as treatments in the first instance, as these are easy to use, effective and cost-efficient. Complications of this form of management are expected to be minimal. Temporary blurred vision may occur with the use of ointments. As well as protection of the cornea in at risk patients, these guidelines also discuss microbial conjunctivitis and keratitis, chemosis and the role of ophthalmology review in patients with positive fungal cultures.
Eye care algorithm for children who are intubated and ventilated
Pull down the lower eyelid and apply a small amount of eye ointment to the inside of the eyelid and manually close in poor lid closure to ensure ointment is spread over the eye. The ointment should not be applied over closed eyelids.
Ensure a different tube is used for each eye. Lubricants used should always be ointments as these last longer than drops. Hylonight should be used in the first instance, however if this is not available then carbomer gel or simple eye ointment can be used.
If drops are also required, use these prior to ointment. Wait 5 minutes between drops if multiple drops are required.
If chloramphenicol antibiotic ointment is being used, this works well as a lubricant so often the lubricant can be omitted at times where this is also being used.
Use 0.9% saline and ensure the lids are closed. Use a new piece of gauze and ensure this edge is not above the lid margin (lower lid) or below it (upper lid). Ensure the gauze swab goes from the inner to the outer canthus and dry it in the same manner.
This may be done via the following methods:
This may cause eyelid injury or irritation and can be distressing to relatives so should only be undertaken where necessary. After applying lubricant, close the lid and stick the tape (such as Micropore) onto the lid and lashes horizontally to ensure closure.
Apply a 10cm x 10cm square over each eye and change it every shift. It does not cause damage if in contact with the eyeball.
Hydrogel or silicone dressings/pads
Use with care to avoid damage to the eye, eg Kerrapro, Gelliperm may be used instead of taping if oedema prevents manual lid closure. They should be changed at least once per shift or sooner if drying out (curling edges).
These patients are more at risk due to compression and conjunctival swelling (chemosis). Lubricants and taping should be used (see algorithm) and a 3 pin head holder can also be used to avoid compression, as in spinal surgery.
The above eye care regime may be discontinued once the patient is awake, eyelid movement is re-established and extubation is performed.
This is a corneal epithelial defect which occurs in those with incomplete lid closure. It is best seen with fluorescein eye drops and a blue light preferably, but may also be visible with a white light.
In the first instance, use chloramphenicol ointment 4 times a day, increase the frequency of lubricants and consider lid taping.
Contact ophthalmology if:
If there is a corneal abrasion with full lid closure, chloramphenicol 4 times a day for 5-7 days can be used.
Conjunctival chemosis, causing swelling and bulging of the conjunctiva, is common in patients who are ventilated, particularly with positive pressure ventilation, patients with generalised oedema or those that are prone.
Chemosis can lead to poor lid closure leading to exposure of the cornea and infection. These patients can often be managed with increased lubrication and taping however refer to ophthalmology if:
Respiratory secretions may be a common source of bacteria in those in PICU, so care should be given when suctioning is being performed. This should be done from the side rather than at the head, and the eyes should be covered.
This is an infection of the conjunctiva.The eye is usually sticky with debris on the lashes and a red eye. If the eye is red without stickiness other causes should be considered. Discuss with ophthalmology if the cornea is not clear.
Conjunctivitis may be bacterial or viral. Use chloramphenicol ointment 4 times a day for 7 days and send a viral and bacterial swab. If the swab shows sensitivities to other antibiotics but there is a clinical improvement, continue chloramphenicol.
This is an infection of the cornea. Patients with exposure keratopathy are more vulnerable to this due to loss of the protective epithelial barrier. A white patch may be visible on the cornea which usually stains with fluorescein, the cornea may be hazy with a bright torch and the eye will turn red. These patients should be referred to ophthalmology.
This is a serious and rare complication of a systemic infection.The eye may be red with poor visibility of the pupil and iris with a bright torch. It should be suspected in those with a white line of pus called a hypopyon andrequires an urgent ophthalmology review. It indicates active sepsis and requires systemic treatment.
Endogenous ocular involvement from candidaemia is rare but can be sight threatening.
Recent published literature suggests a decreasing prevalence of ocular involvement in recent years, possibly due to earlier initiation of systemic therapy, and greater intraocular penetrance of newer generation antifungals.A recent local study in the adult sector of NHS GG&C suggests a prevalence of 1.3%. . This study found that no change in treatment was required as a result of positive ocular findings.
There is no published literature demonstrating ocular candidiasis in the absence of positive blood cultures.
The Royal College of Ophthalmologists guidelines  from 2020 suggests that routine screening of fungal culture positive patients is not indicated and should only be performed as an exception on a case by case basis, taking these principles into account:
No examination required: awake and asymptomatic
May need examination, refer to ophthalmology for advice: awake and symptomatic, unable to report symptoms
Must be examined: Very abnormal eye appearance eg hypopyon, cloudy pupil, possible ocular perforation etc.
Considerations to allow whether examination is required, and timing of the examination should be performed based on:
There is no indication for ophthalmology assessment of patients with no positive blood culture evidence of candida or other fungi, in the absence of other ocular symptoms or signs. Patients with positive fungal line tip cultures do not require ophthalmology review if they are asymptomatic – if there is concern blood cultures should be carried out.
Chloramphenicol 0.5% drops are contraindicated in patients under 2 (theoretical fertility issues related to boric acid) . Chloramphenicol 1% ointment does not contain boric acid so is safe to use in this age group.
Under the age of 7, sensory deprivation can irreparably damage vision causing amblyopia. In PICU, maintaining the integrity of the corneal surface to prevent corneal scarring in this age group is a priority. Sensory deprivation may be reversible.
Last reviewed: 01 March 2022
Next review: 31 March 2025
Author(s): Chloe Shipton, Eoghan Millar, Sonul Gajree, Manaim Shah, Graham Bell
Author Email(s): email@example.com
Co-Author(s): Based on the previous version from 2011 by Karen McCall, Jeanette Grady, Mangosha Hussin, Julie Richardson, Gordon Dutton