Eye care

Microbial keratitis, (or bacterial infection of the cornea) is a serious eye complaint, causing potentially devastating permanent impairment of vision. Patients in intensive care are at risk of developing this condition, as normal ocular defence mechanisms are challenged [1-7]. Sedatives and paralysis interfere with the orbicularis muscle involved in eyelid closure [8]. Passive closure may occur, but is often incomplete [1]. In addition 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 [2]. Capillary leak and fluid shifts associated with sepsis similarly cause conjunctival chemosis [9]. The exposed cornea becomes dry, and small defects may develop [3]. 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.

A recent audit of eye care within RHSC, Yorkhill, Glasgow PICU revealed an overall incidence of corneal defects of 33.3%. This is comparable to reports from other intensive care units, although the majority of previously published data are from adult populations [4-6]. Protective eye treatments, such as lubricants, artificial eye closure and moisture chambers, are effective in reducing eye injury, [1,3,8-9,12-14] but there remain no widely agreed guidelines for eye care within ICU departments [13,15]. Several authors have developed their own guidelines, and implementation of these has resulted in a lower than average incidence of corneal defects [16,17]. Recent audit of eye care within RHSC, Glasgow PICU revealed the majority (80%) of patients were receiving no formal protective eye care. Introduction of formal guidelines for eye care would therefore be expected to reduce the incidence of corneal defects.

The proposed algorithm uses eyelid position and whether the patient is lying prone or not to guide treatment. It is similar to algorithms proposed by previous authors [16,17]. It is simple to follow and includes all patients at risk of painful corneal defects. Even the fully closed eyes of at risk patients are treated, as our recent audit in Yorkhill has shown that these patients were also at risk of developing corneal epithelial damage. There is no current consensus regarding the optimal treatment for prevention of corneal defects [1,3,8-9,12-17]. A randomized controlled trial comparing ocular lubricant to passive eye closure, found lubricant to be favourable [1]. When lubricant was compared to eye taping or covering there was no significant difference between the treatments [18]. In their observational study, Ezra et al found Geliperm, a hydrocoll dressing, to be associated with a greater number of defects than lubricant or simple eye cleansing, but it was thought that the Geliperm had been incorrectly used [19]. Their later randomized controlled study found no significant difference between lubricant and Geliperm [9]. Several recent studies have evaluated moisture chambers, but have failed to agree on whether they are more effective than other treatments [3,8,12,14].

We selected simple eye ointment (a lubricant) and Geliperm as treatments, as these are easy to use, effective and cost-efficient [1,19]. Whilst Geliperm is preferable to taping of the lids, to minimize skin damage in most patients, it does not adhere to the skin in proned patients and therefore tape is used in these patients. Complications of this form of management are expected to be minimal. Temporarily blurred vision may occur with the use of lubricant, but this should not be a significant problem in the patients for whom the guidelines are intended.

• Torch (to assess eye & level of lid closure)
• Latex free non-sterile disposable gloves
• Eye assessment chart
• Simple Eye Ointment
• Sterile gallipot 0.9% saline (for cleaning eye area)
• Sterile low-linting gauze

Also required depending on level of eyelid closure:

• Polyacrylamide – for topical application to ensure eyelid closure (E.g. Geliperm)
• Micropore Tape – may be required to secure eyelid closure where polyacrylamide is not suitable.

a) Simple eye ointment should be prescribed (6 hourly, both eyes) on admission to the unit for all patients for whom the algorithm is applicable.

b) Eyelid position should be assessed and documented at the start and middle of each nursing shift (6 hourly) as follows:

• Eyelid closed
• Conjunctiva exposed (white of eye)
• Cornea exposed (white of eye and pupil/iris)

c) Application of simple eye ointment: Gently pull down the lower eyelid and apply a small amount of simple eye ointment to the inside of the eyelid

d) Use of Geliperm (figure 1): Cut a piece of Geliperm sufficiently large enough to cover both upper and lower eyelids, and place over eyelids, ensuring that lids are closed and not held open by the dressing. Geliperm should be changed 6 hourly or sooner if there are any signs of drying.

e) Closure of eyelids with geliperm and tape when patient is proned (figure 2): Micropore tape should be applied horizontally across the eyelids, to hold the upper and lower lids together.

f) If evidence of conjunctivitis, a bacterial swab should be sent to microbiology

g) If evidence of conjunctivitis, 1% chloramphenicol ointment should be prescribed and applied to both eyes 6 hourly. Stop simple eye ointment. h) If medical / nursing staff suspect corneal ulceration, the on-call ophthalmology registrar should be contacted for urgent review.

The above eye care regime may be discontinued once the patient is awake eyelid movement is re-established and extubation is planned.

Figure 1 – Application of Geliperm

Note that the eyes are fully closed. Large squares of geliperm have been applied to fully cover the eyes. The geliperm is nice and moist. Geliperm must be changed at least 6 hourly or earlier if it is showing any signs of drying out.(e.g. curling edges)

Figure 2 – Application of Geliperm with micropore tape for proned patients

Note that the eyes are fully closed. If the combination of micropore and geliperm does not keep the eyes fully closed, tape should be used alone to close the eyes

Eye examination to be formally incorporated into daily review. Specific place for comment provided on CIS under medical examination as an aide-memoire.

Institute treatment immediately.

a) Saline irrigation – 1 litre collected with a container placed by side of the face.

b) Topical Chloramphenicol drops 4 times a day for 4 days

c) Apply one drop of Fluorescein/Proxymetacaine for pain relief and to allow staining of the cornea

d) Assess staining with blue light source (ophthalmoscope)

e) If uptake of stain then refer to ophthalmology urgently

Prevention is obviously better than treatment. Follow ET taping guidelines. Apply Tinct Benz carefully with cotton bud. Eyes should be shielded with gauze prior to taping.