Original Article - Eye care in ICU

Full text

IJCCM October-December 2003 Vol 7 Issue 4 Indian J Crit Care Med January-March 2006 Vol 10 Issue 1
Original Article
Eye care in ICU
S. Sivasankar, S. Jasper*, S. Simon*, P. Jacob*, G. John, R. Raju*
Abstract
Context: Patients in intensive care units have impaired ocular protective mechanisms, resulting in a high
risk of developing eye complications. Various eye care protocols are being used, but none is proven to be
absolutely effective. Aims: To compare the efficacy of using a combination of ocular lubricants and securing
tape over the eyelids (Open chamber method), with use of swimming goggles and regular moistening of
eyelids with gauze soaked in sterile water (Closed chamber method), to prevent corneal epithelial breakdown
in the sedated and semiconscious intensive care adult patient. Settings and Design: A randomized clinical
study was performed. Patients with Glasgow coma scale score of ≤ 10/15, admitted into the Medical ICU of
a large teaching hospital, over a four month duration, were studied. Materials and Methods: Patients were
examined daily by an Ophthalmologist, using a portable slit lamp and the patient’s corneas were tested
daily using 1% Fluorescein drops. Standard grading scales were used to record eyelid position and corneal
and conjunctival changes. Statistical analysis used: Quantitative variables were described in terms of
their relative frequencies in proportions. Null hypothesis was applied to derive the statistical significance of
the observed variations in both the treatment groups. Chi-square test for relationships was used to assess
the effect of specific variables on the development of keratopathy. Results: Sixty one patients (122 eyes) in
the open chamber group and 63 (126 eyes) in the closed chamber group, were analyzed. Incomplete lid
closure was seen in 74 eyes (30%). Exposure keratopathy was noticed in 39 eyes (32%) in open chamber
group and ten (8%) in closed chamber group and was more severe in the former group. There was no
difference in the incidence of conjunctival oedema in both groups. Incomplete lid closure and use of muscle
relaxants, were significant risk factors for developing keratopathy. Conclusions: Use of swimming goggles
and regular moistening of eyelids with gauze soaked in sterile water providing a moisture chamber, is more
effective than using a combination of ocular lubricants and securing tape over the eyelids, in preventing
corneal epithelial breakdown in sedated and semiconscious intensive care unit patients.
Key words: Exposure keratopathy, Intensive care patients.
Microbial keratitis is a severe complication of corneal clear consensus defining the most effective form of eye
exposure in critically ill patients.[1] A variety of eye care protection.[2] A recent report from the United Kingdom
protocols are being used, to prevent exposure revealed that 75% of the Intensive Care Units (ICU) used
keratopathy in intensive care patients and there is no polyacrylamide gel for eye care, while 25% used ocular
lubricants.[3] Other commonly used methods include,
From: placing a securing tape in a horizontal position over the
Departments of Medical ICU and *Ophthalmology, Christian Medical College closed eye lids[4] and creating a moisture chamber to
and Hospital, Vellore, Tamil Nadu - 632004, India prevent corneal dryness.[5]
Correspondence:
Dr. George John, Department of Medical ICU, Christian Medical College and
Hospital, Vellore, Tamil Nadu - 632004, India. E-mail: yokavi@yahoo.com We carried out a prospective comparative trial to
Free full text available from www.ijccm.org
11

IJCCM October-December 2003 Vol 7 Issue 4Indian J Crit Care Med January-March 2006 Vol 10 Issue 1
compare the efficacy of using a combination of ocular
lubricants and placing a securing tape (Open chamber
method) and creating a moisture chamber by using
swimming goggles and moistening eyelids with gauze
soaked in sterile water every 12 hours (Closed chamber
method), in preventing corneal epithelial breakdown in
intensive care patients [Figures 1 and 2].
Use of closed chamber method offers better protection
against exposure keratopathy in the intensive care
patients, as compared to the use of a combination of
ocular lubricants and securing tape over the eyelids.
Materials and Methods
All patients with a Glasgow coma scale score of ≤ to
10/15 admitted over a four month period to the Medical
Intensive Care Unit of a large teaching hospital in South
India, were included in the study. Patients were
Figure 1: Open chamber method - using ocular lubricants and a
securing tape over the eyelids
Figure 2: Closed chamber method - use of swimming goggles and
moistening of eyelids with gauze soaked in sterile water to provide
a moisture chamber
randomized into one of the treatment groups at
admission. Those patients ≤ 18 years of age, spent less
than 24 hours on the unit, or with primary ocular disease
were excluded at the time of analysis.
A study proforma designed to include various medical
and ophthalmologic details was used for each patient.
Specific factors such use of muscle relaxants, Riker
sedation score and duration of stay in ICU, were
recorded. All patients were examined by an
ophthalmologist within 24 hours of admission into the
ICU and subsequently everyday, until the patient
completed the study. A patient was declared to have
completed the study if he regained spontaneous eye
opening/ died / discharged from ICU, or developed
corneal lesions.
A detailed eye examination was carried out to assess
eyelid position, pupillary reaction, intraocular pressure
and conjunctival and corneal changes. A portable slit
lamp and Perkins’s tonometer were used for bedside
evaluation. The cornea was examined for erosions, by
instillation of 1% Fluorescein drops.The grading of eyelid
position, corneal changes[9] (grades 1-6) and conjunctival
oedema (grades 1-3) are given in Table 1.
Results
A total of 146 patients were recruited. Twenty two
patients were excluded at the time of analysis. Analysis
was carried out for 122 eyes (61 patients) randomized
into the open chamber group and 126 eyes (63 patients)
into the closed chamber group. The mean age of the
Table 1: Grading for eye lid position, conjunctival
oedema and corneal changes
Eye lid position
1. Only conjunctival exposure
2. Lower 1/4th of the cornea exposed
3. Lower ½ of the cornea exposed
4. ¾th of the cornea exposed
5. Cornea fully exposed
Conjunctival oedema
Grade 0 - Absent
Grade 1 - Conjunctival oedema without dellen formation
Grade 2 - Conjunctival oedema with dellen formation
Corneal changes
1. Punctate epithelial erosions involving the inferior third of the
cornea
2. Punctate epithelial erosions involving more than the inferior
third of the cornea
3. Macroepithelial defects
4. Stromal whitening in the presence of epithelial defect
5. Stromal scar
6. Microbial keratitis
12

IJCCM October-December 2003 Vol 7 Issue 4 Indian J Crit Care Med January-March 2006 Vol 10 Issue 1
patients was 39.2 years and 42.3 years in the open
chamber and closed chamber group, respectively.
Incomplete lid closure was noticed in 74 (30%) of the
248 eyes analyzed.The extent of ocular surface exposure
of the eyes analyzed in both the groups is given in Table
2.
A total of 27 patients (21%) had exposure keratopathy.
Twenty two patients (81.5%) had bilateral lesions, while
five (18.5%) had unilateral lesions. Hence, exposure
keratopathy was noted in 49 (19.8%) of the 248 eyes in
the study.Thirty nine (32%) eyes in open chamber group
and ten (8%) eyes in closed chamber group had evidence
of corneal disease, showing a significant difference
between the two groups (
P
-value of 0.001 and chi-square
of 22.5).The extent of exposure keratopathy in both these
groups is given in Table 3. Most corneal lesions developed
within 48 hours of admission in both groups; 37 of 39
(95%) in open chamber and eight of ten (80%) in closed
chamber group. Exposure keratopathy was more severe
in the open chamber group, than in the closed chamber
group. Tarsorrhaphy was performed in one patient in the
open chamber group who had unilateral grade 4 corneal
lesions.
Grade 1 conjunctival oedema was noted in 32 eyes
(22%) in the open chamber group and 36 (28%) in the
closed chamber group. No significant difference was
observed in the incidence of conjunctival oedema (chi-
square = 0.085).
Table 2: Extent of ocular surface exposure
Open chamber Closed chamber
(Total number (Total number
of eyes-122) of eyes-126)
No corneal or conjunctival exposure 88 (72) 86 (68.2)
Only conjunctival exposure 10 (8.2) 14 (11)
Lower ¼th of the cornea exposed 18 (14.7) 20 (15.8)
Lower ½ of the cornea exposed 6 (4.9) 6 (4.8)
Figures in parenthesis are in percentage
Table 3: Extent of exposure keratopathy
Open chamber Closed chamber
(Total number (Total number
of eyes-122) of eyes-126)
No exposure keratopathy 83 (68) 116 (92)
Grade I 18 (15) 8 (6.5)
Grade II 12 (10) 2 (1.5)
Grade III 8 (6.0) -
Grade IV 1 (1.0) -
Figures in parenthesis are in percentage
The other significant problems observed were lid
abrasions and conjunctival abrasions in 15 (12%) eyes
in open chamber group and oedema of the eyelids due
to the pressure of the goggles over the globe in eight
(6.5%) eyes, in the closed chamber group.
Analysis of the influence of specific factors on the
development of keratopathy was carried out for all the
124 patients, irrespective of the eye care protocol
implemented. It was found that incomplete lid closure
and use of muscle relaxants were significantly associated
with corneal disease (
P
-values of 0.001 and 0.025
respectively). However, sedation score and mean
duration of stay in ICU had no significant effect on the
incidence of keratopathy.
All 34 eyes with incomplete lid closure at admission in
the open chamber group developed exposure
keratopathy, while only 11 (27.5%) of the 40 eyes in the
closed chamber group showed evidence of the same.
The protection against keratopathy in the presence of
incomplete lid closure in the closed chamber group
appears significant (
P
-value = 0.001).
Discussion
The ocular surface in healthy individuals is protected
by natural defence mechanisms such as bactericidal
effect of the tear film, blinking of eyelids and adequate
lid closure.[6] The tear film provides mechanical lubrication
to wash away organisms and also contains antimicrobial
substances such as immunoglobulins, lysozyme,
lactoferrin, ceruloplasmin and complement
components.[1] Use of muscle relaxants and sedation in
patients on ventilator contributes to inadequate lid closure
by decreasing the tonic contraction of ocular muscles.[7]
Thus, inadequate protective mechanisms and constant
exposure of the ocular surface to the environmental
pathogens, put the ICU patients at high risk of developing
exposure keratopathy. Eye care is therefore of paramount
importance in ICU patients, to avoid easily preventable
complications of the eye, as poor vision can have a
devastating effect on the quality of life in those who
recover.
Previous studies have reported that about 40% of
patients develop exposure keratopathy during their stay
in the ICU.[8,9] Despite the use of a variety of eye care
protocols, none has been proven to be absolutely
13

IJCCM October-December 2003 Vol 7 Issue 4Indian J Crit Care Med January-March 2006 Vol 10 Issue 1
effective and eye complications continue to be a
significant problem in ICU patients.
Our study revealed that 39 (32%) out of 122 eyes
developed exposure keratopathy with use of ocular
lubricants and securing tape, while 10 (8%) out of
126 patients had evidence of the same, when a
moisture chamber was created with use of swimming
goggles and regular moistening of the eyelids with
gauze soaked in sterile water. This reflects that use
of swimming goggles is more effective in preventing
exposure keratopathy. In a similar study, Cortese
et
al
reported that a moisture chamber is more effective
than lubricating drops, in preventing corneal
epithelial breakdown.[5] Moreover, patients in the
open chamber had more severe corneal disease and
one patient required tarsorrhaphy to facilitate
corneal healing.
Conjunctival oedema termed as ventilator eye, occurred
in 32 (22%) eyes in the open chamber group and 36
(28%) eyes in the closed chamber group. Moisture
chamber did not seem to prevent the development of
chemosis. However, it was technically more difficult to
apply a securing tape over the eyelids when chemosis
was present. Fifteen eyes (12%) in the open chamber
had conjunctival abrasions, while the tape was being
removed.
The pressure of the goggles over the eyelids caused
significant lid oedema in eight eyes (6.5%). However,
oedema subsided when the tension of the goggles was
reduced.
In this study, we have observed that incomplete lid
closure and use of muscle relaxants are the most
important predictive factors for developing exposure
keratopathy. However, it was observed that while all 34
eyes with incomplete lid closure developed corneal
disease in the open chamber group, only 11 (27.5%) of
40 eyes in the closed chamber group showed evidence
of the same. This suggests that a moisture chamber is
better in preventing keratopathy, even in those patients
with incomplete lid closure.
The main strength of our study lies in its prospective
design, systematically comparing the two different
practices. The results of our study clearly indicate that
use of closed chamber method reduces the incidence
of exposure keratopathy to 8%, compared to 32% with
use of ocular lubricants and taping the eyelids. We,
therefore, suggest the use of closed chamber method
as regular eye care practice in the intensive care units
for all sedated and semiconscious patients, to prevent
exposure keratopathy. However, regular assessment of
eye hygiene and a prompt ophthalmologic opinion
obtained early in the event of any evidence of
keratopathy, helps to minimize further complications.
Further studies to assess the benefit of combined use
of ocular lubricants and closed chamber method, are
recommended.
References
1. Kirwan JF, Potamitis T, El-Kasaby H, Hope-Ross MW, Sutton GA.
Microbial keratitis in intensive care. BMJ 1997;314:433-4.
2. Laight SE.The efficacy of eye care for ventilated patients: outline
of an experimental comparative research pilot study. Intens Crit
Care Nurs 1996;12:16-26.
3. King DJ, Healy M. Prevention of eye disease in intensive care - a
telephone survey. Int Care Med 2003;29:15.
4. Wincek J, Ruttum MS. Exposure keratitis in comatose children. J
Neurosci Nurs 1989;21:241-4.
5. Cortese D, Capp L, McKinley S. Moisture chamber versus
lubrication for the prevention of corneal epithelial breakdown. Am
J Crit Care 1995;4:425-8.
6. Parkin B, Cook S. A clear view: The way forward for eye care on
ICU. Intensive Care Med 2000;26:155-6.
7. Lenart SB, Garrity JA. Eye care for patients receiving
neuromuscular blocking agents or propofol during mechanical
ventilation. Am J Crit Care 2000;9:188-91.
8. Hernandez EV, Mannis MJ. Superficial keratopathy in intensive
care unit patients. Am J Ophthalmol 1997;124:212-6
9. Mercieca F, Suresh P, Marton A, Tullo AB. Ocular surface disease
in intensive care unit patients. Eye 1999;13:231-6.
14