Elsevier

The Ocular Surface

Volume 10, Issue 1, January 2012, Pages 26-42
The Ocular Surface

Clinical Practice
Common Ocular Surface Disorders in Patients in Intensive Care Units

https://doi.org/10.1016/j.jtos.2011.10.001Get rights and content

Abstract

Ocular surface disorders are frequently encountered in patients in Intensive Care Units (ICUs). Because of significant impairment of major organs, treatment is focused on the management of organ failures. Therefore, ophthalmological complications are frequently overlooked in this setting. To identify the types and frequencies of ocular surface disorders reported in patients in ICUs, a literature review using the keywords: Intensive Care; Eye care; ICU; ITU; Ophthalmological disorders; Eye disorders was performed. The databases of CINAHL, PUBMED, EMBASE and COCHRANE library were searched. The higher quality papers are summarized in tables with statements of methodology to clarify the level of evidence. The most prevalent ocular disorders identified in ICU patients were exposure keratopathy (3.6% to 60%), chemosis (9% to 80%), and microbial keratitis. Of the various eye care measures that have been advocated to prevent exposure keratopathy, the most effective is the application of moisture chambers or polyethylene covers. Early diagnosis and effective treatment will help to prevent microbial keratitis and visual loss.

Introduction

Patients in the intensive care unit (ICU) often have impaired ocular protective mechanisms as a result of metabolic derangements, multiple organ dysfunction, mechanical ventilation, and decreased level of consciousness. Such patients are at increased risk of ocular surface disorders, which, if not resolved, can result in serious visual impairment.1, 2 Moreover, in the ICU setting, the medical staff is primarily concerned with stabilization of vital bodily functions, including the cardiovascular, respiratory, and neurological status. Sedated ICU patients are incapable of protecting their eyes and may be unable to convey ophthalmological complaints. Because ICU staff members may lack awareness of the risk of injury and fail to perform regular ocular screening, ophthalmological disorders may go unrecognized.2, 3, 4

Section snippets

Method of Literature Search

A literature search was performed, using the keywords Intensive Care, Eye care, ICU, ITU, Ophthalmological disorders, Eye disorders. The search engines of CINAHL, PUBMED, EMBASE and COCHRANE library were all used in the initial search. A manual search was also performed on the reference lists of all papers relevant to the topic.

A total of 714 hits were provided through the search engines. The abstracts of these papers were reviewed by the first and second authors separately, and 165 papers were

Physiological Mechanisms of Eye Protection

In a healthy individual, the eyelids offer a mechanical barrier to the eye against trauma, desiccation, and adherence of microorganisms.5, 6, 7, 8 The blink reflex is necessary for adequate distribution of the tear film over the ocular surface.1, 2, 9 Muscle tonus of the eyelids during sleep is the exact converse of that found during waking. There is a tonic muscular activity in the orbicularis oculi muscle with a concomitant inhibition of tonus of levator palpebrae superioris.10 The lipid

Prevalence

Breakdown of the innate physiological eye protective mechanisms will predispose to ocular surface damage.27 Exposure keratopathy has been reported to occur in 3.6% to 60% of ICU patients, with a peak incidence between 2 and 7 days from admission.14, 28 The major studies on the prevalence and predisposing factors for ocular surface disorders in ICUs are summarized in Table 1.2, 6, 15, 28, 29, 30 A prospective audit designed by Dawson identified a similar rate of ocular surface disease in 37.5%

Conclusion

A review of the current literature shows a significantly high prevalence of ocular surface disease in the ICU setting. Furthermore, considerable variability exists in eye-care management among different ICUs. A number of studies established moisture chambers or polyethylene covers to be more effective than conventional treatments for preventing corneal desiccation and exposure keratopathy. Such methods may be particularly useful in patients with chemosis and lagophthalmos. They may also serve

References (102)

  • R.D. Herr et al.

    Clinical comparison of ocular irrigation fluids following chemical injury

    Am J Emerg Med

    (1991)
  • D. Vaede et al.

    Preservatives in eye drops: toward awareness of their toxicity

    J Fr Ophthalmol

    (2010)
  • T. Kojima et al.

    The effect of autologous serum eyedrops in the treatment of severe dry eye disease: a prospective randomized case-control study

    Am J Ophthalmol

    (2005)
  • C. Creuzot-Garcher et al.

    Treating severe dry eye syndromes with autologous serum

    J Fr Opthalmol

    (2004)
  • S.E. Laight

    The efficacy of eye care for ventilated patients: Outline of an experimental comparative research pilot study

    Intensive Crit Care Nurs

    (1996)
  • E. Hilton et al.

    Nosocomial bacterial eye infections in intensive-care units

    Lancet

    (1983)
  • W.L. Hutton et al.

    Atypical Pseudomonas corneal ulcers in semicomatose patients

    Am J Ophthalmol

    (1972)
  • A. Thakur et al.

    Chemotactic activity of tears and bacteria isolated during adverse responses

    Exp Eye Res

    (1998)
  • L. Herbert

    Ophthalmology in anaesthesia and intensive care

    Anaesthesia Intensive Care Medicine

    (2004)
  • N. Cimolai

    Ocular methicillin-resistant Staphylococcus aureus infections in a newborn intensive care cohort

    Am J Ophthalmol

    (2006)
  • E. Percivalle et al.

    A comparison of methods for detecting adenovirus type 8 keratoconjunctivitis during a nosocomial outbreak in a neonatal intensive care unit

    J Clin Virol

    (2003)
  • J. McHugh et al.

    Screening for ocular surface disease in the intensive care unit

    Eye

    (2008)
  • L.R. Sorce et al.

    Preventing corneal abrasions in critically ill children receiving neuromuscular blockade: A randomized, controlled trial

    Paediatr Crit Care Med

    (2009)
  • J.F. Kirwan et al.

    Microbial keratitis in intensive care

    BMJ

    (1997)
  • F. Mercieca et al.

    Ocular surface disease in intensive care unit patients

    Eye

    (1999)
  • B. Parkin et al.

    A clear view: the way forward for eye care on ICU

    Intensive Care Med

    (2000)
  • I.K. Gipson

    The ocular surface: The challenge to enable and protect vision. The Friedenwald Lecture

    Invest Ophthalmol Vis Sci

    (2007)
  • W.M. Hart

    The eyelids

  • A.J. Hall

    Some observations on the acts of closing and opening the eyes

    Br J Ophthalmol

    (1936)
  • G.R. Trees et al.

    Effect of artificial tear solutions and saline on tear film evaporation

    Optom Vis Sci

    (1990)
  • M. Rolando et al.

    The ocular surface and tear film and their dysfunction in dry eye disease

    Surv Ophthalmol

    (2001)
  • N. Koroloff et al.

    A randomized controlled study of the efficacy of hypromellose and Lacri-lube combination versus polyethylene/Cling wrap to prevent corneal epithelial breakdown in the semiconscious intensive care patient

    Intensive Care Med

    (2004)
  • E. Germano et al.

    Incidence and risk factors of corneal epithelial defects in mechanically ventilated children

    Crit Care Med

    (2009)
  • T. Krupin et al.

    Decreased basal tear production associated with general anesthesia

    Arch Ophthalmol

    (1977)
  • P. Suresh et al.

    Eye care for the critically ill

    Intensive Care Med

    (2000)
  • J.L. Johnson et al.

    An unusual case of corneal perforation secondary to pseudomonas keratitis complicating a patient’s surgical/trauma intensive care unit stay

    Am Surg

    (2000)
  • E. White et al.

    The aetiology and prevention of peri-operative corneal abrasions

    Anaesthesia

    (1998)
  • J.B. Rosenberg et al.

    Eye care in the intensive care unit: Narrative review and meta-analysis

    Crit Care Med

    (2008)
  • F. Ramirez et al.

    The neglected eye: Ophthalmological issues in the intensive care unit

    Crit Care Shock

    (2008)
  • S.B. Lenart et al.

    Eye care for patients receiving neuromuscular blocking agents or propofol during mechanical ventilation

    Am J Crit Care

    (2000)
  • D.M. Maurice

    The Von Sallmann Lecture 1996. An ophthalmological explanation of REM sleep

    Exp Eye Res

    (1996)
  • D.G. Ezra et al.

    Assessment of corneal epitheliopathy in the critically ill

    Intensive Care Med

    (2005)
  • H. Imanaka et al.

    Ocular surface disorders in the critically ill

    Anesth Analg

    (1997)
  • I. Desalu et al.

    Ocular surface disorders in intensive care unit patients in a sub-saharan teaching hospital

    Internet Journal of Emergency and Intensive Care Medicine

    (2008)
  • E.G. Oh et al.

    Factors related to incidence of eye disorders in Korean patients at intensive care units

    J Clin Nurs

    (2009)
  • N. Joyce

    The Joanna Briggs Institute for Evidence-Based Nursing & Midwifery. Eye care for intensive care patients

    Best Practice

    (2002)
  • J. Wincek et al.

    Exposure keratitis in comatose children

    J Neurosci Nurs

    (1989)
  • E.K. Mela et al.

    Ocular surface bacterial colonization in sedated intensive care unit patients

    Anaesth Intensive Care

    (2010)
  • J. Wong et al.

    Non-hormonal systemic medications and dry eye

    Ocul Surf

    (2011)
  • J. Katz et al.

    Corneal exposure during sleep (nocturnal lagophthalmos)

    Arch Ophthalmol

    (1977)
  • Cited by (77)

    View all citing articles on Scopus

    The authors have no proprietary or commercial interest in any concept or product discussed in this article.

    Single-copy reprint requests to Andre Grixti, MD (address below).

    View full text