Thursday September 07, 2006
Eye care in ICU


Not exotic interventions but simple things make difference in patients' outcome in ICU and one of the most ignored aspect of patient care in ICU is opthalmic care. Sedatives, NMB (neuro-muscular blockers) and other meds in ICU cause eye to loose tonic contraction of the orbicularis oculi muscle, random eye movements and blink reflex. These factors interfere with tear protection of eyes as well as increase in tear evaporation by inadequate eyelid closure. Many drugs in ICU decrease secretions. All these lead to superficial or infectious keratitis.

Local hygiene play important role in eye care. One interesting study done 23 years ago found that 9 of their 10 patients have infection only in left eye because Right-handed nurses pulled the suctioning catheter away over the left side of the patient’s face 1. Another study done about 20 years ago found same organism (Pseudomonas aeruginosa) from sputum, the conjunctiva, and later the cornea 2.

Another less know eye problem in ICU is "conjunctival chemosis or edema". Increase in intraocular pressure leading to subconjunctival haemorrhage may occur with third space fluid loss which is universal in ICU patients. It gets exacerbated by positive pressure mechanical ventilation causing high intrathoracic pressure and in particular with high PEEP. Conjunctival edema also occur if the endotracheal tube is taped too tightly (due to venous congestion).

Broadly, there are 2 ways of eye care in ICU:

1. Open eye method which includes drops, gel and ointments

2. Close eye method which includes adhesive tape, saline soaked gauze, eye patches, eye shields/glasses, lower lid traction sutures etc.


Recently one study from India found that use of swimming goggles and regular moistening of eyelids with gauze soaked in sterile water providing a moisture chamber (creating close chamber, see image), is more effective than using a combination of ocular lubricants and securing tape over the eyelids (open chamber, see image) 3. But another study from UK found that Lacrilube is more effective than Geliperm or only basic eye care 4. Important thing is to be aware of dangers of exposure keratopathy.



See evidence based practice information Eye Care for Intensive Care Patients from Joanna Briggs Institute, an Affiliated Institute of the University of Adelaide, Australia.



Reference:

1. Nosocomial bacterial eye infections in intensive-care units. Lancet. 1983;1:1318-1320.

2. Eye infections caused by respiratory pathogens in mechanically ventilated patients. Crit Care Med. 1987;15:80-81.

3. Eye care in ICU - Indian J Crit Care Med 2006;10:11-14

4. Preventing exposure keratopathy in the critically ill: a prospective study comparing eye care regimes - British Journal of Ophthalmology 2005;89:1068-1069

5. A clear view: the way forward for eye care on ICU. Intensive care units. - Intensive Care Med.2000 Feb;26(2):155-6.