Eye Care Guideline for Adult Critical care

Publication: 30/07/2007  
Next review: 28/04/2025  
Clinical Protocol
CURRENT 
ID: 1156 
Supported by: Critical Care CMT
Approved By: ACC clinical governance 
Copyright© Leeds Teaching Hospitals NHS Trust 2022  

 

This Clinical Protocol is intended for use by healthcare professionals within Leeds unless otherwise stated.
For healthcare professionals in other trusts, please ensure that you consult relevant local and national guidance.

Eye Care Guideline for Adult Critical care

Summary of Guideline

This guideline applies to all patients in a critical care setting and to all practitioners who have developed a competency in this procedure. It includes aims and objectives, background information, assessment, nursing cares and interventions.

Please also refer to the Intensive Care Society  guidance Eye Care in the Intensive Care Unit 

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Aims

To improve the diagnosis and management of corneal complications and eye care associated with critical illness.

  • To prevent potential harm/trauma
  • To treat any identified problems

To replace any physiological functions that are compromised / absent.

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Background

Vision is one of the main senses and means of communication for most people. Impaired vision, therefore, can contribute to delirium. Treatments for critical illness, especially sedation and paralysis, may impair a patient’s ability to maintain their own ocular health.  Identified ocular problems should be prevented and treated where possible. Ocular health needs and risks should be assessed to identify whether or not interventions are needed (Woodrow, Elliot & Beldon, 2013). 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, ophthalmic complications are frequently overlooked (Grixti et al 2012a).

Definitions (Rosenberg et al 2008) 

Lagophthalmos - Pathologic incomplete closure of the eyelids

Keratitis - Inflammation of the cornea

Keratopathy - a non-inflammatory disease of the cornea

Chemosis - conjunctival swelling

Sceritis - inflammation of the sclera

Endophthalmitis - inflammation affecting the interior of the eyeball

Blepharitis - inflammation of eyelash follicles and sebaceous glands (Woodrow, Elliot & Beldon, 2013)

Sedation and muscle paralysis cause impaired blink reflexes and loss of eyelid muscle tone, while fluid balance and positive pressure ventilation may lead to chemosis. These factors often result in incomplete lid closure and consequent exposure keratopathy (McHugh et al, 2008, Hisham et al 2012). Excessive volume depletion impairs ocular perfusion resulting in desiccation and prevents restoration of damaged cells. Volume overload provokes conjunctival oedema and exposure keratopathy secondary to lagophthalmos (Grixti et al 2012a). Tears contain antimicrobial chemicals therefore insufficient tear production or spread across the eyes exposes the eye to potential infection. Clean gloves should be worn during eye care to prevent transferring skin-surface microorganisms into the patient’s eye. Separate eye drops, lubricants (Lacrilube is the lubrication of choice at LTHT) and pads should be used for each eye to prevent micro-organisms being transferred between eyes. Suspected ocular infections should be reported to relevant practitioners and topical antibiotics prescribed (Woodrow, Elliot & Beldon, 2013)

The most prevalent ocular disorders identified in ICU patients are exposure keratopathy (3.6% -60%) with a peak incidence between 2 and 7 days from admission, chemosis (9%-80%) and microbial keratitis (Grixti et al 2012a). Soner et al (2014) found that the incidence of exposure keratopathy decreased significantly following the education of ICU staff in eye care and eye diseases and the use of a simple eye care protocol.

Risk factors include

  • Sedation / paralyzing agents / impaired conscious level affecting spontaneous blink reflex
  • Exposure and drying of the ocular surface
  • Preexisting ocular conditions
  • Acute head, ocular or orbital trauma and facial paralysis
  • Positive pressure mechanical ventilation
  • Nursing the patient in the prone position
  • Infected respiratory secretions +/- open suction
  • High flow oxygen and nebulisers
  • Metabolic derangements and multiple organ dysfunction and fluid imbalance.
  • Trauma to the eyes from equipment eg ventilator tubing, linen.
  • Medications eg antihistamines, atropine, muscle relaxants.

(Sonor et al, 2014, Grixti et al 2012b, Woodrow, Elliot & Beldon, 2013).

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Assessment

Specific eye care needs are to be assessed within 6 hours of admission and then a minimum of once a shift. Unnecessary eye opening for assessment can contribute to corneal drying. The initial assessment should include history from family and assessment for any foreign bodies / contact lenses. The admission and ongoing assessment should include the risk factors for eye problems, the ability of the patient to blink and maintain complete eye closure, the evaluation of the eye and eyelid for cleanliness, corneal dryness or discolouration, eye care interventions and the effectiveness of those interventions (Johnson & Rolls 2014).

Patients with identified eye problems will have a documented individual plan of care including frequency of assessments, types of ointments and dressings used. Referral to an Ophthalmologist as dictated by the assessment.

The plan of care will be updated each shift.

Using the assessment tool below, record in the nursing care plan and on the 24 hour chart the number (1-6) that best indicates the condition of the patients’ eyes.  More than 1 condition can be present at any one time.

Staff should adhere to LTH standard universal precautions and hand hygiene policies prior to all procedures. Full explanations and reassurance should be given to the patient at all times and dignity maintained.

Assessment

Rationale and Treatment

1. Adequate blink reflex and clear corneas

Reassess 6-12 hourly.

2. Reduced or absent blink reflex.

Instil prescribed ocular lubricant and reassess 4 hourly.

3. Incomplete lid closure.

Conjunctival exposure (any white of the eye) requires lubrication.

Any corneal exposure requires lubrication and taping of the lids horizontally along the lash line.

4. Crusting.

Clean with sterile water and reassess 4 hourly.

5. Corneal clouding/visibly dry eyes

Inform medical staff/ophthalmology doctor. Instil prescribed ocular ointment.  Reassess 4 hourly.

6. Redness, discharge, Inflammation.

Inform medical staff.  Use individual prescribed treatments.

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Investigation

If there are signs of infection and needs for swabs are indicated. Follow instructions in Marsden Manual ch8.3

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Treatment / Management

The existing literature supports the use of lubricants and the use of regular eye hygiene to prevent complications (Johnson & Rolls 2014, Demirel et al 2014).

Equipment

Sterile gauze, sterile water, examination gloves, any prescribed drops, ointments, lubrication.

Action

Rationale

Following assessment

Wash hands, apply apron and gloves.

Reduces the potential for infection.

Explain procedure.

Ensures patient understands and gives co-operation.

Position patient with head tilted back if possible.

Allows for comfort and ease of eye care.

Always treat any unaffected eye first.

Avoids cross infection.

Moisten gauze with sterile water, taking care not to saturate it.

Excess water can possibly contaminate the other eye. Cotton wool must not be used as fibres can scratch the cornea.

Wiping once from the nasal edge outwards clean the eyelid but avoid touching the cornea.

Avoids swabbing discharge into the lachrymal duct or across the bridge of the nose into the other eye.  Reduces risk of corneal abrasion.

Repeat with new gauze until lid is clean.

Reduces risk of infection.

With a new piece of sterile gauze remove excess water, dry eyes and ensure patient is comfortable.

Leaves no discomfort for patient.

Repeat the procedure  with fresh gauze to the other eye

Prevents cross infection

If lid closure is incomplete apply prescribed ocular lubricant 4 hourly

Provides artificial lubrication. 

If patient is awake, provide explanation and use eye pad to promote eye closure

Helps alleviate fear.  Use of eye pads is more comfortable than tape.

Evaluate, document and report any changes in eye condition.  Take swabs as necessary.

Monitors trends and effectiveness of treatment.

NB If nursing the patient prone; assess the eyes 2-4 hourly especially for signs of chemosis and oedema, apply prescribed ocular lubricant and cover both eyes with eye pads secured with tape. Tilt whole bed in head elevated position to reduce the risks due to the raised intraocular pressure.

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Appendix 1 - Eye care benchmarking

Provenance

Record: 1156
Objective:

To provide evidence-based recommendations for appropriate diagnosis, investigation and management of eye care in critically ill patients

Clinical condition:

Eye Care

Target patient group: Critically ill patients
Target professional group(s): Secondary Care Doctors
Secondary Care Nurses
Adapted from:

Evidence base

References  and Evidence levels:

Alavi NM, Sharifitabar Z, Shaeri M, Hajbaghery MA (2013) An audit of eye dryness and corneal abrasion in ICU patients in Iran. British Association of Critical Care Nurses Vol 19.  No 2 73-77                                               

Dawson, D (2005) Development of a new eye care guideline for critically ill patients. Intensive and Critical Care Nursing. 21.2 119-122                  

Demirel S, Cumurcu T Firat P et al (2014). Effective management of exposure keratopathy developed in intensive care units: the impact of an evidence based eye care education program. Intensive Care Nursing. 30.1 38-44                                                                                                        

Grixti A, Sadri M, Edgar J et al. (2012a) Common ocular surface disorders in patients in intensive care units. Ocular Surface; 10(1):26-42

Grixti A, Sadri M, Datta AV, (2012b) Uncommon ophthalmologic disorders in intensive care unit patients. Journal of Critical Care; 27 746.e9-746e22

Jammal H, Khader Y, Shihadeh W et al. (2012) Exposure keratopathy in sedated and ventilated patients. Journal of Critical Care 27. 6 Dec 537-541

Kam R, Hayes M, Joshi, N. (2011) Ocular care and complications in the critically ill. Trends in Anaesthesia and Critical Care. Vol 1 Issues 5-6 Dec  257-262

Johnson K, Rolls K (2014) Eye Care for Critically Ill Adults SHPN (ACI) 140005 NSW Agency for Clinical Innovation, Intensive Care Coordination and Monitoring Unit.

Lightman S, Montgomery H, (June 2017) Eye Care in the Intensive Care Unit, Intensive Care Society guidelines  http://www.ics.ac.uk/ICS/GuidelinesAndStandards/GeneralGuidance.aspx

McHugh J, Alexander P, Kalhoro A, Ionides A (2008) Screening for ocular surface disease in the intensive care unit. Eye 22, 1465-1468

Rosenberg, JB Eisen LA. (2008) Eye care in the intensive care unit: narrative review and meta-analysis. Critical Care Medicine 36.12: 3151-3155

Royal Marsden Manual of Clinical Nursing Procedures 9th Edition http://www.rmmonline.co.uk/

Woodrow P, Elliot J, Beldon P (2013) ch 12 assessment and care of tissue viability, mouth and eye hygiene needs in Critical Care Manual of Clinical Procedures and Competencies, ed Mallett J, Albarran JW, Richardson A. Wiley Blackwell.

Approved By

ACC clinical governance

Document history

LHP version 5.0

Related information

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