ajn@lww.com AJN January 2006 Vol. 106, No.

1 72AA
Eye Care for Patients in the ICU
with muscle relaxants to facili-
tate care. Other patients may be
unconscious as a result of an
underlying medical condition
such as a head injury. Normal
eyelid closure is maintained dur-
ing sleep by the tonic contrac-
tion of the orbicularis oculi
muscle. The use of muscle relax-
ants reduces that contraction
and often results in the need for
passive eyelid closure.
Additionally, sedation may
result in a lack of random eye
movements and a loss of the
blink reflex. These factors inter-
fere with tear film coverage of
the eye. Inadequate eyelid clo-
sure permits an increase in tear
film evaporation. As a result,
patients become susceptible to
dessication (drying) of the eye.
This can be exacerbated by a
decrease in secretions caused by
medications such as atropine,
antihistamines, phenothiazines,
disopyramide (Norpace), and tri-
cyclic antidepressants. These fac-
tors seriously impair corneal and
conjunctival surface defenses.
POTENTIAL OPHTHALMIC PROBLEMS
Exposure and drying of the eye
can result in superficial ker-
atopathy, a noninflammatory
disease of the cornea. The
epithelial surface of the cornea is
compromised, and the resultant
corneal exposure can lead to
ulceration, perforation, and scar-
ring, which, though usually self-
limiting, may cause permanent
damage. Superficial corneal
abrasions are a more common
result of eye exposure.
According to a systematic liter-
ature review,
1
there are indica-
tions that corneal abrasions can
occur in ICU patients within a
relatively short time, ranging
from 48 hours to one week. In
three randomized controlled tri-
als, the incidence of such abra-
sions in this population ranged
from 3.33% to 22%. In addition,
one prospective analysis of 50
randomly selected intensive care
patients found that 40% had
corneal abrasions. Another study
suggested that up to 60% of ICU
patients who receive sedation for
longer than 48 hours will develop
them. And still another study
reported that corneal abrasions
were detected in 42% of ICU
patients, most within the first
week of admission.
Any inflammation of the
cornea (keratitis) increases the
risk of infection. Bacterial kerati-
tis is considered a dire complica-
tion associated with corneal
exposure and a compromise in
the normal tear film. Conjunct-
ivitis, which may be caused by
bacterial or viral infection,
allergy, or environmental factors,
is another risk.
Conjunctival edema (chemo-
sis; also called ventilator eye)
is viewed as the result of the
adverse effects of both ventila-
tory support and the drugs used
to facilitate it. These can generate
an acute increase in intraocular
pressure, which promotes sub-
conjunctival hemorrhage. Ocular
problems associated with ventila-
tion are thought to occur with
high intrathoracic pressure and,
Best Practice is a new column from the Joanna
Briggs Institute (JBI), Adelaide, South
Australia (www.joannabriggs.edu.au), that
will appear periodically in AJN. This install-
ment is based upon a systematic literature
review conducted by Nicole Joyce under the
supervision of JBI. It is adapted with permis-
sion from the original text by Nicole Joyce
and David Evans, PhD, that appeared in Best
Practice 2002;6(1):1-6. While care has been
taken to ensure that this article summarizes
available research and expert consensus, the
Institute has not conducted a formal update
since the original publication, and no liability
can be accepted as a result of reliance on the
procedures described. [Editors note: An intro-
duction to Best Practice and JBI appears on
page 82.]
CRITICAL CARE EXTRA
A
ll patients in acute
care settings who
have impaired or
compromised pro-
tective mechanisms
are at risk for eye infection or
injury during their stay. Those
who are unconscious, sedated,
or paralyzed are at especially
high risk.
The incidence of eye disorders
in the intensive care population
is difficult to quantify. Factors
may include poor documenta-
tion and the fact that eye care is
often seen as a relatively minor
concern when the patient is criti-
cally ill. Eye complications can
range from mild conjunctival
infection to serious corneal
injury. Permanent ocular damage
may result from ulceration, per-
foration, vascularization, and
scarring of the cornea.
LOSS OF PROTECTIVE MECHANISMS
People admitted to ICUs often
require mechanical ventilation,
and the majority of these
patients are sedated to ensure
comfort and facilitate treatment.
Some patients may be paralyzed
t

conjunctiva prolapse beyond the
eyelids, this can cause corneal
drying and defective epithelial
repair.
The literature search found no
studies that had investigated
interventions to prevent conjucti-
val edema or infection. The lack
of research in this area makes
determination of both the scope
of these problems and the effec-
tiveness of treatments difficult.
REVIEW FINDINGS
Eye care procedures often vary
considerably from one institu-
tion to another. Interventions
may be grouped into four cate-
gories: eye hygiene, preventing
dry eyes, ensuring eyelid closure,
and programs of eye care.
The literature search identi-
fied six clinical trials that evalu-
ated the effectiveness of eye care
interventions: three randomized
controlled trials, one controlled
trial, one uncontrolled trial, and
a before-and-after study. It
should be noted that results
from the three randomized con-
trolled trials are relevant in more
than one intervention category,
as these trials evaluated a range
of interventions.
Eye hygiene. Cleansing meth-
ods typically included the use of
sterile packs containing sterile
water, cotton balls, and a gallipot
(a small vessel to hold solution);
irrigation with normal saline; or
gauze soaked in normal saline or
sterile water. Despite many sug-
gestions in the literature regard-
ing hygiene regimens or regular
cleansing of the eye, no research
was identified evaluating this
aspect of eye care.
Preventing dry eyes. A vari-
ety of approaches have been used
to maintain the tear film and pre-
vent corneal dessication, including:
moisture chambers created by
using polyethylene film to
cover the eye covers)
methylcellulose drops
methylcellulose ointment
general lubricants
polyacrylamide gel
paraffin gauze dressing
hypromellose drops (artificial
tears)
lubricating prophylactic
antibiotics
Two randomized controlled
trials were identified that evalu-
ated methods to prevent the dry-
ing of the ocular surface. One
trial investigated the effectiveness
of eye drops, the other, eye oint-
ments. The effectiveness of these
two interventions was measured
in terms of their ability to pre-
vent corneal abrasions.
Eye drops. A single random-
ized controlled trial compared
the effectiveness of regular instil-
lations of methylcellulose drops
(Methopt Forte) to that of poly-
ethylene film covers (Gladwrap)
over the eyes. The polyethylene
film group had significantly
fewer corneal abrasions (one
person out of 30) than did the
methylcellulose drops group
(eight people out of 30).
Eye ointments. Two random-
ized controlled trials examined
the instillation of ointments for
the prevention of corneal abra-
sions. One trial compared the
effectiveness of artificial-tear
ointment (Duratears) to that of
passive eyelid closure. Passive
eyelid closure in this trial con-
in particular, with the use of posi-
tive end-expiratory pressure
(PEEP) of 5 cm H
2
O or higher.
Exacerbation of conjunctival
edema has been said to occur if
the tape securing the endotra-
cheal tube is too tight. This can
compromise venous return from
the head, leading to venous con-
gestion and potentially increasing
intraocular pressure. Conjunc-
tival edema may lead to inade-
quate eyelid closure; if the
72BB AJN January 2006 Vol. 106, No. 1 http://www.nursingcenter.com
CRITICAL CARE EXTRA
Levels of Evidence
All studies were categorized
according to the strength of the evi-
dence, based on the following revised
classification system.
2
Level 1: The evidence was obtained
from a systematic review of all rele-
vant randomized controlled trials.
Level 2: The evidence was obtained
from at least one properly designed
randomized controlled trial.
Level 3.1: The evidence was
obtained from well-designed,
pseudorandomized (randomized by
alternate allocation or other
method), controlled trials.
Level 3.2: The evidence was
obtained from cohort studies with
concurrent controls and nonrandom-
ized allocation, case-control stud-
ies, or interrupted time (multiple
observations over time) series with
a control group.
Level 3.3: The evidence was
obtained from comparative studies
with historical controls, two or more
single-arm studies, or interrupted
time series without a control group.
Level 4: The evidence was obtained
from case series, either posttest or
pretest and posttest.
t
instilled products in reducing
corneal abrasions.
Ensuring eyelid closure. Num-
erous approaches have been used
to ensure eyelid closure, including
adhesive tape, treated gauze, eye
patches, and temporary sutures,
but none have yet been evaluated.
However, one study found that
passive eyelid closure performed
by nurses was significantly less
effective at preventing corneal
abrasions than was the use of arti-
ficial tear ointment (Duratears).
Eye care programs. The liter-
ature suggests that attempts have
been made to standardize eye
care in ICUs through education
of staff, development and imple-
mentation of eye care algo-
rithms, and development of
general guidelines for eye care.
However, although specific pro-
grams of eye care have been pro-
posed in the literature, none
have been evaluated by random-
ized controlled trials.
Impact on the family. One
paper noted that placing
Gladwrap over the eyes of a
patient in the ICU had a signifi-
cant impact on the patients
appearance; anecdotal informa-
tion suggests that this and other
sisted of the nurse physically
closing the eyelids. Fewer corneal
abrasions occurred in the artifi-
cial-tear ointment group (two
people out of 25) than occurred
in the passive eyelid closure
group (nine people out of 25).
The other trial examined the
effectiveness of hypromellose
ointment (Lacrilube) applied
every two hours to that of poly-
ethylene film covers. The results
suggested that there was no sig-
nificant difference in the inci-
dence of corneal abrasions
between the hypromellose oint-
ment group (four people out of
60) and the polyethylene film
group (none out of 50).
Polyethylene film covers. Two
randomized controlled trials
evaluated the use of polyethylene
film covers as a measure to pre-
vent dry eyes. Both trials com-
pared the efficacy of polyeth-
ylene film covers to that of
instilled eye products (methylcel-
lulose drops in one trial and
hypromellose ointment [Lacri-
lube] in the other). The findings
were then pooled in a meta-
analysis, which demonstrated a
significant difference in favor of
polyethylene film covers over
Polyethylene film covers
are more effective at reducing
the incidence of corneal abrasions
than are ointments and drops.
eye care interventions may also
have significant effects on family
members. However, this issue
has not yet been investigated.
RECOMMENDATIONS
In summary, although many eye
care interventions and products
are used, or are recommended for
use in the literature, few have
been evaluated in the intensive
care setting. The following recom-
mendations are based on the find-
ings of three small randomized,
controlled trials (level 2 evidence):
Eye care should be part of the
care provided to all people
upon admission to ICUs.
Polyethylene film covers are
more effective at reducing the
incidence of corneal abrasions
than are ointments and drops.
Ointments and drops are
more effective at reducing the
incidence of corneal abrasions
than is no eye instillation.
Further research is urgently
needed.
For more information, con-
tact the Joanna Briggs
Institute, Level 4, Margaret
Graham Building, Royal
Adelaide Hospital, Adelaide
5000, SA, Australia; +61-8-
8303-4880; or visit www.
joannabriggs.edu.au.
REFERENCES
1. Joyce N. Eye care for the intensive
care patienta systematic review.
Adelaide, Australia: The Joanna Briggs
Institute for Evidence Based Nursing
and Midwifery; 2002. No. 21.
2. National Health and Medical
Research Council. A guide to the
development, evaluation and imple-
mentation of clinical practice guide-
lines. Canberra, Australia: The
Council; 1999: http://www.nhmrc.
gov.au/publications/_files/cp30.pdf.
CRITICAL CARE EXTRA t
72DD AJN January 2006 Vol. 106, No. 1 http://www.nursingcenter.com