Special article

Journal of the Intensive Care Society

2018, Vol. 19(4) 345–350
! The Intensive Care Society 2018
Eye care in the intensive care unit Article reuse guidelines:
sagepub.com/
journals-permissions
DOI: 10.1177/1751143718764529
Benjamin J Hearne1 , Elewys G Hearne2, Hugh Montgomery3 journals.sagepub.com/home/jics
and Susan L Lightman4

Abstract
Ocular surface disease is common in the intensive care population with 20–42% of patients developing corneal epithelial
defects. The ocular surface is normally protected by the ability to produce tears, to blink and to close the eyes with rest
or sleep. All of these mechanisms can be disrupted in the intensive care population, increasing the risk of developing
ocular surface disease. Despite the scale of the problem, eye-care protocols are commonly not instigated and docu-
mentation of eye care is often poor. This review details the risk factors for developing ocular surface disease. It also
provides evidence-based guidance on protecting the eyes in vulnerable patients, identifying diseases affecting the eye in
intensive care patients and delivering the best treatment to the eye. There is growing evidence that adherence to a
correctly performed eye-care guideline prevents the majority of corneal problems encountered in the intensive care unit.

Keywords
Eye care, intensive care, ophthalmology, eye disease, ocular surface disease

2. Identify disease affecting the eye in ICU patients,

Introduction
and specifically those which might need ophthalmic
Eye care is an important aspect of managing the crit- referral
ically ill patient, as many of the mechanisms normally 3. Deliver treatment to the eye when it is prescribed
involved in protecting the eye from infection and
injury are compromised. The ocular surface comprises It concentrates primarily on the common problems of
the sclera, an avascular cornea and conjunctival epi- the eye surface but also touches on other less common
thelium. Ocular surface disease (OSD) can involve conditions. As such, it should also be helpful to those
any of these structures and can present as: ophthalmologists asked for advice about ICU
patients. These guidelines have been reviewed and sup-
1. Direct injury to the cornea – most often a superfi- ported by the Joint Standards Committee of the
cial corneal abrasion (scratch) Intensive Care Society (ICS) and Faculty of
2. Exposure keratopathy Intensive Care Medicine (FICM).
3. Chemosis (conjunctival swelling)
4. Microbial conjunctivitis and keratitis
Risk factors
The development of OSD among intensive care unit The health of the front surface of the eye, particularly
(ICU) patients is common, affecting 23–60% of the cornea (the clear front window of the eye),
patients.1 ICU eye care protocols are sometimes haphaz- depends on the ability to produce tears, to blink and
ardly followed, and documentation of eye care is often to close the eyes with rest or sleep. Incomplete eyelid
poor. However, having a clear protocol for assessment
and intervention, which is applied rigorously and cor- 1
Anaesthetics Department, Royal United Hospital, Bath, UK
rectly, will prevent the majority of corneal problems.2,3 2
Ophthalmology Department, Royal United Hospital, Bath, UK
This document aims to provide advice and infor- 3
University College London, London, UK
4
mation for clinical staff who are involved in eye care University College London/Institute of Ophthalmology and Moorfields
in the ICU. It is primarily intended to help non- Eye Hospital, London, UK
ophthalmic ICU staff to:
Corresponding author:
BJ Hearne, Anaesthetics Department, Royal United Hospitals, NHS
1. Protect the eye in vulnerable patients, thus prevent- Foundation Trust, Combe Park, Bath BA1 3NG, UK.
ing ICU-related eye problems Email: ben.hearne@nhs.net
346 Journal of the Intensive Care Society 19(4)

closure is called lagophthalmos. All of these mechan- or irritation. It should therefore only be underta-
isms can be impaired in patients in ICU by disease ken when definitely necessary.
(e.g. facial oedema, reduced conscious level, periph- . Liberal use of lubricants into the eye: ointment
eral or central neurological injury) or treatments (e.g. (such as simple eye ointment, LacrilubeTM and
the drying effects of gas flows from CPAP or oxygen VitA-POSTM) is recommended as drops do not
masks). In particular, muscle relaxants reduce the last long enough. This needs to be applied correctly
tonic contraction of the orbicularis muscle around into the eye as demonstrated in Figure 2. Such
the eye, which normally keeps the lids closed, and action is superior to manual eye closure alone
sedation reduces blink rate and impairs (and can elim- and to the (once prevalent) application of
inate) the blink reflex. Whatever the cause, those GelipermTM.5
unable to close the eye for themselves, or in whom
blinking rates are substantially reduced, are at The action required is based on the grading of
increased risk of damage to the front of the eye. lagophthalmos (see Figures 1 and 2):
This risk is higher in those mechanically ventilated,
due to greater length of stay, use of sedative/paralys- . Grade 0 exposure (i.e. no exposure) requires no
ing drugs and the effects of positive pressure ventila- action.
tion. These risk factors are summarised in Table 1. . Grade 1 exposure requires lubrication
. Grade 2 exposure needs lubrication and taping of
the lids with Micropore tape along the lash margin.
Protecting the eye of the vulnerable
patient Eyes should be bathed with warm water first to
Assessment: Identifying those at greatest risk remove dried ointment. Before the next lubricant
application, the eye should be examined with a
of OSD
bright light to look for redness, areas of chemosis or
Assessment of eyelid closure must be done at the onset corneal dullness or opacity. If these are found, the
of the care plan, and then regularly throughout the medical staff should be alerted (and consideration of
patient’s stay. There is a strong correlation between referral for ophthalmological opinion given) and con-
lagophthalmos and the development of corneal ero- siderably increased lubrication given. New ointment is
sion, which can then lead to keratitis or corneal ulcer- applied to the eye surface: pull the lower eyelid down
ation.4 The main aim of this assessment is to grade the with a finger and insert the ointment over the top of
severity of lagophthalmos from zero to two. the lower lid into the gap between the lid and the
conjunctiva every 4 h (see Figure 2). If taping is also
performed, ointment is put in first and the eyes are
Protective measures closed.6–8 The position of the lashes is then checked as
A variety of methods can be used to protect the eyes the lashes must be clear of the cornea if iatrogenic
of ICU patients. These include: corneal abrasion is to be avoided. The outside of the
eye must be free of the lubricant ointment for tape to
. Manual closure of the eyes or taping the eyes shut. stick properly. MicroporeTM tape is then applied hori-
Lid taping is not always necessary and can be dis- zontally across the lids to seal them shut as demon-
tressing to relatives, and repeated removal may strated in Figure 2. Horizontal taping is
lead to some degree of facial skin or eyelid injury recommended, but if vertical taping is used, care

Figure 1. Schematic showing the different grades of lagophthalmos.

Hearne et al. 347

Figure 2. Schematic demonstrating action required depending on degree of lagophthalmos identified.

Figure 3. (a) Eye showing corneal abrasion without fluores- Figure 6. (a) A red eye with a white patch on the cornea, this
cein. (b) Eye showing corneal abrasion stained with fluorescein is likely microbial keratitis. (b) A red eye stained with fluores-
under blue light. cein dye showing a dendrite on the cornea, this is likely Herpes
Simplex keratitis.

Figure 4. Eye showing swollen conjunctiva (chemosis) (*).

Figure 7. An eye with a level of pus in the anterior chamber,

this is called a hypopyon (#). Suspect endogenous
endophthalmitis and request immediate ophthalmology review.

must be taken to ensure the eye remains shut and is

not open where there is no tape.
In those patients nursed prone, the eyelids and face
can become oedematous and chemosis is common. As
in all ventilated patients, exposure keratopathy
(a drying of the corneal surface) can occur.9 Direct
eye compression can occur and can be avoided using
Figure 5. (a) An eye that is red and sticky is most likely a three-pin head holder as is used for prone spinal sur-
bacterial conjunctivitis. (b) An eye that is very red but not gery.10 The eyes should always be re-lubricated every
sticky might not be conjunctivitis, so seek an ophthalmology 4 h and taped shut. Where there is severe oedema and
opinion. the swollen conjunctiva prolapses through the closed
348 Journal of the Intensive Care Society 19(4)

Table 1. Summary of common risk factors for OSD in ICU patients

Category Risk factors in ICU patients for developing OSD

Disease processes Fluid maldistribution

- Risk of facial oedema, chemosis and lid swelling.
Altered level of consciousness (low GCS)
- Reduces blink reflex and is associated with lagophthalmos
Peripheral or central neurological injury
Immunosuppression
Pre-existing eye conditions
Treatment processes Continual positive airway pressure (CPAP) and oxygen masks
- Gas flow causes drying effects of the eye.
Use of muscle relaxants or sedation
- Reduces blink rate, impairs blink reflex and is precursor to lagopthalmos.4
Mechanical positive pressure ventilation
- Increases jugular pressure, causes conjunctival oedema increasing risk of lagophthalmus.2
- Associated with increased length of stay and use of sedation and muscle relaxants.
Prone position
- Direct injury during positioning.
- Causes conjunctival oedema increasing risk of lagophthalmos.
ICU environment Length of stay
- Increased length of stay associated with increased risk of OSD.5
Respiratory micro-organisms
- Increased exposure to micro-organisms (can be multi-resistant organism).
- Increased risk of exposure from tracheal suctioning.2
GCS: Glasgow Coma Scale; ICU: intensive care unit; OSD: ocular surface disease.

eyelids, the medical staff should be contacted as the increased lubrication and lid taping if there is signifi-
eyelids may need to be temporally closed with sutures. cant unwanted corneal exposure.

Identifying diseases of the eye Chemosis

Conjunctival oedema which causes the conjunctiva to
Exposure keratopathy and corneal abrasion bulge out (chemosis) is common in ICU patients (see
The cornea can be accidentally injured and nearly Figure 4). Risk factors include compromised venous
always in ICU this is in the form of a corneal abrasion return from the ocular structures (positive pressure
(a superficial scratch removing the surface epithelium) ventilation, escalating positive end expiratory pres-
(see Figure 3). It will cause the eye to become red and sures or tight endotracheal tube taping); those states
is best seen using fluorescein dye eye drops and a blue associated with generalised oedema (such as fluid
light, where the epithelial defect glows bright yellow; a overload or hypalbuminaemia); gravitational causes
white light will also work but the injury is less of increased hydrostatic pressure (prolonged recum-
obvious. bency or prone ventilation); or states that increase
Exposure keratopathy represents a dryness of the capillary leak (such as systemic inflammatory
cornea due to incomplete lid closure allowing exces- response syndromes).14 Chemosis can cause impaired
sive tear evaporation and a consequent failure of the eyelid closure, whilst incomplete eyelid closure can
tears to spread adequately across the eye surface. It also predispose to chemosis.
manifests as a red eye, and fluorescein dye drops
reveal smaller or larger epithelial defects which look
identical to corneal abrasions. It affects 20–42% of
Microbial infections
ICU patients,11 and 60% of those sedated for >48 h The eye commonly becomes colonised with bacteria
develop corneal epithelial defects (42% within the first (in a time-dependent fashion) in ICU: as many as
week) as a result.12,13 Prolonged epithelial defects can 77% of ventilated medical patients are colonised by
cause scarring or even, in severe cases, perforation of at least one abnormal bacterial species in 7–42 days
the cornea. Secondary infection (microbial keratitis, and multiple abnormal bacteria colonise up to 40% of
see Figure 6) can occur. those with prolonged ventilation and sedation. The
Treatment of a simple corneal abrasion without most commonly isolated organisms are Pseudomonas
secondary infection can be with chloramphenicol aeruginosa, Acinetobacter spp. and Staphylococcus
ointment four times daily for five to seven days, and epidermidis.15
Hearne et al. 349

Respiratory secretions are thought to be the major develop herpes simplex keratitis which takes the
source of ocular surface infection, with aerosols from form of typical ‘‘dendrites’’ in the corneal epithelium
tracheal suctioning and direct contact from suction and/or ulcers that stain yellow with fluorescein dye,
catheters both being implicated. Pseudomonas infec- but which can also appear as non-staining grey areas
tion rates can thus be reduced if open endotracheal in the cornea (see Figure 6b). If any of these corneal
suctioning is done from the side (rather than head) of problems are seen, urgent ophthalmic help must be
the patient and with their eyes covered.2,5,14 sought.

Conjunctivitis Rare eye conditions in ICU

ICU staff should look for a sticky eye, which is usu-
ally (but not always in ICU) red (see Figure 5). Note
Endogenous endophthalmitis
that if the eye is very red but not sticky, this might This is a very serious problem caused by spread of
not be conjunctivitis and staff must seek expert oph- systemic infection in the blood stream to the inside
thalmological help. Conjunctivitis in the ICU setting of the eye. The eye may be red, although sometimes
is usually bacterial and can be very infectious and much less red than might be expected.
virulent. Without due care it can be spread to other Endophthalmitis is to be suspected if a white line is
patients and staff. visible in the eye in front of the iris, which represents a
level of pus in the anterior chamber of the eye
Management of conjunctivitis. It is wise to take a swab of (hypopyon, see Figure 7). Immediate ophthalmic
the eye discharge and send it for microbial culture help needs to be sought as this is a sight-threatening
because of the increased possibility of infection with emergency and it also indicates systemic active sepsis.
unusual organisms.
The discharge can be removed by bathing the eye-
lids with warm water, using separate gauze for each
Other problems
eye. Chloramphenicol ointment (rather than drops Other eye problems can complicate ICU care. Severe
to utilise the continued good lubrication from the or recurrent hypotension can cause blindness from
ointment) is applied in the eye four times a day for ischaemic optic neuropathy.10,16 In those ventilated
5–7 days. prone, increased intra-ocular pressures or intraorbital
pressure with marked periocular swelling can decrease
. If the microbial results suggest that the organism is ocular perfusion pressures (worse with concurrent sys-
not sensitive to chloramphenicol, but the eye is temic hypotension), leading to ischaemic optic neur-
better, leave alone and do not change this. If the opathy, central retinal artery occlusion and
eye is still sticky or red, then the ointment can be permanent visual loss.10
changed to one containing an antibiotic to which Rarely, those nursed prone can develop bilateral
the organism is sensitive, or other antibiotic drops acute glaucoma in which there is a sudden rise in
can be used in addition to simple lubricant intraocular pressure which can cause visual loss very
ointment. quickly as a result of retinal or optic nerve ischaemia.
. If the discharge and redness have not markedly In this condition, the cornea becomes cloudy and grey
improved in 48 h, the medical staff must be and the pupil becomes fixed at a mid-dilated position
informed, and ophthalmic help sought. and unresponsive to light. This needs immediate oph-
. If the cornea becomes dull or a white patch thalmic treatment.
appears, an urgent ophthalmological opinion
must be sought.
Delivering treatment to the eye
This is usually given in the form of drops or ointment.
Sometimes several different drops are required.
Microbial keratitis
The damaged cornea (for instance, that affected by . When giving several different drops, do not give
exposure keratopathy) is especially vulnerable to bac- them at the same time as one drop may wash out
terial invasion which can occur very rapidly (see another, thereby reducing its effectiveness. Ideally,
Figure 6a). Whilst superficial infection can result, allow 5 min (and at least 1 min as a minimum)
deeper infection can lead to permanent and severe between each medication.
damage, and loss of vision. . Always put drops in before ointment. The oint-
Most cases are due to bacteria and appear as a red ment is water repellent and prevents the drops
eye, which may be watery or sticky, with a corneal from getting into the eye tissues.
ulcer (an epithelial defect – which stains with fluores- . When putting in ointment in poor lid closure, after
cein dye on top of an underlying white/grey/yellowish instilling ointment manually shut eyelids to ensure
opacity). Less commonly, debilitated patients may ointment is spread over whole eye surface.
350 Journal of the Intensive Care Society 19(4)

Consent 6. Ben Parkin, Turner A, Moore E, et al. Bacterial kera-

The authors confirm that consent has been given for the titis in the critically ill. Br J Ophthalmol 1997; 81:
publication of images contained within this manuscript. 1060–1063.
7. Hilton E, Adams AA, Uliss A, et al. Nosocomial bac-
terial eye infections in intensive-care units. Lancet 1983;
Declaration of conflicting interests
1: 1318–1320.
The author(s) declared no potential conflicts of interest with 8. Lenart SB and Garrity JA. Eye care for patients receiv-
respect to the research, authorship, and/or publication of ing neuromuscular blocking agents or propofol during
this article. mechanical ventilation. Am J Crit Care 2000; 9:
188–191.
Funding 9. Mercieca F, Suresh P, Morton A, et al. Ocular surface
The author(s) disclosed receipt of the following financial disease in intensive care unit patients. Eye 1999; 13:
support for the research, authorship, and/or publication 231–236.
of this article: Hugh Montgomery is partially funded by 10. Panchabhai TS, Bandyopadhyay D, Kapoor A, et al.
the National Institute for Health Research University Acute ischemic optic neuropathy with extended prone
College London Hospitals Biomedical Research Centre. position ventilation in a lung transplant recipient. Int J
Crit Illn Inj Sci 2016; 6: 45–47.
ORCID iD 11. Hernandez EV and Mannis MJ. Superficial keratopa-
thy in intensive care unit patients. Am J Ophthalmol
Benjamin J Hearne http://orcid.org/0000-0001-6100-3975
1997; 124: 212–216.
12. Grixti A, Sadri M and Watts MT. Corneal protection
References during general anesthesia for nonocular surgery. Ocul
1. Johnson K and Rolls K. Eye Care for Critically Ill Surf 2013; 11: 109–118.
Adults, Version 2. Chatswood, NSW: Agency for 13. Werli-Alvarenga A, Ercole FF, Botoni FA, et al. Corneal
Clinical Innovation, 2014, pp.1–43. injuries: incidence and risk factors in the intensive care
2. Rosenberg JB and Eisen LA. Eye care in the intensive unit. Rev Lat Am Enfermagem 2011; 19: 1088–1095.
care unit: narrative review and meta-analysis. Crit Care 14. Suresh P, Mercieca F, Morton A, et al. Eye care for the
Med 2008; 36: 3151–3155. critically ill. Intensive Care Med 2000; 26: 162–166.
3. Dawson D. Development of a new eye care guideline for 15. Mela EK, Drimtzias EG, Christofidou MK, et al.
critically ill patients. Intensive Crit Care Nurs 2005; 21: Ocular surface bacterial colonisation in sedated inten-
119–122. sive care unit patients. Anaesth Intensive Care 2010; 38:
4. Ramirez F, Ibarra S, Varon J, et al. The neglected eye: 190–193.
ophthalmological issues in the intensive care unit. Crit 16. Bansal S, Ansons A and Vishwanath M. Hypotension-
Care Shock 2008; 11: 72–82. induced blindness in haemodialysis patients. Clin
5. Ezra DG, Lewis G, Healy M, et al. Preventing exposure Kidney J 2014; 7: 387–390.
keratopathy in the critically ill: a prospective study com-
paring eye care regimes. Br J Ophthalmol 2005; 89:
1068–1069.