Eye Care (Adult Critical Care)

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Title of Guideline –
Eye Care within Adults Critical Care Critical
Date First Issued: 2009

Latest Re-Issue Date:
2012

Version: 1

Review Date: 2015

Author and Job Title:

Local Contact
including job title and
Ext. No.

Anne Illsley,
Service Improvement Sister, Critical Care

Document Derivation:
No specific Guidelines for eye care within
Critical Care

Service Improvement
Sister ext 59820
Consultation
Process:
Critical Care Cross
Town Policies and
Guidelines Group.
Critical Care
Directorate

Ratified by:

Distribution:

Critical Care Cross Town Polices and
Guidelines Group

City Critical Care
C Floor Critical Care
QMC Campus
E Floor Critical Care
QMC Campus
Medical High
Dependency Unit

Plans for training on/implementing
guideline:

Plans for audit of
guideline:

Training continuous

Audit identified.

This guideline has been registered with the Trust. However, clinical
guidelines are guidelines only. The interpretation and application of
clinical guidelines will remain the responsibility of the individual
clinician. If in doubt contact a senior colleague or expert. Caution is
advised when using the guidelines after the review date.

Eye Care Within Adult Critical Care
General Eye Care Guidelines (refer also to NUH Trust Nursing
practice guidelines: eye care package)

Introduction
Eye care is recognised as a basic nursing procedure essential for critically ill patients to
prevent complications such as eye infection or injury. It is one of the most important, yet
simple to perform nursing interventions. All patients in acute care settings who have
impaired or compromised protective mechanisms are at risk of eye injury or infection during
their stay in Hospital (Briggs, 2002).
Unconscious, sedated and / or paralysed patients and patients with a reduced Glasgow
Coma Score are high risk groups who are dependent on eye care to maintain the integrity
of the ocular surface (Briggs, 2002).
There is evidence that eye care is a neglected area of patient care in the critically ill, as
health professionals are mainly concerned with the stabilisation of vital body systems
(Suresh,P.,Mercieca,F.,Morton,A.,Tullo,A.B., 2000; Dawson,2005) – eye care is often seen
as a relatively minor problem (Briggs, 2002).
Eye complications can range from mild infections to serious corneal injury and ulceration.
Permanent damage may occur from ulceration, vascularisation and scarring of the cornea
(Briggs, 2000).
Parkin and Cook (2000) argue that preventative measures in eye care should be simple,
quick and effective in preventing complications whilst being acceptable to both patients and
staff.
Implementation of Eye Care Guidelines have been shown to reduce eye surface disease
(Dawson, 2005; Rosenberg, J.B. and Eisen, L.A., 2008). To ensure effectiveness and
compliance with the guideline, training methods will need to be developed; providing
education to the multidisciplinary team is a vital part of any successful change programme
(Thurston and King, 2004).
Injuries and infections to the eye as a result of the critically ill patients environment and
treatment therapy can result in damage and sometimes permanent damage to the eye, it is
therefore imperative that Eye care Guidelines for the Critically Ill Patient are devised and
implemented.

EYE CARE WITHIN ADULT CRITICAL CARE
ANNE ILLSLEY SERVICE IMPROVEMENT SISTER, CRITICAL
CARE

November 2011

1

Inclusion Criteria:
This Guideline is to be used for all patients admitted onto Adult Critical Care within
Nottingham University Hospitals.

Risk Factors
Risk factors for the Critically Ill Adult include:











Exposure and drying of the ocular surface
Inadequate blinking and drying of the ocular surface
Infected respiratory tract secretions
Fluid mal-distribution
High flow oxygen and nebulisers
Increased ocular pressure
Positive pressure ventilation
Nursing the patient in the prone position
Sedation / paralysing agents impair normal / protective mechanisms and eye
closure
Decreased resistance to infection

Lid Closure
Eye lids offer mechanical and physical protection.
Critically ill patients frequently have poor eyelid closure and a reduced ability to use the
protective blink reflex due to the effects of sedation and muscle relaxants used to enable
other aspects of care (Dawson,2005).
Conjunctival oedema can prevent adequate closure if the conjunctiva prolapses beyond the
eyelids, this can cause corneal drying and defective epithelial repair – this is as a result of
the adverse effects of both ventilatory support and the drugs used to facilitate it (Briggs,
2006). This can be exacerbated if the endotracheal tape securing the endotracheal tube is
secured too tightly. Venous return is compromised leading to venous congestion and a
potential increase in ocular pressure (Dawson, 2005).
A constant flow of the preocular tear film into the lacriminal sac, aided by the blink reflex,
helps in flushing out contaminating microrganisms. Tears prevent bacterial adherence and
also kill the organisms (Dua, 1998). Administration of artificial tears, such as hypromellose
eye drops can be administered to reduce dryness and irritation and prevent further
complications.
Lid closure has shown to be of great importance, as any corneal exposure will lead to
epithelial drying increasing the risk of keratitis and epithelial erosion (Suresh et al., 2000)

It is vital to assess and maintain lid closure in patients.

Taping lids closed is unpopular with nursing staff as there is a potential risk of damage to the
eyelid, repeated application and removal of micropore tape can cause excoriation of the lid
skin. The appearance of tape across the patients eyes is also thought to increase relatives
stress levels (Farrell and Way, 1993; Suresh et al.,2000)
An alternative is the Donaldson eye patch which uses a Velcro system to achieve closure.
When the lids cannot be opposed, for example due to rigidity following burns or injury or
when oedematous, polyacrylamide gel patches of high water content or polyethylene
covers i.e. cling wrap can be used. These provide adequate cover and conserve moisture
on the ocular surface. (Dua,1998)
Suresh et al, 2000 advocate the use of lubricants in patients but there is no evidence to
suggest frequency or the most effective solutions (Dawson,2005). Polyethylene covers
when compared to lubricants have been shown to be more effective in reducing the
incidence of eye surface disease (Cortese, D., Capp,L., McKinley,S. 1995; Suresh,P. et al
2000; Koroloff et al,2000), but lubrication and lid closure together have not been compared
with polyethylene covers.
75% of Intensive Care Units use Geliperm routinely in eye care with 25% using ocular
lubricants (King and Healy, 2003) Geliperm was originally designed as a wound dressing
and there is no evidence to support its use in eye care. However, the lubricant Lacrilube
has been shown to be effective (Lenart, S.B. and Garrity, J.A.,2000, Ezra,D.G.,
Lewis,G.,Healy,M.,Coombes,A. 2005).
The method of treatment in Nottingham University Hospitals will be based upon
patients’ lid position.

the

Lid positioning will be graded.
GRADE
GRADE 1
GRADE 2
GRADE 3

LID POSITION
LIDS APPOSED
WHITE OF EYE VISIBLE (CONJUNCTIVA)
CORNEA VISIBLE

Patients assessed as Grade 1 and 2 will have Lacrilube applied to the eye.
Grade 3 will have Lacrilube applied and geliperm to cover the eye area.

Infection
Early detection of infection is important. Lid swelling and conjunctival swelling and redness
are important signs. Discharge and crusting of the eyelid margins should be viewed with
suspicion. Early signs of corneal involvement include loss of the normal shine or lustre,
corneal haziness and localised white infiltrates (Dua, 1998).

Infected respiratory tract secretions are known to be a source of ocular contamination
during suction procedures. If the patient is requiring open rather than closed suctioning
techniques suctioning of respiratory tract secretions should be performed to the side of the

patient rather than over the top of the head. Care should be taken when disconnecting
patients from the ventilator and high flow t-pieces that spray from the tubing does not go
over the patients face. At all times the eyes should be adequately covered and shielded.
Eye swabs (APPENDIX 1) should be not performed routinely. If an infection is suspected the
medical team must be informed and a swab taken.
Referral to an ophthalmologist should be made at the first signs of infection.
If a swab proves positive antimicrobial / antiviral eye drops should be
following consultation with the ophthalmology and microbiology teams.

commenced,

Eye Injuries that can occur in the Critically Ill Patient
Corneal exposure, can lead to abrasions, ulceration, perforation and scarring.
Damage can be permanent.



Corneal Abrasion



Keratopathy is a non-inflammatory disease of the cornea, usually as a result of
incomplete eye closure it is secondary to corneal drying.

Keratopathy



Corneal Ulceration

Hypopyon / Corneal Clouding

Hypopyon



Conjunctival chemosis also known as “ventilator eye”
A dramatic swelling of the tissue surrounding the eye.
Conjuctivall Chemosis

 Sub- conjunctival haemorrhage
Sub- haemorrhage

Infections that can occur in the Critically Ill Patient
 Infections
Conjunctivitis

Keratitis

Blepharitis

Conjunctivitis is the inflammation of the conjunctiva and can be caused by bacteria or
viruses. There is redness and discharge.
Keratitis is inflammation of the cornea, symptoms are similar to conjunctivitis with
excess tear production.
Blepharitis is inflammation of the eye lash follicles and sebaceous glands. There is
redness, swelling and dried mucous

Nursing Cares And Interventions
The Nurse will perform an eye assessment at the beginning of her shift using the
Guideline flow charts (See Appendix 2 ).
All Patients must have an eye assessment performed every 12 hours and
documented in the nursing careplan.
Each episode of eye care must be documented on the 24 hour observation chart.

REFERENCES
Briggs, J. (2000) Eye care for intensive care patients. Evidence based practice sheets
for health professionals. 6(1) pp1-6
Cortese, D., Capp, L., McKinely, S. (1995) Moisture chamber versus lubrication for the
prevention of corneal epithelial breakdown. American Journal of Critical Care. 4:425428
Dawson, D. (2005) Development of a new eye care guideline for the critically ill.
Intensive and Critical Care Nursing, 21 pp119-122
Dua, H.S. (1998) Bacterial keratitis in the critically ill and comatose patient. The
Lancet, 351pp387-388
Ezra, D.G., Lewis, G., Healy, M., Coombes, A. (2005) Preventing exposure
keratopathy in the critically ill: a prospective study comparing eye care regimes.
89pp1063-1071
Farrell, M., Wray, F. (1993) Eye care for ventilated patients. Intensive Critical Care
Nursing, 9(2) pp137-141

King, D.J., Healy, M. (2003) Prevention of eye disease in intensive care – a telephone
survey. Intensive Care Medicine, 29(15) supplement.

Koroloff,N., Boots,R.,Lipman,J.,Thomas,P.,Rickard,C.,Coyer,F. (2004) A randomised
controlled study of the efficacy of hypomellose and Lacri-Lube combination versus
polyethylene/cling wrap to prevent corneal epithelialbreakdown in the semi-conscious
intensive care patient. Intensive Care Medicine, 30 pp 112-1126
Lenart, S.B., Garrity, J.A. (2000) Eye care for patients receiving neuromuscular
blocking agents or propofol during mechanical ventilation. American journal of critical
care. 9(3) pp188-191
Parkin, B., Cook, S. (2000) A clear view: the way forward for eye care on ICU.
Intensive Care Medicine, 26 pp155-156
Parkin, B., Turner, A., Moore, E., Cook, S. (1997) Bacterial keratitis in the critically ill.
British Journal of Ophthalmology, 81(12) pp1060-1063
Rosenberg, J.B., Eisen, L.A. (2008) Eye care in the intensive care unit: Narrative
review and meta-analysis. 36(12) pp3151-3155
Royal Marsden NHS Trust (2008) The Royal Marsden Hospital Manual of Clinical
Nursing Procedures 7th Edition: WileyBlackwell
Suresh, P., Mercieca, F., Morton, A., Tullo, A.B. (2000) Eye care for the critically ill.
Intensive Care Medicine, 26 pp162-166
Thurston, N., King, K. (2004) Implementing evidence based practice: walking the talk.
Applied Nursing Research 17(4) pp239-47

AUDIT POINTS
1. Has the patient had a documented eye assessment performed at least 12 hourly?
2. How often has the bedside Nurse performed an eye assessment on the patient?
- is this appropriate for the patient?
3. Is the Nurse cleaning the eye correctly?
4. Has the patient been prescribed artificial tears?
5. Is the patient receiving lacrilube ointment?
6. Is the patient receiving geliperm eye treatment?
7. Does the patient have an eye injury?
- have they been seen by the opthamologist?
- are they receiving prescribed treatment?
8. Does the patient have an eye infection?
- have they been seen by an opthamologist?
- are they receiving prescribed treatment?
9. Has the Nurse received training on care of the eye in the critically ill patient?
10. Is the patient proned?
- is the patient receiving the correct eye care?

Original Authors
Anne Illsley / Sonya Finucane, 2009
Reviewed November 2011: Anne Illsley
Next Review Date 2014

APPENDIX 1
PROCEDURE FOR EYE SWAB COLLECTION
EQUIPMENT LIST
Universal swabs, 1 per eye
Microbiology form
Patient sticker label for specimen and form
Non-sterile gown and gloves
ACTION
1. Explain procedure to patient
2. Wash hands, and wear non-sterile
gown and gloves
3. Unwrap a universal swab and hold
the swab parallel to the cornea and
gently rub the conjunctiva in the lower
eyelid. (The Royal Marsden NHS Trust
2008)
4. Place the patient labels on the
closed swab and place in a labelled
microbiology form.
5. Remove gown and gloves and place
in the sterile waste bin.
Wash hands.
6. Send the swab promptly to the
microbiology Department.
7. Document in the microbiology forms
that the swab has. been sent and the
date of sending

RATIONALE
Ensure patient understands the procedure and if
able gives consent.
To minimise the risk of cross-infection
To ensure that a swab of the correct site is taken.
To avoid contamination by touching the eyelid
To ensure the swab is labelled correctly and
Promptly.
To minimise cross-infection
To ensure the swab is processed quickly
To ensure there is an accurate record kept.

APPENDIX 2

EYE CARE FOR THE CRITICALLY Ill ADULT
GUIDELINE A
All Patients will have a documented Eye Assessment by the Nursing Staff at least
every 12 hours
If there is suspected or known foreign bodies in the eye(s) inform the Medical Team
immediately and refer to ophthalmology.
Do not attempt removal until seen by ophthalmology, await plan of care following review.
Does the patient have trauma to the eye
and / or surrounding area?

YES

Go to Guideline

D

YES

Go to Guideline

C

Does the patient have burns to the eye
and surrounding area ?
NO

Is the patient in the proned position?
NO

Is the patient able to fully close their eyelids?
YES

NO

Go to Guideline

B

Are the patients eyes reddened, without discharge?
YES
NO




Assess eyes 6 hourly
hourly
Clean as per Trust
Guideline If required

Assess eyes 6

Are the Patients
eyes reddened,
with discharge?

Yes

Is the patient ventilated, receiving high – flow oxygen
therapy and /or the patient has an altered G.C.S.
YES

NO

Refer to medical Team.
Refer to Ophthalmologist
Take a conjunctiva swab
Administer prescribed
treatment.
.





Assess eyes 6 hourly
Assess eyes 6 hourly
Clean as per Trust
Guideline
Apply celluvisc 1% eye
drops to both eyes QDS
Apply Lacrilube nochte (waiting a few minutes after the administration of the celluvisc 1%eye drop)

EYE CARE WITHIN ADULT CRITICAL CARE
ANNE ILLSLEY SERVICE IMPROVEMENT SISTER, CRITICAL
CARE

November 2011

10

EYE CARE FOR THE CRITICALLY Ill ADULT
GUIDELINE B
All Patients will have a documented Eye Assessment by the Nursing Staff at least
every 12 hours
The patient is unable to fully close their eyes.
Determine severity of Lid Closure

GRADE 1.

Examine eyes 6 hourly
Clean as per Trust Guideline
Apply Lacrilube ointment to both eyes

GRADE 2.

Examine eyes 6 hourly
Clean as per Trust
Guideline
Apply lacrilube ointment to both eyes

GRADE 3.

Examine eyes 2 hourly
Clean as per Trust Guideline
Apply lacrilube ointment to both eyes
Cover eyes with geliperm
Refer to ophthalmologist

GELIPERM
 A new packet of geliperm must be opened for each
application. (1 packet can be used for both eyes)
 The pieces required must be cut with sterile scissors.
 The unused geliperm must be discarded.
 A new piece of geliperm must be applied to each eye two hourly, after cleaning.

CORNEAL CHEMOSIS

Examine eyes 4 hourly
Clean as per Trust
Guideline
Apply lacrilube ointment to both eyes –
Consider geliperm if chemosis
severe.

If the patients’ eyes become reddened, there are corneal signs of opacity (cloudiness) and there
are signs of infection






Discuss with the Medical Team
REFER TO OPTHAMOLOGY IMMEDIATELY.
Consider conjunctival swab
Administer prescribed Medication
Reassess 4 hourly

EYE CARE WITHIN ADULT CRITICAL CARE
ANNE ILLSLEY SERVICE IMPROVEMENT SISTER, CRITICAL
CARE

November 2011

11

EYE CARE FOR THE CRITICALLY Ill
ADULT
GUIDELINE C

PRONED PATIENTS
Prior to proning the patient the Nurse should perform an eye assessment.
Both eyes should be cleaned as per Trust Guideline, lacrilube applied to both
eyes and then both eyes covered with eye pads and secured with micro pore
tape.















Assess eyes 2-4 hourly once proned
Clean eyes as per Trust Guideline
Apply lacrilube ointment to accessible eye
Apply a melolin dressing to accessible eye
Cover accessible eye with an eye pad, and secure with micro pore
tape

On resuming the supine position, assess the patient 2 hourly
Grade lid position and assess for corneal chemosis
Clean eyes as per Trust Guideline
Administer treatment as per assessment findings
Maintain 2 hourly assessments for at least 8 hours after turning supine
Refer to Medical Team if signs of infection present
Refer to ophthalmologist

Patients in the proned position are at risk of developing
complications of the eye due to the raised intraocular pressure.

EYE CARE FOR THE CRITICALLY Ill ADULT
GUIDELINE D

ALL PATIENTS WITH FRACTURED ORBITS AND / OR
TRAUMA TO THE EYE AND SURROUNDING AREAS




Refer to the ophthalmologist
Assess eye(s) 2 hourly – or as directed by the ophthalmologist
Clean eyes as per Trust Guideline – or as directed by
ophthalmologist.
Administer prescribed treatment.
If the eye(s) cannot be opened they must not be forced.




Great caution must be taken in examining the eyes and performing cares as
further damage can occur.

PATIENTS WITH BURNS TO THE EYE AND
SURROUNDING AREAS





Refer to the ophthalmologist.
Assess eye(s) 2 hourly – or as directed by the
ophthalmologist.
Clean eyes as per Trust Guideline - or as directed by
ophthalmologist.
Administer prescribed treatment.

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