Screening for ocular surface disease in the intensive care unit

Abstract

Purpose Ventilated patients in the intensive care unit (ICU) often develop exposure keratopathy. This predisposes to the development of bacterial keratitis, which in ICU is often bilateral, with a high risk of perforation. As regular examinations of all ventilated patients by ophthalmologists would be impractical, the purpose of this study was to assess whether ICU staff can screen reliably for keratopathy. Methods A prospective study was performed in a general adult ICU. Twice each week, two junior ICU doctors examined the lid position and ocular surface of all patients who had been continuously sedated for more than 24 h, using fluorescein and a pen torch with a blue filter. An ophthalmologist performed similar examinations using a portable slit lamp. Results A total of 48 ocular examinations were performed in 18 patients. Exposure keratopathy was found by the ophthalmologist in 37.5% of examinations and by ICU doctors in 31.3% of examinations. ICU doctors had a sensitivity of 77.8% and a specificity of 96.7% in detecting keratopathy, when compared with the findings of the ophthalmologist. All cases missed by ICU doctors had punctate erosions of less than 5% of the corneal surface. Keratopathy was significantly commoner in patients with incomplete lid closure than in patients with closed lids (70.0 vs 28.9%; two-tailed Fisher's exact test P ¼ 0.027). Conclusions ICU staff can perform screening examinations for exposure keratopathy with reasonable sensitivity and specificity. Regular screening by ICU staff would facilitate appropriate treatment of exposure keratopathy and promote earlier identification of cases of keratitis.

Exposure Keratopathy in the Intensive Care Unit: Do Not Neglect the Unseen

“…McHugh et al demonstrated in a study of ICU patients that poor or inadequate eyelid closure was associated with 70% incidence of EK when compared to 29% incidence among patients able to fully close their eyelids [4]. The use of pharmacologic-induced paralysis or heavy sedation may inhibit this important natural mechanism of eye protection [6].…”

“…ICU doctors had 77.8% sensitivity and 96.7% specificity in detecting EK, with all "missed" cases having erosions involving <5% of the corneal surface. The authors concluded that using regular eye checks, ICU staff should be able to adequately diagnose EK and facilitate ocular therapy [4].…”

“…In one study, McHugh et al [4] set out to determine if specialization enhanced ocular disease detection. Two junior ICU physicians, twice a week, examined lid position and ocular surfaces of all patients continuously sedated for >24 h. An ophthalmologist performed similar examinations with a slit lamp.…”

“…While management priorities of the critically ill patient must emphasize life-threatening problems, other issues with less immediate consequences may go unnoticed. Exposure keratopathy (EK), noted to occur in 37-57% of sedated or intubated ICU patients, is one of those "silent" morbidities [3][4][5][6]. Visual impairment or loss of vision due to EK, especially when secondary complications such as corneal infection are present, is a serious problem that can arise if proper precautions are not observed, and has the potential to cause long-term disability [7][8][9].…”

Fatores de risco para lesão de córnea em pacientes criticos na terapia intensiva: uma revisão integrativa Risk factors for injury in the cornea in critical patients in intensive care: an integrative review

“…13,17 It was observed, so, that the muscular relaxation promoted by the action of neuromuscular blocking causes the decrease of the tonus of the eyelid which favors the incomplete closure. 6,16,18,20 The lowering of the low score evidenced awareness level on the Glasgow Coma Scale is identified in several studies as a risk factor that contributes significantly to the development of the injury, since patients with neurological deficits have their natural reflexes and protection mechanisms committed. The respiratory tract infection associated with prolonged use of mechanical ventilation settles frequently in these patients so that bacterial translocation respiratory tract eyewear during tracheal aspiration without eye protection patient was identified as an aggravating factor, because in many cases there are accidental spills of tracheal aspirates during the procedure.…”