ORIGINAL ARTICLE
Development of a new eye care guideline for critically ill patients

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Summary

Ventilated, critically ill patients have an increased risk of corneal exposure and microbial keratitis; however there is evidence that eye care is a neglected area of patient care. An audit of eye surface disease and eye care documentation revealed a problem within one general intensive care unit (GICU). An education programme was developed to highlight the incidence of eye surface disease and importance of eye care in the ventilated patient.

Introduction

Critically ill patients frequently have poor eyelid closure and a reduced ability to use the protective blink reflex due to the effects of sedative agents used to enable other aspects of care. In addition, patients requiring artificial ventilation may suffer decreased tear production, decreased resistance to infection and a decrease in venous return leading to conjunctival chemosis. These factors lead to an increased risk of eye surface disease including corneal exposure and microbial keratitis (Hilton et al., 1983, Hutton and Sexton, 1972, Ommeslag et al., 1987, Wincek and Ruttum, 1989). The actual incidence of eye surface disease is difficult to quantify (JBIEBNM; Joanna Briggs Institute, 2002), however four prospective studies have published rates ranging between 37.5% and 60% in critically ill patients (Hernandez and Manis, 1997, Imanaka et al., 1997, McHugh et al., 2004, Mercieca et al., 1999). It is also difficult to quantify how many patients who suffer eye surface disease progress to eye infections such as conjunctivitis and keratitis; although of those patients who develop keratitis, the evidence suggests that they suffer a significant reduction in visual acuity (Hilton et al., 1983, Parkin et al., 1997).

Eye care guidelines have been shown to reduce eye surface disease (Suresh et al., 2000). Eye care is therefore an important aspect of care to maintain the integrity of the ocular surface, however there is evidence to suggest that this is a neglected area of care (Farrell and Wray, 1993, JBIEBNM, 2002, Laight, 1996). Within one general intensive care unit, it had been observed that adherence to local unit guidelines based on Suresh et al. (2000) was poor. An audit was undertaken to identify the incidence of eye surface disease and adherence to the local guideline. This also involved a literature search of the published eye care literature.

Section snippets

Literature review

The literature suggests practice is varied and that the evidence base for developing guidelines is limited, however there is sufficient evidence on which to base care. Further studies are required to assess the effectiveness of various eye care regimes (Farrell and Wray, 1993) and to establish keratitis rates. The eyes should be kept lubricated (JBIEBNM, 2002, Suresh et al., 2000) although there is no evidence to suggest frequency or the most effective solutions. Lid position has shown to be of

Audit

A prospective audit was conducted by two junior intensive care doctors to assess the adherence to the eye care guideline and the prevalence of eye surface disease in ventilated patients on the general intensive care unit. This was conducted over two months and included all patients in the general intensive care unit who were ventilated and sedated for more than 24 h. This resulted in a total of 31patients, providing 47 examinations which were validated by an ophthalmologist on 24 occasions. At

Discussion

This local audit identified a rate of eye surface disease in ventilated patients comparable to previous studies. In addition it identified a problem with adherence to current evidence based guidelines for this group of patients. The literature search did not provide any further evidence on which to base new guidelines, but supported the requirement for eye lubrication and closure. Therefore a discussion took place between the multi-disciplinary team to decide the best practice for lubrication

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