Highlights
- •
Ocular surface disorders (OSD) have been observed in nearly 60% of critically ill patients.
- •
The eye is more often looked at as a diagnostic aid, and the return reward of care has not been reciprocal.
- •
A simple test of observing torch light reflection from the cornea can help pick up early signs of exposure keratopathy.
- •
Optimal eye care in unconscious patients can avert development of exposure-related complications and subsequent ocular morbidity.
Abstract
Aim
To study the prevalence of lagophthalmos and its related complications among the unconscious patients admitted in the intensive care units (ICU)/wards of a tertiary care centre.
Methods
Cross-sectional observational study.
Results
A total of 87 unconscious patients were included. 44 were children and 43 were adults. The overall median age of patients was 16 years (range: 9 days- 85 years). 53/87 (60.91%) showed signs of lagophthalmos, among which 56.60% (30/53) were children and 43.40% (23/53) were adults. There was no significant difference in the exposure patterns between children and adults (p = 0.25). Exposure related manifestations (conjunctival/corneal) were found in 49/87 patients (56.32%). The most common conjunctival manifestation was chemosis, occurring in 28/53 patients (52.83%). Corneal exposure was seen in 31/53 patients (58.49%), of which fragile epithelium was the commonest finding (32.08%). Only 17/31 (54.83%) cornea exposed eyes were taped, of which 15 were sub-optimal. 6 patients were unnecessarily taped. Signs of infection were noted in 8/53 eyes (15.09%).
Conclusion
Optimal eye care in unconscious patients can avert the development of exposure-related complications and subsequent ocular morbidity. Adoption and implementation of systematic protocols can help improve the standard of care.
1
Introduction
The eyes are a window to the body system. The exceptional ability of the eyes to directly display its vasculature helps in diagnosis of various systemic angiopathies such as diabetes, hypertension, vasculitis, etc. Also, the optic nerve being a direct continuation of the central nervous system, guides in prompt diagnosis of dangerous disorders like raised intracranial tension and demyelinating diseases. Collagen vascular disorders and systemic infections also have significant ocular manifestations that can hint a timely diagnosis. Monitoring of pupillary size and reactions is an invincible study tool for all intensivists. While these diagnostic opportunities are being utilized to the fullest, the return reward of care to the eyes have not been reciprocal. The ocular apparatus is more often looked at as a diagnostic aid.
Ocular surface disorders (OSD) have been observed in nearly 60% of critically ill patients [ ]. The unconscious patients are at high risk for OSD, and their manifestations are preventable. Though the neglected ocular surface care in the critical care setting is a known problem, it is frequently under-appreciated, especially in the developing countries where the doctor-to-patient ratio and nurse-to-patient ratio is sub-optimal. Also, data on exposure keratopathy in the paediatric setting is limited at present [ , ]. Therefore, this study was undertaken to assess the differential patterns of ocular surface exposure & related complications in the paediatric and adult intensive care setting of a tertiary care hospital.
2
Methods
This was a cross-sectional observational study assessing the ocular surface health of unconscious patients who were admitted in the adult and paediatric wards/intensive care units (ICU) of a tertiary care centre. A written informed consent was obtained from the guardian of each patient. The study adhered to the tenets of declaration of Helsinki.
When an ophthalmic consultation for expert opinion was received, the examining ophthalmologist (one of two observers), in addition to those patients for whom opinion was sought, also screened the nearby unconscious patients. Both paediatric and adult patients were included. All patients were unconscious, and some were under ventilatory support. Records of those under assisted breathing showed that they had received sedatives and muscle relaxants dosed as per their body weight.
All eyes were assessed for lagophthalmos, and were graded as complete lid closure (grade 0), incomplete lid closure with visible conjunctiva (grade-1) ( Fig. 1 A) and incomplete lid closure with visible cornea (grade-2) ( Fig. 1 B) [ ].
In the presence of exposure, on bed-side torch light examination, it was noted if the conjunctiva was normal, or was dry, had chemosis, and congestion. For cornea, it was noted if cornea was normal, or had exposure keratopathy in the form of dull reflex suggestive of fragile epithelium/ epithelial defect, or a white lesion in the inferior cornea which could be infiltrates/opacity. In the presence of associated redness, mucopurulent discharge, sticky lids and matting of lashes, ocular surface infection was suspected clinically.
When any amount of exposure was present, the management undertaken was reviewed. If found sub-optimal, appropriate changes were advised and the attending staff were educated about the fallacies, in accordance to the Intensive Care Society-The Royal College of Ophthalmologists guidelines [ ]. If management had not been started, the ophthalmologist advised treatment accordingly.
All patients except two showed a bilaterally symmetric picture, and hence one eye per patient was included for the analysis. Statistical analysis was done using Stata 12.0 software. Categorical values were summarised as frequency (%) and quantitative values were summarized as mean ± standard deviation, or median (range) if non-normally distributed. The qualitative variables were compared using Chi-square/Fisher’s exact test. A p-value of <0.05 was considered statistically significant.
3
Results
A total of 87 unconscious patients were included. Both eyes of all 87 patients were observed, and all were found to be symmetrical except for two, who showed asymmetric uniocular exposure keratopathy. One of them had undergone ipsilateral craniotomy while the other had ipsilateral facial nerve palsy. 44 were children and 43 were adults. The overall median age of patients was 16 years (range: 9 days- 85 years), with median age of children being 3.5 years (range: 9 days-16 years) and median age of adults being 34 years (range: 18–85 years). 52/87 patients showed signs of active exposure and one patient showed sign of previous exposure (dense white lesion in lower 1/3rd cornea, but currently no lagophthalmos), thereby computing a total of 53/87 (60.91%) exposure overall. Of them, 56.60% (30/53) were children and 43.40% (23/53) were adults. There was no significant difference in the exposure patterns between children and adults (p = 0.25).
Exposure related manifestations (conjunctival/corneal) were found in 49/87 patients, accounting to 56.32%. The distribution of the various exposure-related conjunctival and corneal manifestations have been summarised in Table 1 .
| Conjunctival | ||
|---|---|---|
| s.no | manifestations | n (%) |
| 1 | Normal | 4 (7.55%) |
| 2 | Dry | 13 (24.53%) |
| 3 | Chemosis | 28 (52.83%) |
| 4 | congestion | 8 (15.09%) |
| Total | 53 (100%) | |
| Corneal | ||
|---|---|---|
| s. no | Manifestations | n (%) |
| 1 | Not exposed | 22 (41.51%) |
| 2 | Exposed but normal | 5 (9.43%) |
| 3 | Fragile epithelium | 17 (32.08%) |
| 4 | White lesion (infiltrate/opacity) | 9 (16.98%) |
| Total | 53 (100%) | |
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
