Felon Mahrous

Introduction

Eye care is a vital yet often under-prioritised aspect of managing unconscious or sedated patients in the Intensive Care Unit (ICU). Without appropriate precautions, patients are at risk of serious ophthalmic complications that may lead to long-term vision impairment or permanent blindness. This article outlines the best practices for eye assessment and protection, highlights common ICU-related ocular conditions, and provides recommendations for prevention, treatment, and when to seek ophthalmology input.

Best Practices for Eye Assessment and Protection

In the ICU setting, patients who are sedated and ventilated are vulnerable to ocular injury due to factors like impaired eyelid closure (lagophthalmos), decreased blink reflex, and compromised tear film (1). Daily eye assessments should be part of routine patient care, checking for incomplete eyelid closure, conjunctival swelling, discharge, or signs of infection. Maintaining eyelid closure is critical and can be achieved through methods such as gentle eyelid taping (ensuring lashes do not touch the cornea), use of moisture chambers, or, in more severe cases, temporary surgical closure of the eyelids (tarsorrhaphy).

Grade 0	Grade 1	Grade 2
Lids completely closed	Conjunctival exposure but NO corneal exposure	Any corneal exposure

Lubrication is also a cornerstone of prevention. Preservative-free artificial tears or ointments should be administered regularly, taking care to apply drops before ointments as ointments can prevent drops from effectively penetrating the ocular surface. When using eye ointment in patients with lagophthalmos, the eyelids should be manually closed afterwards to ensure even distribution across the cornea (2). Additionally, staff should ensure that nothing is pulling on the skin around the eyes and that the eye area is gently cleaned with sterile, warm water and gauze.

Eye Risks in Proned Patients

Proning is a common intervention used to improve oxygenation in ventilated patients, but it presents specific risks to the eyes. The gravitational shift in prone positioning leads to fluid accumulation in the face, resulting in eyelid oedema and conjunctival chemosis. Positive pressure ventilation and high positive end-expiratory pressures can further compromise venous return from the orbital structures, exacerbating oedema. If pressure is applied to the eyes in this position, intraocular pressure can rise while ocular perfusion pressure falls, leading to ischaemic optic neuropathy or, in extreme cases, permanent visual loss.

To mitigate these risks, ICU teams must ensure careful positioning of the head with the use of soft pillows, gel rings, or 3-pin head holders (although these are not commonly used) that avoid direct pressure on the eyes. Regular repositioning and checks for swelling or conjunctival prolapse are essential (3).

Common Eye Conditions in the ICU

One of the most frequent issues is corneal abrasion, usually caused by direct trauma or desiccation. These injuries present with a red, painful eye and can be diagnosed using fluorescein dye and a blue light, as a bedside test, to highlight the epithelial defect. If untreated, these abrasions may become infected or lead to scarring which then presents further complications.

Exposure keratopathy is another serious concern, primarily resulting from lagophthalmos and the drying of the ocular surface (4). This condition disrupts the tear film and leads to corneal epithelial defects, which can progress to scarring and reduced visual acuity or, in severe cases, corneal perforation. Again, fluorescein staining is instrumental for diagnosis.

Microbial conjunctivitis is another potential complication, especially in patients with corneal defects (5). It typically presents with redness and sticky discharge. When suspected, it is important to swab the conjunctiva and send samples for microbiological analysis before initiating treatment with chloramphenicol ointment. Given the contagious nature of microbial conjunctivitis and the immunocompromised status of many ICU patients, staff must follow strict infection control procedures. If symptoms do not improve within 48 hours, or if there is any concern about deeper corneal involvement, an urgent ophthalmology referral is warranted.

If microbial keratitis develops, it can lead to corneal ulceration and significant vision loss. It is typically preceded by exposure keratopathy and presents with a red eye and a visible epithelial defect under fluorescein staining. In immunocompromised patients, herpes simplex virus reactivation may also occur, complicating the clinical picture (6). Prompt ophthalmology referral and initiation of treatment is crucial to prevent further deterioration. If microbial keratitis is suspected or confirmed, it is important to obtain a corneal scrape for culture and initiate intensive topical treatment, typically with fluoroquinolones.

Chemosis, or conjunctival swelling, is commonly observed in ICU patients and has multiple causes. It may result from impaired venous return due to positive pressure ventilation, systemic fluid overload, hypoalbuminemia, or a systemic inflammatory response (7). In patients who are proned, gravitational forces further exacerbate fluid accumulation in the periorbital tissues, leading to visible bulging of the conjunctiva.

Treatment and Management Approaches

Management of ocular conditions in ICU patients begins with prevention. Eyelid taping must be done with care to avoid lashes rubbing against the cornea. Regular eye care should consist of regular, gentle cleaning of the periocular area using sterile warm water and gauze. Any skin tension or devices pulling on the skin around the eyes should be adjusted to reduce mechanical stress on the skin and reduce risk of disruptions in eyelid closure. Regular lubrication is essential and should be performed in a stepwise fashion—drops first, followed by ointments. In patients with incomplete eyelid closure, manual eyelid closure after application helps distribute medication across the entire ocular surface.

For proned patients, protective positioning is essential as mentioned above to reduce risk of complications such as chemosis. In cases of severe conjunctival chemosis, temporary closure of the eyelids with sutures may be necessary.

Guidelines and Protocols

While there is no single national guideline dedicated exclusively to eye care in ICU, several resources provide valuable frameworks. The Royal College of Ophthalmologists (RCOphth), in collaboration with the Intensive Care Society, have produced guidance relevant to eye care in the intensive care unit (8). Many NHS trusts have local standard operating procedures (SOPs), often drawing from research, such as “Eye Care for the Critically Ill” (9). Since nurses play a central role in administering eye care, the Royal College of Nursing (RCN) also offers practical guidelines tailored to ICU settings.

It is also important to consider that many ICU patients may be on long-term ophthalmic treatments for pre-existing conditions. Staff should ensure that prescribed drops are continued where possible, and if multiple drops are required, they should be spaced five minutes apart to prevent dilution or washout. Drops should always be applied before ointments, as ointments can form a barrier that prevents absorption of aqueous medications.

Special Considerations and When to Refer

Several conditions warrant urgent ophthalmology referral. Patients with suspected endogenous endophthalmitis, a potential complication of certain bacteraemias or fungemia, require immediate attention. Patients who are immunocompromised are at an increased risk of this and may present with a red eye, cloudy pupil, or hypopyon in the anterior chamber. Historically, all patients with positive fungal blood cultures were screened by ophthalmologists, but current practice supports case-by-case decisions. If a patient is awake and asymptomatic, examination may not be needed. However, if they are symptomatic or unable to report symptoms, clinical signs such as an abnormally red eye or cloudy pupil warrant an urgent ophthalmic review. In endogenous fungal endophthalmitis, fundoscopy may reveal subretinal infiltrates with vitritis. Endophthalmitis is a time critical emergency, and treatment involves systemic antifungals—typically intravenous caspofungin and voriconazole—with guidance from microbiology (10).

Severe dermatological conditions such as Stevens-Johnson Syndrome (SJS) also necessitate early ophthalmology input due to the high risk of ocular surface damage and potentional irreversible sight impairment. In the UK, the current management of ocular manifestations of SJS involves early ophthalmology referral, ideally within 24 hours of diagnosis, to assess and initiate preventative treatment for ocular surface damage. Management includes frequent lubrication with preservative-free drops or ointments, topical corticosteroids in the acute phase to reduce inflammation, and amniotic membrane transplantation in severe cases to prevent long-term complications such as symblepharon or corneal scarring (11). This is given alongside systemic steroid and immunosuppressant therapy to manage the other symptoms whilst on intensive care.

In trauma cases, patients admitted with orbital blowout fractures may require joint care between the maxillofacial and oculoplastic teams, especially if there is concern for extraocular muscle entrapment or ischaemia.

Other conditions such as corneal abrasion, microbial keratitis, or worsening exposure keratopathy also require prompt referral. In proned patients, prolonged or repeated sessions can lead to elevated intraorbital pressure, reduced perfusion, and risks of central retinal artery occlusion or ischaemic optic neuropathy. This can be challenging to detect in unconscious patients but should be considered in those who develop unexplained visual changes upon recovery. Similarly, vasoplegic patients with prolonged hypotension are at increased risk of ocular ischaemia and potential blindness, and should be closely monitored.

Procedural Safety

When invasive ophthalmic procedures are necessary—such as vitreous tap and injection—it is essential to consider the patient’s coagulation status. Thrombocytopenia is common in ICU patients, and platelet counts should be confirmed to be above 30 x10⁹/L before any such procedures are performed. If levels are lower, a platelet transfusion may be required in advance to reduce the risk of haemorrhagic complications.

Conclusion

Eye care is a critical component of ICU management that requires proactive attention from the multidisciplinary team. With appropriate assessment, regular preventive measures, and timely intervention, the risk of vision-threatening complications can be significantly reduced. Nurses and ICU staff play a pivotal role in identifying early signs of ocular issues and implementing protective strategies. When in doubt, or when complications arise, ophthalmology input should be sought without delay to preserve vision and improve outcomes for critically ill patients.

References

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