Promoting patient safety in critically ill patients: nursing interventions in surveillance and prevention of ocular injuries

Anabela Carvalho Raposo; Maria Candida Durao; Maria do Rosário Pinto; Helga Rafael Henriques; Joana Ferreira Teixeira

doi:10.4266/acc.005014

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Review Article Nursing Promoting patient safety in critically ill patients: nursing interventions in surveillance and prevention of ocular injuries: Anabela Carvalho Raposo^1,2,#, Maria Candida Durao^1,2, Maria do Rosário Pinto^1,2, Helga Rafael Henriques^1,2, Joana Ferreira Teixeira^1,2; Acute and Critical Care 2025;40(1):10-17.
DOI: https://doi.org/10.4266/acc.005014
Published online: February 12, 2025

¹Medical-Surgical Nursing – Critical Care Program at Nursing School of Lisbon (ESEL), Lisbon, Portugal

²Nursing School of Lisbon (ESEL) - Nursing Research, Innovation and Development Centre of Lisbon (CIDNUR), Project id.Care, Lisbon, Portugal

Corresponding author: Anabela Carvalho Raposo Medical-Surgical Nursing – Critical Care program at Nursing School of Lisbon (ESEL), Av. Prof. Egas Moniz, Lisbon 1600-190, Portugal Tel: +351-962-816-727 Email: araposo1@campus.esel.pt

#Current affiliation: Infection Prevention and Control Department, Unidade Local de Saúde Lisboa Ocidental, Lisbon, Portugal

• Received: November 19, 2023 • Revised: October 22, 2024 • Accepted: November 16, 2024

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

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Abstract
INTRODUCTION
METHODS
RESULTS
DISCUSSION
CONCLUSIONS
KEY MESSAGES
NOTES
REFERENCES

Abstract

Corneal surface injuries occur frequently (59.4%) in critically ill patients, and the average time for their appearance is 8 days. Such injuries are primarily related to dry eye, which increases the risk of exposure injury in patients admitted to intensive care units. This can result in a severe ulcer or perforation that results in partial to total loss of vision, decreasing the quality of the patient's life. This is a sensitive nursing care area requiring further investigation. Thus, this review aims to analyse nursing interventions that aim to prevent ocular surface injuries. An integrative literature review was carried out from May to August 2023 in the Medline, CINAHL, Scopus, Web of Science, and PubMed databases using the Whittemore and Knafl methodology. Inclusion and exclusion criteria were subsequently applied to assess the results. After verifying result eligibility, seven documents were identified for data extraction and analysis. The results suggest the importance of recognizing risk factors for ocular injuries in critically ill patients, surveillance as a nursing competency, adequate ocular hygiene and effective lubrication, and managing environmental conditions to prevent corneal injuries. Implementing surveillance and intervention protocols for critically ill patients at risk of corneal injuries requires specialized training for critical care nurses. Specifically, environmental management, including temperature and humidity control, is highlighted as an area that merits further research.
Key Words: corneal injuries; critical care; nursing care; safety; surveillance

INTRODUCTION

A critically ill patient (CIP) is one who, due to dysfunction or profound failure of one or more organs or systems, is dependent for survival on advanced means of surveillance, monitoring, therapy, and use of support technology to guide the practice of nursing care [1,2]. A patient in a critical situation, often sedated or curarised, has a risk of ocular injuries and does not directly manifest discomfort associated with pain, photophobia, or low visual acuity caused by a lesion of the ocular surface [3-5].

Tears have antimicrobial properties that are essential for response to microorganisms and are fundamental for lubrication of the ocular surface. The normal blinking reflex varies between 15 and 20 times per minute [6,7], and a decrease in tear quality and blinking reflex (less than five times per minute) is associated with poor eyelid closure (lagophthalmos), inducing greater evaporation of tears and increasing tear film osmolarity and inflammation of the ocular surface [8,9]. The Meibomian glands at the margins of the eyelids produce the lipid secretion indispensable for ocular lubrication, requiring spontaneous and mechanical action of the blinking reflex [10-12].

According to O'driscoll and White [13], eye injury and blindness are rare but serious complications in the perioperative period, related to general anaesthesia due to it reduction of the action of the orbicularis muscle. This inactivity can cause lagophthalmos, with decreased quantity and quality of tears in as many as 59% of surgical patients. Additionally, a ventral or lateral decubitus surgical approach may induce trauma by compression of the eyeball, and the proximity of the surgical access may increase the risk of chemical injury caused by disinfectant products [13].

A corneal injury is an inflammatory or infectious lesion of the corneal tissues. It can be superficial, infectious, traumatic, degenerative, or even a fusion of all and can be considered an emergency in ophthalmology [4]. In CIPs, several factors have been associated with poor eyelid cleft corneal lesions. Prolonged intensive care unit (ICU) stay, associated comorbidities, and age influence the risk of corneal injuries. Administration of drugs, namely sedatives, muscle blockers, antihypertensives, antibiotics, anaesthetics, vasoconstrictors, and benzodiazepines, also plays a role in poor eyelid outcomes, as do mechanical ventilation and high positive end-expiratory pressure [4,5,10]. Additionally, the loss of sensory and motor reflexes (V cranial nerve in the ophthalmic branch), lagophthalmos, and temperature/humidity of the environment also can impact corneal injuries, which, when not identified and treated promptly, can result in total and irreversible vision loss [4].

According to the World Health Organization (WHO), vision is the most dominant sense, playing a crucial role in all stages of life. About 2.2 billion people worldwide have visual deficits, about half of which could have been prevented [14]. Thus, this review article aims to analyse nursing interventions for CIP with risk of corneal injury to prevent complications and promote patient safety and quality of life [4,15-22].

This review falls within the scope of project id. “Care-centred care for complex chronic patients in critical and acute care: managing physical environment and supporting clinical decision-making and self-management.” This reinforces the importance of nursing decision-making in the context of critical care, specifically to prevent ocular injury, which impacts patient safety and personal and family satisfaction [18,23,24]. The care plan should aim for patient recovery and return to family and social life, which is impacted by visual acuity. It is also possible that preserved eyes of people in an end-of-life situation may be eligible for organ donation [4,25,26].

METHODS

An integrative literature review (ILR) combines different research studies to understand a specific phenomenon [27]. Specifically, this ILR aims to identify and analyse nursing interventions for preventing ocular surface lesions using the methodology of Whittemore and Knafl [27]. The use of this research method is consistent with an evidence-based nursing care practice. The protocol of this review is registered in PROSPERO with the identification CRD42023438938.

Research Question

The research question was developed according to the PI[C]O mnemonic [28]. What are the nursing interventions (I) to the CIP with eyelid cleft closure deficits (P) for prevention and mitigation of lesions on the surface of the cornea (O)?

Search Strategy

The research was conducted from May to August 2023, using the Medline, CINAHL, Scopus, Web of Science, and PubMed databases, including studies from 2013 to 2023, according to the following research strategy: ((critical illness) OR (critically ill patients) OR (lagophthalmos)) AND ((critical care nursing) OR (nursing care) OR (nursing interventions) OR (interventions) OR (treatment) OR (vigilance)) AND ((corneal ulcer) OR (corneal diseases) OR (corneal injuries) OR (blinking) OR (corneal lesions) OR (corneal affections)) OR (corneal reflex) OR (corneal swelling) OR (corneal oedema)).

Inclusion and Exclusion Criteria

The following eligibility criteria were applied to all databases. Inclusion criteria are (1) Population: CIPs hospitalized in the ICU and/or emergency department (ED), older than 18 years, without previous corneal injury, presenting ocular exposure and decreased blinking reflex. (2) Interventions: nursing care for CIPs, related to surveillance and prevention of corneal injuries. (3) Outcomes: absence of corneal injuries. (4) Documentation: primary studies were considered. (5) Date: studies performed within the previous 10 years. (6) All languages were considered.

Exclusion criteria: all articles whose criteria did not specify fulfilment of the above inclusion criteria; articles written in languages that could not be translated or understood by the researchers; all documents written before 2013; and secondary research, background articles, or letters to editors were excluded.

Selection of Studies

After conducting the research and applying the eligibility criteria, articles were selected in different stages using the Rayyan software [29]. First, all duplicate articles were deleted. Subsequently, two authors independently applied the eligibility criteria by reading the title, abstract, and full text, if needed. Any disagreements in the process were solved through discussion between all researchers.

Data Extraction

Data were extracted according to the Prisma Flow Diagram [30] (Figure 1), and the final documents obtained were analysed according to the recommendations of the Joanna Briggs Institute [28].

RESULTS

The results are presented in Table 1. Seven final documents were obtained: two randomised controlled trials, two quasi-experimental studies, two prospective cohort studies, and one descriptive observational study. The studies had an average quality assessment of 86.83%, using the critical appraisal tool for each type of study, according to Joanna Briggs Institute [28]. Data with greater relevance regarding nursing interventions to CIP hospitalised in ICU/ED reveal that it is essential to provide nurses with knowledge about the functioning of the visual system and eye care. Researchers agree that application of training programs, acquisition of knowledge, and training of nurses in the ICU/ED improve the quality of care for prevention of eye damage in CIP, with positive impacts on family outcomes. Action protocols and eye hygiene associated with adequate lubrication and eyelid closure should be implemented to reduce the risk of corneal lesions and improve quality of life [31]. Evaluating the results of several studies allowed us to verify that lubrication with ointment associated with a polyethylene film coating helps retain optical moisture, reducing the incidence of corneal injuries [32-37]. Passive blinking exercises also can have positive effects, hindering keratopathies [37]. Ideal environmental conditions must be maintained to achieve temperatures between 21 °C–24 °C and humidity of 40%–60% [35]. The different nursing interventions described in the studies are categorised in Table 2.

DISCUSSION

Problems associated with reduced eyelid closure and consequent injury of the cornea have been the subject of research for several centuries. According to Latkany et al. [38], the first published articles on the subject predate the 20th century and involve nocturnal lagophthalmos (poor eyelid closure during sleep), which can be found in up to 5% of the adult population. This condition may not be noticed initially in a CIP [39-41], but its consequences will become evident in the form of keratopathies. Such corneal lesions vary in severity and usually appear between the second and seventh days of care [41]. Although the incidence of corneal lesions in CIP is relatively high, complications can be reduced with proper prevention techniques [31-37].

However, lack of consensus among researchers on the most effective lubrication method (eye drops, gel, or ointment) complicates nurses' decision-making [36]. According to Askaryzadeh et al. [42], different lubricants (eye drops, gel, or ointments) and different forms of eye protection for maintenance of eyelid closure may result in different outcomes with respect to reduced incidence and prevalence of ocular surface changes. An individual treatment plan is the most important factor in reducing the occurrence of lesions.

The temperature and humidity of the ICU are extrinsic to the CIP and are highly important and can impact treatment outcomes. Ideal conditions of a temperature between 21 °C–24 °C and humidity of 40%–60% should be maintained [35]. Signs and symptoms of corneal lesions may begin even before the patient reaches the ICU. Eyelid closure is an essential intervention in preventing exposure keratopathy, which occurs in 27%–44% of ICU patients [13]. Upon patient entry into the critical care unit, it is essential for care and prevention of complications to be aware of their origin and context and to carry out an initial systemic and systematised assessment followed by effective and efficient surveillance [18,26]. Systemic hemodynamic changes, such as severe and prolonged arterial hypotension, can cause ischemic optic neuropathy due to impaired oxygenation of retinal vessels by hypoperfusion, leading to irrecoverable vision loss [39]. A systematic and holistic focus on patient ventilatory and hemodynamic stability is important for prevention of ischemic optic neuropathy, occlusion of the central vein of the retina, and resulting irreversible blindness [39].

The care team should discuss the treatment plan as a group. Awareness of the relevance of this theme should be extended to the transdisciplinary team. In this context, nursing training programs will allow development of expert skills in evaluating corneal integrity and early identification of ocular surface lesions [15]. Likewise, the use of nursing diagnoses regarding this theme allows a common language and the structuring of a nursing intervention plan to be elaborated and executed rigorously, following the findings after validating the risk factors involving critically ill care [26].

Therapeutic reconciliation is also needed in the planning and delivery of quality care, focusing on preventing complications and promoting patient safety. Investment in patient safety has been a concern of health systems worldwide. The global action plan involves policies, strategies, and actions based on scientific evidence, systems, and partnerships and on patient experience to eliminate avoidable risks and harms for patients and health professionals [14,39]. Hospital discharge should be planned to prepare for a return to the pre-hospitalisation conditions of personal, family, and social life, promoting an improvement in the quality of life with the least possible damage resulting from the critical situation experienced [43-45].

In the analysis of the different articles, no reference was found on reconciliation of ophthalmic therapy in CIP. The environmental conditions of critical care units and their management are equally important in this area. However, scant evidence was found regarding unit hygiene, temperature, and humidity control.

CONCLUSIONS

This integrative review analysed nursing interventions for a CIP with risk of ocular injury in the ICU, regarding surveillance and prevention of ocular injuries, with a focus on the individual patient and their family, which is the basis of fundamental nursing care. These interventions also involve the interdisciplinary team to improve quality of care and patient safety. Therefore, this integrated plan must include training actions related to the factors that predispose a CIP to the risk of eye injuries, specific specialized nursing interventions for the CIP to prevent such injury, as well as the possibility of preserving the organ’s eligibility for subsequent donation in end-of-life patients. For future research, we suggest developing studies on the reconciliation of ophthalmic therapy and environmental management and its importance for CIP.

KEY MESSAGES

▪ The risk of corneal injury in critically ill patients is high.

▪ Specialized nursing care for critically ill patients at risk of corneal injury, including surveillance and implementation and management of protocols in this area, is of great importance.

NOTES

CONFLICT OF INTEREST

No potential conflict of interest relevant to this article was reported.

FUNDING

None.

ACKNOWLEDGMENTS

None.

AUTHOR CONTRIBUTIONS

Conceptualization: ACR, JFT. Data curation: ACR, JFT. Formal analysis: ACR, JFT. Methodology: all authors. Project administration: JFT. Writing-original draft: ACR. Writing-review and editing: all authors. All authors read and agreed to the published version of the manuscript.

Figure 1.

Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow diagram.

Table 1.

Study results

Study	Study type	Aim	Participant	Intervention	Level of evidence	Quality assessment
Azfar et al. (2013) [31]	Prospective observational cohort study	Provide a general and patient-specific intensive care plan	184 Patients	After introducing the ophthalmic nursing care protocol, corneal complications decreased significantly. The protocol is based on the following nursing interventions: (1) hand hygiene; (2) periocular hygiene; (3) eye lubrification.	3e	6/10, 60%
Masoudi Alavi et al. (2014) [32]	Descriptive observational study	To determine the incidence of dry eye and corneal abrasion on the fifth day after admission in patients in a coma in the ICU	87 Patients	Eye care and evaluation should be essential parts of nursing care for ICU patients. Using eye lubricants is more effective than closing the eyes with duct tape to prevent corneal abrasion.	2c	6/9, 66.66%
Kalhori et al. (2015) [33]	Simple blind clinical trial	To compare the effect of three different nursing care methods on the prevention of exposure keratopathy in patients in the ICU	96 Patients	Ocular lubrication, either by artificial tears or ointment was significantly more effective than other methods in preventing keratopathy, in nursing care.	2c	9/9, 100%
Ahmadinejad et al. (2020) [34]	Randomised, double-blind Clinical Trial	To compare three different nursing eye care methods, in preventing ocular surface disorders in ICU patients	151 Patients	Polyethylene coating followed by simple ocular ointment and eyelid occlusion were the most effective methods in preventing eye disease syndrome in ICU patients. Increased knowledge and nursing training can prevent corneal and ocular surface problems or complications.	1c	13/13, 100%
Hayakawa et al. (2020) [35]	Self-paired clinical trial	To analyse the occurrence of ocular surface lesions in the ICU, in patients sedated or unable to blink	27 Patients	Implementing eye protection using transparent polyurethane film is a nursing care strategy indicated for patients in ICU and it can contribute to reducing associated complications.	2c	9/9, 100%
de Oliveira Pinheiro et al. (2023) [36]	Prospective cohort study	Perform causal validation of the nursing diagnosis: risk for corneal injury in clinically critical adult patients	209 Clinically critical adults	Concomitant use of a polyethene wet chamber and eye gel appear to be the most effective nursing intervention for preventing corneal lesions.	3b	8/9, 88.88%
Rezaei et al. (2022) [37]	Randomised, single-blind Clinical Trial	To evaluate the effects of passive blinking exercise on exposure keratopathies in ICU patients.	51 Patients	Using passive blinking exercises is a nursing intervention with potentially positive effects, preventing exposure to keratopathies.	1c	12/13, 92.30%
Rezaei et al. (2022) [37]	Randomised, single-blind Clinical Trial		51 Patients	ICU nurses should be encouraged to train and use this practice.	1c	12/13, 92.30%

ICU: intensive care unit.

Table 2.

Categorization of the areas of nursing intervention to the CIP with risk of ocular injury and family

Categorization of nursing interventions	Azfar et al. (2013) [31]	Masoudi Alavi et al. (2014) [32]	Kalhori et al. (2015) [33]	Ahmadinejad et al. (2020) [34]	Hayakawa et al. (2020) [35]	de Oliveira Pinheiro et al. (2023) [36]	Rezaei et al. (2022) [37]
Hand hygiene	×	×	×	×	×	×	×
Periocular hygiene	×	×	×	×	×	×	×
Eye lubrication: eye drops, gel		×	×	×	×	×	×
Passive blinking							×
Eye occlusion with protective dressing, polyethene				×	×	×
Training sessions and training for professionals	×			×	×	×	×
Introduction of a preventive therapeutic protocol	×				×
Early preparation for hospital discharge						×

CIP: critically ill patient.

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Promoting patient safety in critically ill patients: nursing interventions in surveillance and prevention of ocular injuries

Acute Crit Care. 2025;40(1):10-17. Published online February 12, 2025

DOI: https://doi.org/10.4266/acc.005014

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Promoting patient safety in critically ill patients: nursing interventions in surveillance and prevention of ocular injuries

Figure 1. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow diagram.

Figure 1.

Promoting patient safety in critically ill patients: nursing interventions in surveillance and prevention of ocular injuries

Study	Study type	Aim	Participant	Intervention	Level of evidence	Quality assessment
Azfar et al. (2013) [31]	Prospective observational cohort study	Provide a general and patient-specific intensive care plan	184 Patients	After introducing the ophthalmic nursing care protocol, corneal complications decreased significantly. The protocol is based on the following nursing interventions: (1) hand hygiene; (2) periocular hygiene; (3) eye lubrification.	3e	6/10, 60%
Masoudi Alavi et al. (2014) [32]	Descriptive observational study	To determine the incidence of dry eye and corneal abrasion on the fifth day after admission in patients in a coma in the ICU	87 Patients	Eye care and evaluation should be essential parts of nursing care for ICU patients. Using eye lubricants is more effective than closing the eyes with duct tape to prevent corneal abrasion.	2c	6/9, 66.66%
Kalhori et al. (2015) [33]	Simple blind clinical trial	To compare the effect of three different nursing care methods on the prevention of exposure keratopathy in patients in the ICU	96 Patients	Ocular lubrication, either by artificial tears or ointment was significantly more effective than other methods in preventing keratopathy, in nursing care.	2c	9/9, 100%
Ahmadinejad et al. (2020) [34]	Randomised, double-blind Clinical Trial	To compare three different nursing eye care methods, in preventing ocular surface disorders in ICU patients	151 Patients	Polyethylene coating followed by simple ocular ointment and eyelid occlusion were the most effective methods in preventing eye disease syndrome in ICU patients. Increased knowledge and nursing training can prevent corneal and ocular surface problems or complications.	1c	13/13, 100%
Hayakawa et al. (2020) [35]	Self-paired clinical trial	To analyse the occurrence of ocular surface lesions in the ICU, in patients sedated or unable to blink	27 Patients	Implementing eye protection using transparent polyurethane film is a nursing care strategy indicated for patients in ICU and it can contribute to reducing associated complications.	2c	9/9, 100%
de Oliveira Pinheiro et al. (2023) [36]	Prospective cohort study	Perform causal validation of the nursing diagnosis: risk for corneal injury in clinically critical adult patients	209 Clinically critical adults	Concomitant use of a polyethene wet chamber and eye gel appear to be the most effective nursing intervention for preventing corneal lesions.	3b	8/9, 88.88%
Rezaei et al. (2022) [37]	Randomised, single-blind Clinical Trial	To evaluate the effects of passive blinking exercise on exposure keratopathies in ICU patients.	51 Patients	Using passive blinking exercises is a nursing intervention with potentially positive effects, preventing exposure to keratopathies.	1c	12/13, 92.30%
Rezaei et al. (2022) [37]	Randomised, single-blind Clinical Trial		51 Patients	ICU nurses should be encouraged to train and use this practice.	1c	12/13, 92.30%

Categorization of nursing interventions	Azfar et al. (2013) [31]	Masoudi Alavi et al. (2014) [32]	Kalhori et al. (2015) [33]	Ahmadinejad et al. (2020) [34]	Hayakawa et al. (2020) [35]	de Oliveira Pinheiro et al. (2023) [36]	Rezaei et al. (2022) [37]
Hand hygiene	×	×	×	×	×	×	×
Periocular hygiene	×	×	×	×	×	×	×
Eye lubrication: eye drops, gel		×	×	×	×	×	×
Passive blinking							×
Eye occlusion with protective dressing, polyethene				×	×	×
Training sessions and training for professionals	×			×	×	×	×
Introduction of a preventive therapeutic protocol	×				×
Early preparation for hospital discharge						×

Table 1. Study results

ICU: intensive care unit.

Table 2. Categorization of the areas of nursing intervention to the CIP with risk of ocular injury and family

CIP: critically ill patient.