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 vs28.9%; two-tailed Fisher's exact test P=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.
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References
Mercieca F, Suresh P, Morton A, Tullo A . Ocular surface disease in intensive care patients. Eye 1999; 13: 231–236.
Suresh P, Mercieca F, Morton A, Tullo A . Eye care for the critically ill. Intensive Care Med 2000; 26: 162–166.
Kirwan JF, Potamitis T, El-Kasaby H, Hope-Ross MW, Sutton GA . Microbial keratitis in intensive care. BMJ 1997; 314: 433–434.
Wincek J, Ruttum MS . Exposure keratitis in comatose children. J Neurosci Nurs 1989; 21: 241–244.
Bergmans DCJJ, Bonten MJM, van Tiel FH, Gaillard CA, van der Geest S, Wilting RM et al. Cross-colonisation with Pseudomonas aeruginosa of patients in an intensive care unit. Thorax 1998; 53: 1053–1058.
Bertrand X, Thouverez M, Talon D, Boillot A, Capellier G, Floriot C et al. Endemicity, molecular diversity and colonisation routes of Pseudomonas aeruginosa in intensive care units. Intensive Care Med 2001; 27: 1263–1268.
Hilton E, Uliss A, Samuels S, Adams AA, Lesser ML, Lowy FD . Nosocomial bacterial eye infections in intensive-care units. Lancet 1983; 1(8337): 1318–1320.
Ramphal R, McNiece MT, Polack FM . Adherence of Pseudomonas aeruginosa to the injured cornea: a step in the pathogenesis of corneal infections. Ann ophthalmol 1981; 13: 421–425.
Stern GA, Weitzenkorn D, Valenti J . Adherence of Pseudomonas aeruginosa to the mouse cornea: epithelial v stromal adherence. Arch ophthalmol 1982; 100: 1956–1958.
Stern GA, Lubniewski A, Allen C . The interaction between Pseudomonas aeruginosa and the corneal epithelium. Arch ophthalmol 1985; 103: 1221–1225.
Fleiszig SMJ, Evans DJ . The pathogenesis of bacterial keratitis: studies with Pseudomonas aeruginosa. Clin Exper Optom 2002; 85: 271–278.
Parkin B, Turner A, Moore E, Cook S . Bacterial keratitis in the critically ill. Br J Ophthalmol 1997; 81: 1060–1063.
Hutton WL, Sexton RR . Atypical pseudomonas corneal ulcers in semicomatose patients. Am J Ophthalmol 1972; 73: 37–39.
Ommeslag D, Colardyn F, de Laey J . Eye infections caused by respiratory pathogens in mechanically ventilated patients. Crit care med 1987; 15: 80–81.
Johnson JL, Sagraves SG, Feild CJ, Block EF, Cheatham ML . An unusual case of corneal perforation secondary to Pseudomonas keratitis complicating a patient's surgical/trauma intensive care unit stay. Am Surg 2000; 66: 972–974.
Tuft SJ, Matheson M . In vitro antibiotic resistance in bacterial keratitis in London. Br J Ophthalmol 2000; 84: 687–691.
Hernandez EV, Mannis MJ . Superficial keratopathy in intensive care unit patients. Am J Ophthalmol 1997; 124: 212–216.
Parkin B, Cook S . A clear view: the way forward for eye care on ICU. Intensive Care Med 2000; 26: 155–156.
Farrell M, Wray F . Eye care for ventilated patients. Intensive Crit Care Nurs 1993; 9: 137–141.
Dua H . Bacterial keratitis in the critically ill and comatose patient. Lancet 1998; 351: 387–388.
Dawson D . Development of a new eye care guideline for critically ill patients. Intensive Crit Care Nurs 2005; 21: 119–122.
Joanna Briggs Institute for Evidence-Based Nursing & Midwifery. Eye care for intensive care patients. Best Practice 2002; 6 (1): 1–6.
Imanaka H, Taenaka N, Nakamura J, Aoyama K, Hosotani H . Ocular surface disorders in the critically ill. Anesth Analg 1997; 85: ndash;346.
Wilson JM, Junger CT . Principles and Practice of Screening for Disease, World Health Organisation Public Health Paper 34 World Health Organisation: Geneva, 1968, pp 26–37.
Keay L, Edwards K, Naduvilath T, Taylor HR, Snibson GR, Forde K et al. Microbial keratitis. Predisposing factors and morbidity. Ophthalmology 2006; 113: 109–116.
Acknowledgements
We thank Dr Jan Poloniecki, Reader in Medical Statistics, St George's University of London, for providing statistical advice.
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Part of this material has previously been published as a poster at the 2004 annual congress of the Royal College of Ophthalmologists. It has not been published in any other journal. Local ethics committee approval was granted before the study (reference 03.0116). No proprietary interests declared. No funding was received
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McHugh, J., Alexander, P., Kalhoro, A. et al. Screening for ocular surface disease in the intensive care unit. Eye 22, 1465–1468 (2008). https://doi.org/10.1038/sj.eye.6702930
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DOI: https://doi.org/10.1038/sj.eye.6702930
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