Ocular surface disorders are usually self-limiting. They may lead to visual impairment or blindness if extensive. Post-recovery visual loss would be devastating to any patient who has recovered from the physical and psychological impact of intensive care therapy [1,2].

In the critically ill and unconscious patients, in the Intensive Care Unit (ICU) patients are susceptible to a number of ophthalmic conditions that may result in visual loss. Predisposing factors include position of the lid, use of mechanical ventilation, presence of respiratory tract infection or organ failure and prophylactic eye care instituted. Temperature and humidity also play an important role in patients with incomplete eye closure [2].

Examination of the eye yields important information necessary for making accurate differential diagnosis; hence, ocular examination should always be considered an important element of the patient’s examination. The eye’s natural protection is composed of the upper and lower lids, lacrimal film and the conjunctiva. The eyelids and tears help flush organisms and abrasive particles from the eye with each blink. The conjunctiva has lymphoid tissue that provides the eye with immediate immune response [3,4].

Several studies around the globe have reported eyelid positions at different interval of time in ICU patients. However, no such study of its kind has been reported from this hilly region. Hence, we planned this study to evaluate eyelid positions and Discharge from eyes among patients admitted in Adult Intensive Care Unit either on mechanical ventilation or on spontaneous respiration.

Aim and Objectives

To evaluate eyelid positions and Discharge from eyes among patients admitted in Adult Intensive Care Unit of Dr RPGMC Kangra (Tanda), H.P.

• Study Design: It was a prospective observational study

• Study Area: Department of Ophthalmology, Dr. RPGMC Kangra at Tanda

• Study Period: After approval by Institutional Ethical Committee (IEC), this study was carried in Adult Intensive Care Unit (AICU) at Dr. Rajendra Prasad Government Medical College, Kangra at Tanda (HP) over period of one year

• Study Population: This prospective study was carried out in 126 patients, 18-65 years of age in Adult Intensive Care Unit (AICU) at Dr. Rajendra Prasad Government Medical College, Kangra at Tanda (HP)

Inclusion Criteria:

• All patients aged 18-65 years admitted in AICU for a time period >48 hours were included

• Prior informed consent was obtained from attendant authorized to do so

Exclusion Criteria:

• Patients who presented with ocular surface disorders prior to admission in AICU

• Patients or authorized attendant not willing to participate in the study

Methodology of Data Collection

All the patients who were admitted in ICU greater than 48 hours between age of 18-65 years were included in this observational study. All patients who were on mechanical ventilation or on spontaneous ventilation were taken for this study. Mechanically ventilated patients were those patients who are intubated either by Endotracheal Tube (ETT) or Tracheostomy Tube (TT) and were on mechanical ventilation. Spontaneous breathing patients were patients who were either on room air or on venti mask.

Patients were evaluated with special reference to Demographic information like name, age (in years), gender (male/female). Thorough ophthalmic examination including Pupil size and reaction, Relative afferent pupillary defect by swinging flash light examination, External eye examination for conditions like presence of lagophthalmos, exophthalmos, buphtalmos and deviation of eyeball, Hand held Slit lamp examination for complete anterior segment evaluation.

Operational Definition: Eyelid Position

Eyelid position grading was defined as per Momeni et al. [6]:

• Grade 1 - lid apposed

• Grade 2 - conjunctiva exposed

• Grade 3 - limbus exposed

Follow-up of the patients was done on every alternate day or depending upon the ocular surface involvement.

Statistical Analysis

Data were entered in to spreadsheet and analysed using SPSS v21. Data were presented as frequency, percentage, mean and Standard Deviation (SD). Normality of data was determined by Shapiro Wilk test. Normally distributed quantitative variables were compared using Student t-test. Categorical variables were compared using Chi square test. p-value <0.05 was considered statistically significant. 

A total of 126 patients were included in the study. Out of 126 patients, 102 patients were later shifted to respective wards, 17 patients did not survive while 7 patients were referred to higher centre for further management. The study findings have been presented below.

Figure 1: Age and Gender Distribution of the Study Participants (n = 126)

Figure 2: Eye Discharge in the Study Subjects. X-Axis Shows Discharge in Right and Left Eyes while Y-Axis Shows Number of Eyes

Table 1: Eyelid Position in the Study Subjects

Mean age of the study participants was 41.8 years with a range from 18 years to 65 years. 23.8% of the patients were in age group of 51 and 60 years. 23% of the patients were each aged between 21 and 30 years and 41 and 50 years. 13.5% patients belonged to age-group of 31 to 40 years. 8.8% of the patients were elderly (>60 years). Remaining, 7.9% of the patients aged up to 20 years. In the present study, male to female ratio was 1.8:1. 64.3% of the patients in our study were males while remaining 35.7% of the patients were females (Figure 1).

In the present study, 26.2% of the right eyes had grade 3 eyelid position at 48 hours. At the end of first week, 67% of the right eyes had grade 3 eyelid position while at the end of second week, 64% of the right eyes had grade 3 eyelid positions. At the end of fourth and fifth week, none of the right eyes had grade 3 eyelid positions. About 24.6% of the left eyes had grade 3 eyelid position at 48 hours. At the end of first week, 67% of the left eyes had grade 3 eyelid position while at the end of second week, 64% of the left eyes had grade 3 eyelid position. At the end of fourth and fifth week, none of the left eyes had grade 3 eyelid position (Table 1).

In the present study, rate of mucopurulent discharge was 14.2% and 11.9% in right and left eyes respectively at 48 hours. At the end of first week, the rate of mucopurulent discharge was 59.2% in the right eyes and 63% in left eyes. At the end of second week, the rate of mucopurulent discharge was 18.2% and 36.4% in right and left eyes respectively. Three right eyes out of 5 eyes and one left eye out of 5 eyes showed mucopurulent discharge at the end of third week. At the end of fourth and fifth week, none of the eyes showed mucopurulent discharge (Figure 2).

The eyelids are important physical barriers to trauma and infections preventing the adherence of microorganisms to the ocular surface. The sedatives and neuromuscular blockers inhibit contraction of the orbicularis oculi muscle, resulting in incomplete eyelid closure, which has been reported to occur in 20% to 75% of sedated patients in AICUs [5]. In our study, majority of the patients had incomplete eye closure during the first 2 weeks of ICU stay of these patients.

ICU medical and nursing staff are primarily concerned with life threatening conditions; therefore, the ocular signs and symptoms may be missed leading to serious ocular complications. If they are properly educated about eye care along with general care, they can markedly reduce eye related complications which may cause blindness. Eye care may include lubrication with eye drops (carboxymethylcellulose, 0.5%), administration of broad-spectrum antibiotics, taping of eye lids with chloramphenicol ophthalmic ointment in case of lagophthalmos and regular examination by ophthalmologists [6,7].

Study concluded that many patients at the time of admission in AICU had grade 3 eyelid position and mucopurulent discharge which may resoles over time with proper clinical care. Eye care which may include lubrication with eye drops, administration of broad-spectrum antibiotics, taping of eye lids and regular examination by ophthalmologists can markedly reduce eye related complications among AICU admitted patients.

Funding

There was no any additional financial burden on the subjects because of participation in the study. Investigator did not get any financial benefit from any source for this study.

Ethical Approval

The study was approved by IEC at Dr RPGMC Kangra at Tanda. Consent forms were signed and collected from attendants of all the patients, who were included in the study.

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6. Momeni Mehrjardi, Z. et al. "Effect of training eye care clinical guideline for ICU patients on clinical competence of eye care in nurses." Critical Care Research and Practice, January 2021, 2021:6669538.

7. Saritas, T.B. et al. "Ocular surface disorders in intensive care unit patients." The Scientific World Journal, October 2013, 2013:182038.