Eye care in the intensive care unit during the COVID-19 pandemic and beyond.

Exposure keratopathy is common in critically ill patients, affecting more than half of mechanically ventilated patients in the UK [1]. It may progress to sight loss from devastating ocular surface scarring and may also lead to microbial keratitis. The Royal College of Ophthalmologists (RCOphth), in collaboration with the Intensive Care Society, has endorsed a guideline to prevent exposure keratopathy in the the intensive care unit (ICU), [2]. However, there remains significant variability in practice and limited awareness regarding the existence of the guidelines among ICU staff. An audit performed in adult ICUs at St George’s Hospital, London in November 2018, more than a year since the publication of the RCOphth guidelines, showed documentation of eye care in the last 24 hours in 16 of 20 patients (80%). However key aspects outlined by the guideline, including lid closure, were recorded in just 2 out of 20 patients (10%) and preventative measures undertaken in 4 out of 20 patients (20%).

Exposure keratopathy typically results from a combination of lagophthalmos and tear film defect. Many factors contribute in the unconscious patient, including: sedation; use of neuromuscular blocking drugs; reduced tear production and blink rate; impaired or absent corneal reflex; eyelid oedema; and conjunctival chemosis. Exposure keratopathy is easily preventable in most patients, but with the life‐threatening problems affecting patients currently in the ICU, their eye care can easily be overlooked. There is evidence that raising the profile of the condition among ICU staff and introducing a clear protocol for simple preventative measures can radically reduce the risk of exposure keratopathy to < 5% [1].

With the ongoing COVID‐19 pandemic, although less than 15% of affected patients will require hospital admission [3], a significant number of these will require ventilatory support. As part of the management of acute respiratory distress syndrome, patients whose lungs are mechanically ventilated receive neuromuscular blocking drugs and the resultant reduction in orbicularis muscle tone, combined with patients being nursed in a prone position, will increase patients’ risk of exposure keratopathy.

Training ICU staff in recognising risk factors and applying preventative measures, particularly during these challenging conditions, is paramount in order to reduce the risk of long‐term sequelae from exposure keratopathy. We have designed a training tool and a simple protocol (online Appendix S1) for eye care in sedated or mechanically ventilated patients, based on the RCOphth guideline [2]. These are available via the Microguide smartphone application under the Moorfields Eye Hospital, Pandemic Eye Care Guide. In a joint effort between ophthalmologists and intensivists, this protocol is being implemented in a number of London hospitals providing care for patients with COVID‐19.

We invite intensive care and ophthalmology trainee networks in the UK to collaborate in implementing the protocol for eye care and reach a national consensus of standard of eye care in the ICU.

Appendix S1. Eye care in sedated or mechanically ventilated patients.

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