Comment on: "Care for critically ill patients with COVID-19: don't forget the eyes".

To the Editor:

Ting et al. [1] recognized that prevention of exposure keratopathy is paramount in critically ill patients with COVID-19. We agree, particularly as the COVID-19 patients who require mechanical ventilation and sedation tend to have longer stays in critical care, which increases their risk of developing exposure keratopathy. However, eye care may be overlooked in busy critical care units under strain during this pandemic. Using guidelines from the Royal College of Ophthalmologists [2], we audited our experience (see Table 1).

Table 1

Quality of eye care in COVID-19 patients in the critical care unit.

	Initial audit n (%)	Re-audit n (%)
Number of patients surveyed	49 (100%)	46 (100%)
Number of patients with exposure (grade 1 or 2) • Grade 1 = conjunctiva visible • Grade 2 = cornea visible	25 (51%)	16 (34.8%)
Number of patients with exposure (grade 1 or 2) who had adequate lubrication	8/25 (32%)	14/16 (87.5%)
Number of patients with severe exposure (grade 2)	17 (34.7%)	10 (21.7%)
Number of patients with severe exposure (grade 2) who had adequate lubrication AND assisted lid closure	4/17 (23.5%)	2/10 (20%)
Number of patients nursed in ‘prone position’	4 (8.2%)	Nil patients ‘proned’ within 72 hours of re-audit
Number of patients nursed in ‘prone position’ who had adequate lubrication AND assisted lid closure	3/4 (75%)

We found 51% of COVID-19 patients in critical care had some degree of eye exposure due to incomplete lid closure (lagophthalmos) in our first audit. Only a third of these patients had adequate lubrication, and less than a quarter with severe exposure (grade 2: cornea visible) had any form of assisted lid closure. Those who needed to be nursed ‘proned’ fared slightly better in eye treatment; perhaps by virtue of being sicker with COVID-19, these patients were seen to more attentively.

Whilst redeployed from our eye departments to critical care, we instituted an eye teaching program in the intensive care unit, with a simple message:

Following our teaching, our re-audit data showed nearly 90% of COVID-19 patients in critical care with lagophthalmos had adequate lubrication, including those with severe exposure. However, there was still room for improvement regarding assisted lid closure. Therefore, we repeated a teaching session with a new message:

COVID-19 is a cruel illness; we have seen its devastating effect on patients, and the strain on healthcare services. We must ensure that patients who recover from COVID-19 do not develop sight-threatening complications from their stay in critical care.

On reflection, redeployment has been an enriching experience, throughout which we have felt supported and valued by our colleagues. If there is a ‘second wave’ of COVID-19 as predicted, we are optimistic that the healthcare community will continue to show adaptability, teamwork and resilience for the benefit of our patients.