Improving eye care in an intensive care unit.

In Intensive Care Units (ICUs), patients are at risk of developing ocular complications, especially exposure keratopathy. Plan, Do, Study, Act for PDSA cycle. Despite national guidelines, implementation remains challenging. Using the PDSA cycle, we devised an eye care protocol integrated into the electronic patient record system, complemented by a poster summary of guidelines. An initial audit showed 2% adherence to eye exposure guidelines; post-intervention, adherence rose to 76%. A 9-month analysis revealed 16% of patients experienced eye exposure in ICU. This initiative emphasises the new protocol's efficacy and the role of education in its adoption, advocating a more standardised approach to eye care in ICUs.

Systematic review of ocular surface treatments in the setting of thyroid eye disease.

Introduction: Approximately 85% of patients with thyroid eye disease experience ocular surface symptoms. Although corneal exposure plays a role in inducing inflammatory changes to the ocular surface, multiple studies reveal more complexity to the abnormal tear film composition and parameters in thyroid eye disease patients including those who do not have proptosis or increased corneal exposure. Currently, a majority of cases of thyroid associated dry eye symptoms are given treatments intended for ocular surface disease arising from different etiologies. Methods: Medline via Ovid, Cochrane CENTRAL, PubMed, and Google Scholar were systematically searched for articles evaluating the efficacy of treatments for dry eye symptoms in patients with thyroid eye disease. Articles were from all geographic regions and dates ranged from inception until October 2023. Results: Seven papers ultimately met inclusion criteria and were included in this review. These papers revealed that multiple topical and non-topical treatment modalities address dry eye symptoms in thyroid eye disease and improve subjective and objective ocular surface parameters. However, due to the few studies that exist and due to disparities in sample size and study design, no overwhelming best practices were identified that could influence clinical practice. Conclusion: This systematic review identifies the current treatments that exist and highlights the clear unmet need for a large population suffering with dry eye symptoms. Ideally, further well-designed investigations into this area would target topical, non-invasive modalities to develop first line options for thyroid eye disease patients.

Factors influencing medical expenditures in patients with unresolved facial palsy and pharmacoeconomic analysis of upper eyelid lid loading with gold and platinum weights compared to tarsorrhaphy.

There are no standards in diagnostic and therapeutic approaches to eye care in incomplete eyelid closure due to unresolved facial palsy (FP). Loading of the upper eyelid (UELL) with gold weights (GWs) or platinum chains (PCs) is a highly effective procedure for the correction of lagophthalmos. Despite this, the procedure is used infrequently in our country because of the relatively high price of the implant and the lack of reimbursement. The aim of this research was to assess the factors influencing medical expenditures in this group of patients and to analyze utility costs for the UELL procedure with the use of GW and PC compared to tarsorrhaphy.Material and methods The costs of 88 surgical procedures (40 GWs, 11 PCs and 37 tarsorrhaphies) and medical expenditures before and after surgery were calculated based on reporting of materials, staff salaries and the SF-36 questionnaire. Distribution quartiles of the cost per QALY measure (dependent variable) was assessed via an ordered logistic regression model with eight explanatory variables.Results The calculated total cost of the surgery was US$209 for tarsorrhaphy, US$758 for UELL with a GW and US$1,676 for UELL with a PC. Bootstrapped costs per QALY values (CUI) in 88% of cases were below the US$100,000 cutoff. Etiology and duration of facial palsy and presence of Bell's phenomenon were factors that significantly influenced the CUI. Patient gender and age, history of previous eyelid surgery, and presence of corneal sensation were found to be not significant (p > 0.1). Calculated ICER for GW was US$1,241.74/1QALY and ICER for PC was US$13,181.05/1QALY compared to tarsorrhaphy.Conclusions Eye protection in patients with FP should be a crucial element of health policy. Findings suggest UELL procedure with a GW or a PC to be a cost-effective procedure with GW being the most cost-effective.

Scleral Contact Lens to Preserve a Corneal Graft in Chronic Lagophthalmos.

Facial burns involving the periorbital region may lead to cicatricial ectropion and lagophthalmos, causing severe exposure keratopathy and eventually blindness if uncorrected. In these patients, it is critical to provide aesthetic and functional surgical correction to protect the ocular surface from chronic desiccation in addition to visual rehabilitation. Conventional methods may not be sufficient to provide visual rehabilitation in complex cases. Scleral lenses can be a multipurpose alternative for these patients. Herein, we present the challenging case of a patient who developed cicatricial lagophthalmos and exposure keratopathy after facial transplantation due to gasoline burns and received a scleral contact lens for visual rehabilitation.

Clinical features, evaluation, and management of ophthalmic complications of facial paralysis: A review.

The purpose of this review was to study the evaluation, diagnosis, and management of ophthalmic complications associated with facial nerve palsy and to discuss the current and future interventions. The ophthalmic complications of facial paralysis include lagophthalmos, ectropion, exposure keratopathy, ocular synkinesis, and crocodile tears. Evaluation by an ophthalmologist skilled in recognizing and managing complications of facial paralysis shortly after its initial diagnosis can help identify and prevent long-term complications. Several types of grading scales are used to evaluate, measure the severity, and track surgical and patient-reported treatment outcomes. Lagophthalmos or ectropion are managed using temporary measures aimed at lubricating and covering the eye, including scleral lenses; however, these measures can be expensive and challenging to acquire and maintain. Temporary surgical interventions include lateral tarsorrhaphy, weighted eyelid implants, lateral canthoplasty, and other procedures that tighten or lift the eyelid or surrounding tissues. Management of flaccid facial paralysis due to iatrogenic injury or neoplasm requires neurorrhaphy or graft repair. The most common techniques for dynamic reconstruction in chronic facial paralysis are regional and free muscle flap transfer. Future directions for the management of ophthalmic complications aim to induce blinking and eye closure by developing systems that can detect blinking in the normal eye and transmit the signal to the paralyzed eye using mechanisms that would stimulate the muscles to induce eyelid closure. Blink detection technology has been developed, and a study demonstrated that blinking can be stimulated using electrodes on the zygomatic branch of the facial nerve. Further studies are needed to develop a system that will automate blinking and synchronize it with that of the normal eye.

Tape-splint tarsorrhaphy technique to manage exposure keratopathy in a patient refusing surgical intervention.

This case report describes the benefits of a unique tape-splinting technique to serve as a nonsurgical tarsorrhaphy in the management of exposure keratopathy in a patient who refuses surgical intervention.

Effect of Implementation of an Eyecare Bundle on Incidence of Exposure Keratopathy in Intensive Care Unit of Tertiary Care Center in North India.

Background: Lack of eyecare protective measures especially in unconscious and sedated critically ill patients, make them prone to ocular surface diseases (OSDs), e.g., exposure keratopathy. This study is aimed to frame an algorithm-based approach to eyecare via eyecare bundle to bring down the burden of OSDs in critically ill patients especially in resource-limited settings. Materials and methods: After clearance from institutional ethical committee, a quasi-experimental single center study was conducted over a period of 6 months. Incidence of exposure keratopathy was calculated before and after induction of eyecare bundle and was compared. Statistical analysis was done using SPSS software v20. p-value of less than 0.05 was considered significant. Results: A total of 218 patients were enrolled in the study after obtaining informed written consent and after fulfilling inclusion criteria. Patients were divided into control and experimental groups, with baseline characteristics similar in both the groups, respectively, in terms of gender, age (40 years), APACHE II score, and specialty distribution except predominantly medical patients in experimental group. In control group (n = 99), total 69 patients (41 medical and 28 surgical) developed exposure keratopathy, while in experimental group (n = 109) only 15 patients (6 medical and 9 surgical) developed exposure keratopathy, hence a significant reduction was observed. Further follow-up of patients in the experimental group was also done on Days 5 and 7, respectively. Conclusion: The proposed protocolized algorithm-based eyecare bundle significantly reduced the incidence of exposure keratopathy in sedated, mechanically ventilated, and vulnerable critically ill patients. How to cite this article: Sama S, Abrol R, Dhasmana R, Sharma N, Khandhuri S, Chauhan R, et al. Effect of Implementation of an Eyecare Bundle on Incidence of Exposure Keratopathy in Intensive Care Unit of Tertiary Care Center in North India. Indian J Crit Care Med 2023;27(6):426-432.

Diagnostic and therapeutic challenges in non-specific orbital inflammation - a case report.

Objective: The aim of this report is to present the diagnostic and therapeutic approach in a case of non-specific orbital inflammation complicated with sight-threatening exposure keratopathy. Case presentation: An 81-year-old female patient presented to our Ophthalmology Department for left, painful, unilateral exophthalmia and decreased vision in the same eye. The clinical examination revealed left proptosis, inferior dystopia, upper lid edema, erythema and moderate retraction, ocular motility restriction, chemosis and corneal epithelial defect. The keratopathy complicated in evolution with hypopyon. The patient received treatment for the exposure keratopathy and, after every specific cause of unilateral exophthalmia was ruled out using imagistic and laboratory examinations, systemic corticosteroid treatment was initiated. Although the response to treatment was prompt, it was incomplete because of the long-standing evolution. Discussions: In this case, the diagnosis was difficult because a malignant breast tumor was encountered and an orbital biopsy was impossible to be performed. The presence of exposure keratopathy complicated with hypopyon imposed the exclusion of an infectious process and delayed the initiation of the corticosteroid therapy. Conclusions: The diagnosis and treatment of this disease represent a challenge given the need to rule out all the local and systemic conditions that may present with exophthalmia.

Ocular factors predicting requirement for corneal protective oculoplastic surgery.

BACKGROUND: Currently there is no universally agreed schema for predicting ocular morbidity in facial nerve palsy. The House Brackmann Scale has limitations in assessing ocular morbidity from facial nerve palsy. Our aim was to create a scoring system to help quantify ocular morbidity to aid in decision making regarding the need for corneal protective oculoplastic surgery. METHODS: We conducted a large cohort study observing 606 patients attending the specialist facial palsy clinic in Manchester UK between March 2002 and October 2017. Retrospective multivariate analysis identified clinical predictors for the 316 patients that required oculoplastic surgery. ß coefficients generated in the multivariate analysis helped formulate a new facial nerve palsy scoring instrument to predict the need for corneal protective oculoplastic surgery. RESULTS: The House Brackmann Scale, corneal lagophthalmos and loss of corneal sensation proved clinically significant predictors for requiring corneal protective oculoplastic surgery. The scoring system derived from these factors provided an accurate and repeatable prediction tool demonstrated by validation studies on our patient population. The area under the ROC curve for the multivariate prediction model was 0.769 (0.726, 0.811). A score of 5 points out of a possible 8 was the best cut off score to recommend oculoplastic surgery, giving a sensitivity of 0.750 and a specificity of 0.671. CONCLUSION: This study demonstrates that corneal lagophthalmos, corneal sensation and the House Brackmann Scale are important in predicting the need for corneal protective oculoplastic surgery. Our scoring tool is an important clinical decision tool for ophthalmic and ENT colleagues.

Corneal manifestations and treatment among patients with COVID-19-associated rhino-orbito-cerebral mucormycosis.

Purpose: TO report the corneal manifestations in patients with COVID-19-associated rhino-orbito-cerebral mucormycosis (ROCM). Methods: This study was a retrospective, observational, and record-based analysis of patients of ROCM with corneal involvement. Results: A total of 220 patients were diagnosed with ROCM over a period of 3 months. Thirty-two patients had developed corneal manifestations. The mean age at diagnosis was 52.84 ± 12.8 years. The associated risk factors were systemic mucormycosis, uncontrolled diabetes, recent COVID-19 infection, and injudicious use of systemic steroids. Twenty-nine patients were known diabetics, 32 had recent COVID-19 infection, and 13 gave a history of injudicious use of steroids. The right eye (RE) was affected in nine patients, the left eye (LE) in 20 patients, and both eyes in three patients. Nine patients had a round-oval corneal ulcer. One patient each had a perforated corneal ulcer with uveal prolapse, sealed perforated corneal ulcer, spontaneously healed limbal perforation, diffuse corneal haze with hyphemia, panophthalmitis, diffuse corneal stromal abscess, limbal ischemia, anterior uveitis with posterior synechiae, inferior corneal facet, and filamentary keratitis. Three patients each had a corneal melt and inferior conjunctival xerosis with chemosis. Orbital exenteration was performed in six patients. Five patients with corneal ulcers healed. Topical eye drops of amphotericin (0.5 mg/ml) cycloplegic, antiglaucoma medications, and lubricant eye drops were started along with systemic antifungals. Conclusion: Central corneal ulcer was the most common manifestation of mucormycosis. A concentration as low as 0.5 mg/ml of amphotericin eye drops was effective in the treatment.

Online Questionnaire-Based Study on the Knowledge, Attitude, and Practices of Non-Ophthalmic Physicians-in-Training Regarding Exposure Keratopathy Among Patients Admitted in a Tertiary Referral Hospital.

Objective: This study aimed to determine the knowledge, attitude, and practices of non-ophthalmic physicians-in-training regarding recognition and prevention of exposure keratopathy among patients admitted in a tertiary referral hospital. Methods: This study was a single-center cross-sectional study. An anonymous self-administered online questionnaire was distributed among non-ophthalmic physicians-in-training at the Philippine General Hospital (PGH) using convenience and snowball sampling. Results: A total of 77 responses were recorded with a response rate of 37%. The majority of the respondents uniformly reported the absence of an established eye care protocol or policy being implemented for different subsets of patients at risk for developing exposure keratopathy. Ninety-six percent (96%) was aware of exposure keratopathy. The most urgent reason for referral to the ophthalmology service was the presence of whitish of opacity at 46.8%, while the least urgent reason was the presence of eye redness at 36.4%. Only 43% of the patients with incomplete eyelid closure was referred to the ophthalmology service. The most frequently used modality of prophylactic eye protection treatment was eyelid taping (84.4%) followed by lubricants (drops and gels, 79.1%). The most common reason for not referring was the absence of an established protocol on the appropriate indication for referral to the ophthalmology service. Conclusion: This study showed that the majority of non-ophthalmic physicians-in-training had adequate knowledge and favorable attitude regarding recognition and prevention of exposure keratopathy among patient admitted at the PGH; however, the absence or the unavailability of an eye care protocol among patients with inadequate eyelid closure in our institution on the prevention of exposure keratopathy and its early treatment and appropriate indications for ophthalmology referral resulted in non-uniformity and varied practice patterns on its management.

Implications of neuropathy and management of the corneal surface in a patient with Stuve-Wiedemann syndrome.

Purpose: To describe the ophthalmological management of a girl diagnosed with Stuve Wiedemann syndrome (SWS). Clinical and in vivo confocal microscopy (IVCM) are described. Methods: Case report of a 6-year-old girl, who presented with neurotrophic keratitis and was treated with intense lubrication including heterologous serum and tear plugs. Results: In the following months, the evolution of the neurotrophic keratitis was good, but a hypertrophic corneal leukoma persisted with mild neovascularization in the left eye. Conclusion: Close ophthalmological follow-up in patients with SWS is needed, given that most of the time they do not present symptoms due to the characteristic neuropathy of their lesions. Abbreviations: SWS = Stuve-Wiedemann syndrome, IVCM = in vivo confocal microscopy, CNTF = ciliary neurotrophic factor, BCVA = best corrected visual acuity, LIFR = Leukemia Inhibitory Factor Receptor, IGF1 = Insulin-like growth factor-1.

[Incidence and risk factors of exposure keratopathy in intensive care units: About 91 patients]. / Incidence et facteurs de risque des kératopathies d'exposition en milieu de réanimation : à propos de 91 patients.

Exposure keratopathy is a sight-threatening complication which can occur in patients admitted to intensive care units. This is a prospective study over a period of 5 months in the intensive care unit of the specialty hospital of the IBN SINA medical center, with a capacity of 8 beds. The purpose of our study was to determine the incidence of and risk factors for exposure keratopathy in intensive care settings. Forty-two percent of patients developed exposure keratopathy, 48% exhibited chemosis, and 40% showed lagophthalmos with the cornea visible in 30% of cases. The frequency of keratopathy was significantly higher in patients with chemosis and lagophthalmos (P<0.0001). Lagophthalmos was significantly related to chemosis (P<0.0001). Chemosis in the ventilated patient, also known as "ventilator eye," is a serious complication leading to the risk of keratopathy. The risk factors for keratopathy found in our series were chemosis (OR=25.28, 95% CI=[3.339-191.52] P-value=0.002), lagophthalmos (OR=40.8, 95% CI=[4.347-383.666] P-value=0.001) and length of stay in intensive care (OR=12.28, 95% CI=[1.476-102.230] P-value=0.020). Several methods might be used and adapted to each case for prevention of exposure keratopathy, and we found that raising nursing staff awareness is of paramount importance.

Case Report: Botulinum Toxin-A for Complication of Exposure Keratopathy Following Frontalis-Orbicularis Oculi Muscle Flap Shortening.

Background: Lagophthalmos with exposure keratopathy is a potential vision-threatening complication following surgery for blepharoptosis. We report three cases successfully treated with botulinum toxin-A (Botox®, Allergan, Irvine, USA) for this complication. Cases: Three patients presented with severe blepharoptosis after surgery for orbital and frontal base tumors. They obtained good appearances after frontalis-orbicularis oculi muscle (FOOM) flap shortening. However, exposure keratopathy developed after the surgery despite frequent use of topical lubricants and autologous serum eye drops. We injected 5-10 units of botulinum toxin-A around the central supra-brow area, which was near the origin of the FOOM flap. One week later, they developed ptosis and could close the eye completely. The corneal defect gradually resolved. They recovered from ptosis 3 months later and never required a second injection. Observations: Lagophthalmos with exposure keratopathy is a potential vision-threatening complication following FOOM flap surgery. In severe cases, surgical revision should be considered to partially or totally release the FOOM flap attachment, which also decreases its function permanently. In this case series, we demonstrated that injecting botulinum toxin-A may be a promising method to manage this complication without permanently affecting the function of the FOOM flap. Conclusions: A botulinum toxin-A injection may be an effective treatment for patients developing exposure keratopathy after FOOM flap surgery.

Pillar tarsoconjunctival flap: An alternative approach for the management of refractory corneal ulcer.

PURPOSE: To report the effectiveness of the surgical procedure of the tarsoconjunctival flap (FTC) in patients with severe ocular surface impairment refractory to previous conventional treatments. METHODS: A retrospective, noncomparative, consecutive case series. RESULTS: Pillar tarsoconjunctival flap (PTCF) was performed in eight eyes of eight patients. Three patients had neurotrophic corneal ulcer (NCU), three had exposure keratopathy and two had corneal melting. Seven of them had satisfactory postoperative results, showing total corneal re-epithelialization that lasted throughout the postoperative follow-up (mean 10.33 ± 2.65 months [SD], range 6 to 12 months). Mean time for the re-epithelization was 11.28 ± 8.97 days [SD] (range 4 to 30 days). CONCLUSION: This study suggest PTCF is a valid alternative to tarsorrhaphy in cases of persistent epithelial defect (PED) or NCU resistant to conventional treatments. Notwithstanding, prospective comparative trials comparing PTFC with conventional and/or novel therapies in PED or NCU are needed to corroborate these findings.

Ocular surface disease in thyroid eye disease: A narrative review.

Ocular surface disease (OSD) in the setting of thyroid eye disease (TED) is traditionally thought of as a natural consequence of anatomical changes such as proptosis and corneal exposure. However, a growing body of research suggests that ocular surface inflammation and multi-factorial changes to the homeostasis of the ocular surface contribute substantially to the OSD seen in TED patients. In this paper we review the existing literature which highlights the work and existing theories underlying this new paradigm shift.

Frontalis Sling Using a Silicone Rod for Ptosis in Third Nerve Palsy: Cosmesis versus Safety.

PURPOSE: To evaluate the results of the frontalis sling operation using a silicone rod for the correction of ptosis in patients with third nerve palsy with a focus on corneal safety. METHODS: Patients with third nerve palsy who underwent the frontalis sling operation using a silicone rod between 2008 and 2019 were included in this study. The medical records of all patients were reviewed, and their clinical characteristics and postoperative outcomes were analyzed. In this retrospective, interventional case series, the main outcome measures were eyelid contour, eyelid height by margin reflex distance, and corneal status. RESULTS: Twenty-four eyes of 18 patients (12 male and six female patients) were included. The mean age at the time of surgery was 35.1 years (range, 5-64 years). Twelve patients underwent a unilateral ptosis operation, and six patients received a bilateral ptosis operation. The mean follow-up period was 32.1 months (range, 2-87 months). Most patients (21 of 24 eyes, 88%) showed poor Bell's phenomenon on preoperative examination. Satisfactory eyelid height and eyelid contour were achieved in almost all patients (mean postoperative margin reflex distance, +1.2 mm) postoperatively. Although corneal erosions were detected for several months in eight of 24 eyes after surgery, these findings were well controlled medically with artificial tear eye drops and ointments. CONCLUSIONS: Frontalis sling surgery using a silicone rod can safely and effectively correct ptosis without severe corneal complications in patients with third nerve palsy. Our study outlines a new method to define the postoperative safety outcome by specifically focusing on categorized corneal status.

Prevention of Exposure Keratopathy in the Intensive Care Unit: Evaluation of an EMR-Based Lubrication Order Protocol for Ventilated Patients.

Purpose In this pilot study, we aimed to investigate the efficacy of an electronic medical record (EMR) order set for lubricating ointment (four times daily) in the prevention of exposure keratopathy in ventilated patients in the intensive care unit (ICU) at the University of Utah. We attempted to capture the magnitude of morbidity, cost, and care burden in ventilated patients, as well as the utility of a systematic EMR-based preventative lubrication protocol in the ICU setting. Methods After implementation of the order set, a retrospective chart review was performed to capture all ventilated ICU patients pre- and postintervention. Three separate study periods were used: (1) Six months prior to coronavirus disease 2019 (COVID-19) and prior to the ocular lubrication intervention; (2) the subsequent 6-month period including COVID-19 patients but prior to any intervention; and (3) the subsequent 6-month period postintervention, including COVID-19 patients. The primary endpoint of ointment use per day was analyzed with a Poisson regression model. Secondary endpoints including rates of ophthalmologic consultation and exposure keratopathy were compared with Fisher's exact test. A poststudy survey of ICU nurses was included. Results A total of 974 ventilated patients were included in the analysis. Ointment use per day increased by 155% (95% confidence interval [CI] 132-183%, p < 0.001) following the intervention. Rates also increased 80% (95% CI 63-99%, p < 0.001) during the COVID-19 study period but prior to intervention. The percentage of ventilated patients requiring a dilated eye exam for any indication was 3.2, 4, and 3.7% in each of the study periods, respectively. There was an overall down trend in the rate of exposure keratopathy which was diagnosed in 33.3, 20, and 8.3% of those receiving ophthalmologic consultation, though these rates were not statistically significant. Conclusion These preliminary data show a statistically significant increase in the rates of lubrication in mechanically ventilated patients using an EMR-based order set in the ICU setting. There was no statistically significant decrease in the rates of exposure keratopathy. Our preventative protocol with lubrication ointment was of minimal cost burden to the ICU. Further longitudinal and multicenter studies are needed to better assess the efficacy of such a protocol.