Effectiveness of Nursing Interventions to Prevent Dry Eye in Critically Ill Patients

Diego Dias de Araujo, PhD, MSN, RN; Daniel Vinicius Alves Silva; Carolina Amaral Oliveira Rodrigues; Patricia Oliveira Silva; Tamara Goncalves Rezende Macieira, BSN; Tania Couto Machado Chianca, PhD, MSN, RN


Am J Crit Care. 2019;28(4):299-306. 

In This Article


Most studies conducted to date on eye care practices for hospitalized patients focus on the prevention of corneal ulcers and associated risk factors. Little attention has been given to the problem of dry eye, especially among patients admitted to ICUs. Yet dry eye, if not adequately treated, can lead to corneal ulcers.[9,13]

Our results showed that artificial tears gel is more effective than liquid artificial tears (RR = 0.400; 95% CI, 0.166–0.964; P = .04) in preventing dry eye in adult ICU patients. We found no other published studies comparing these 2 interventions. Ezra et al[14] compared artificial tears gel and hydrogel in the prevention of exposure keratopathy among critically ill patients. They found that exposure keratopathy developed in 15% of patients in the artificial tears gel group, compared with 90% of patients treated with hydrogel (P = .04). In Brazil, hydrogel is approved as a dressing for the treatment of lesions or cutaneous wounds, but it has not been approved for use in ophthalmology.

Zhou et al[15] conducted a meta-analysis on the prevention of corneal alterations among critically ill patients; they found no statistically significant differences in effectiveness between moisture chambers and lubricating gel (RR = 0.81; 95% CI, 0.51-1.29; P = .38). The authors also examined studies that tested polyethylene film versus lubricating eye drops, but those studies were of lower quality.[15] In other studies,[16–18] polyethylene film was more effective in preventing corneal ulcers than liquid artificial tears and ocular gel, although the differences were not statistically significant.

The incidence of dry eye during the 5-day evaluation period in our study was from 1% to 21% in the liquid artificial tears group and from 3% to 9% in the artificial tears gel group. The development of dry eye was assessed for a relatively short time. However, this assessment period is supported by a study conducted in Brazil,[5] where researchers found a mean time of 3.5 days for the development of dry eye among the same target population. Although the patients were exposed to internal and external risk factors related to a decrease in production of tears or an increase in their evaporation, the present study showed that after the fourth day of hospitalization, the artificial tears gel intervention was more likely than the liquid artificial tears intervention to prevent dry eye.

The use of block randomization for allocation of participants to either the artificial tears gel group or the liquid artificial tears group ensured an even distribution of participants between the groups within the established data collection time frame. This type of randomization is preferred over individual patient randomization to avoid the risk of having a smaller number of participants in one of the study groups in the event of premature completion of data collection due to unforeseen reasons.

Because nursing professionals provide uninterrupted care to patients admitted to ICUs, they are well positioned to help reduce the risk of dry eye in these patients through appropriate eye care practices. Dry eye is a precursor to more serious eye changes that can result in severe harm to patients. Therefore, the nursing team must be knowledgeable about this condition and follow eye care practices designed to prevent or minimize damage to the ocular surface and resulting visual impairment. Once a patient is admitted to the ICU, the nursing team should assess the patient's ocular surface and identify possible risk factors for dry eye, implementing necessary interventions such as artificial tears gel as early as possible.

Liquid artificial tears or artificial tears gel cannot directly prevent the evaporation of tear film in patients with lagophthalmos. However, in the present study we observed that the artificial tears gel could keep the upper and lower eyelids adhered, in addition to forming a thin film in the palpebral space, increasing its retention time on the ocular surface. This mechanism might facilitate lid closure and thus help prevent complications. Nonetheless, polyethylene film is the preferred intervention to prevent corneal ulceration in patients with lagophthalmos. In covering the eye area, it creates a moisture chamber that prevents evaporation of tears.[2,14,16,19] If corneal ulceration is identified during ocular assessment, an ophthalmologist should be consulted.

This study has a few limitations, which may have affected the findings. The sample consisted only of patients admitted to an ICU, and the interventions were delivered twice a day (to suit the study site routine), whereas it is generally recommended to administer treatment whenever necessary. We did not test polyethylene film or other interventions that have been described in clinical guidelines developed to prevent eye diseases. Moreover, although it is unlikely, it is possible that the protocol of cleaning the patient's eyes with 0.9% sodium chloride solution did not completely remove all traces of the intervention substances applied.

In this study, patients with a Glasgow Coma Scale score of 7 or lower were under sedation for 5 days, which may not accurately represent sedation practices outside of Brazil or other developing countries. Future studies on prevention of dry eye should recruit a sample that is representative of the range of sedation practices. The protocols used for application of the interventions and ocular assessment for the development of dry eye were designed to enhance the rigor of the study and may not be applicable in clinical practice. However, the artificial tears gel intervention can be delivered by nurses on schedules different from the one in this study, including its use as a preventive measure at intervals of up to 12 hours.