Incidence, risk factors and impact of protocolised care on exposure keratopathy in critically ill adults: a two-phase prospective cohort study

Background: Exposure keratopathy (EK) has a high incidence in critically ill patients. We aimed to determine the rate of EK in patients admitted to our intensive care unit (ICU), identify risk factors for developing EK and ascertain the effectiveness of a protocol to prevent EK. Methods: We undertook a two-phase prospective cohort single-centre study in a general adult ICU. The first phase of the study was observational. In the second phase of the study an eye care protocol was introduced. Daily ophthalmic assessment was carried out using a portable slit lamp. We also recorded Acute Physiology and Chronic Health Evaluation II score, daily Sequential Organ Failure Assessment score, mechanical ventilation, Richmond Agitation-Sedation Scale, and level of eye care. Student's t test and chi(2) statistics were used for simple analysis of continuous data and categorical data, respectively. Binary logistic regression was used to analyse the relationship between EK (yes/no), as the dependent variable, and multiple independent variables, calculating unadjusted and adjusted odds ratios. Results: We studied 371 patients. In the first phase, the overall rate of EK was 21% but the rate in mechanically ventilated patients was 56%; chi(2) (1, N = 257) = 80.8, p < 0.001. Adjusted odds ratios (AOR) for development of EK were 28.6 (8.19-43. 37), 13.0 (3.16-54.38) and 1.2 (1.03-1.33) with incomplete eye closure, mechanical ventilation, and higher SOFA score, respectively. Following the introduction of the protocol in the second phase, the overall rate of EK reduced to 2.6% (three cases); chi(2) (1, N = 371) = 18.6, p < 0.001. Compliance with the protocol was 97%. Conclusions: EK is common in critically ill patients, and is associated with mechanical ventilation and incomplete eye closure. A simple protocol substantially reduces the incidence of EK and is easily achieved in clinical practice.