Effect of Risk Reduction Nursing Measures on the Occurrence of Corneal Injury for Patients at Intensive Care Unit

Background: Prevention of corneal complications for Intensive Care Unit patients considered an effective way to avoid corneal damage. Polyethylene covering is transparent dressing which creates moist chamber providing a barrier against tear-film evaporation and physical barrier for micro-organisms Aim: This study was carried out to evaluate the effect of risk reduction nursing measures on the occurrence of corneal injury for patients in Intensive Care Unit. Design: Quasi-experimental design. Setting: Anesthetic Intensive Care Unit, at Tanta Emergency Hospital and Anesthetic Intensive Care Unit, at Tanta University Educational Hospital affiliated to Ministry of Higher Education and Scientific Research. Subjects : A convenience sampling of 60 mechanically ventilated patients divided into study and control groups (30 patients for each). Tools : Tool I: Critically Ill Patients Assessment Tool. Tool II: Richmond Agitation Sedation Scale. Tool III: Clinical Indicators of Corneal Injury Assessment Tool. Results: Findings of the present study revealed that there was statistical significant difference were observed among study group regarding physical assessment indicator of corneal injury regarding left eyelids, right and left conjunctiva which (P= 0.001, 0.021, 0.003) respectively. The current results revealed that more than two-third (73.33%) and the majority (93.33%) of study group patients have normal cornea in right and left eyes respectively from 1st to 7th days, and there was a statistical significant difference between control and study groups on the 7 th day in relation to corneal ulcer in right and left eyes (P = 0.001 and 0.00) respectively. Conclusion: Using eye care protocol reduced the incidence of keratitis, conjunctivitis, dry eye, and corneal ulcers in patients admitted to ICU. Recommendations: Eye care should be standardized as a basic part of nursing care provided to all critically ill patients in ICU. Emphasize the importance of assessing critically ill patient's eyelids, conjunctiva, cornea, and pupil for early detection of any eye problem. The study should be applied on large probability sample.


Introduction
Critically ill patients who admitted to Intensive Care Unit are provided with comprehensive and specialized medical and nursing care.With recent advances in the critical care medicine, it is evident that intensive care plan cannot limit itself with the resuscitative measures only.In contrast, it needs to provide the quality care plan to every organ of the patient. (1)Eye care became the integral part of care plan for critically ill patients.Those patients who are mechanically ventilated have high propensity to develop corneal injury which may lead to keratitis, corneal perforation and blindness.In addition to alteration in the protective mechanism of eyes, intensive care environment predisposes exposure of ocular surface to microorganisms and complications of overzealous resuscitation that may end up with chemosis and other eye complications.The incidence of eye-related complications in intensive care patients in different studies varies from 23% to 60% which include exposure keratitis and other corneal complications as well. (1)ll over the world, the number of mechanically ventilated patients in Intensive Care Unit rises to 56% at 2020. (2)In Egypt, the incidence of patients requiring mechanical ventilation in Intensive Care Unit is about 40-65% . (3)Annually at Internal Anesthetic Intensive care unit, Emergency Hospitals at Gharbia Governate, Egypt, according to Statistical record center in Tanta University 2021, there are About 220 patients are admitted Intensive Care Unit, and about 120 needs mechanical ventilation. (4)he ventilated intensive care patients are prone to many eye complications as a result of loss of normal defense mechanism in response to high dose of sedation after mechanical ventilation therapy. (5,6)orneal injury indicates damage to the surface layers of the eye, namely the cornea and conjunctiva.There are many factors that cause corneal injury in the Intensive Care Unit.)(10) Prevention of corneal injury is a very important and vital role of the ICU nurse.Eye assessment should be part of a routine patient physical assessment and be performed on admission, followed by an ongoing assessment at the beginning of each new nursing shift.Nurses provides a baseline assessment, monitor response to clinical treatment, identify any changes of the eyes.Each eye should be assessed independently.Eye assessment in ICU should include eye opening, reaction, and eyelid closure, eyelid position, blinking reflex, pupil size and signs of corneal complications. (11)ye care is an important aspect refers to measures that maintain ocular health, comfort and protect eye surfaces from potential harm . (12)(17)(18)(19)(20)(21)(22) Vol. 31.No. 4 (Suppl 1) ,November 2023 Polyethylene film is a single polymer, obtained by polymerization of ethylene.This is low-density plastic that contains no trace of potentially toxic materials.It is a transparent film containing 100% polyethylene in the middle of the cover and double-sided and adhesive drape forms the edges of the cover.This polymer has high resistance to water and other solutions.This feature enables polyethylene film to cover the area from the eyebrow to the cheek that keep eye from any organisms.It is also an eye protector that prevents tears from evaporating away from the eye surface which keeping the eye moistened by tears, and thus forming a moist chamber to preserve the integrity of the cornea. (23,24)ignificance of the study Critically ill patients who admitted to the Intensive Care Unit have many risk factors for corneal injury, including loss of consciousness, receiving sedative and neuromuscular blocking agents, and mechanical ventilation which lead to lose of eye-protective mechanisms causing exposure to corneal injury, it found to be between 23% and 60% in critically ill patients.The high incidence of ocular complications in ICU may remind the fact that eye care is important nursing care for patients undergoing mechanical ventilation.Therefore, the present study was conducted to evaluate the effect of different risk reduction nursing measures on the occurrence of corneal injury.

Aim of the study
The aim of the study is to evaluate the effect of risk reduction nursing measures on the occurrence of corneal injury for patients at Intensive Care Unit.

Research hypothesis
Critically ill patients who will receive risk reduction nursing measures are expected to decrease corneal injury compared to control group who receive routine care.

Subjects and Method Subjects Study Design
A quasi-experimental research design was utilized in this study.

Setting
This study was conducted the Anesthetic Intensive Care Unit, in Tanta Emergency Hospital and the Internal Anesthetic Intensive Care Unit, in International Educational Hospital at Tanta University affiliated to ministry of higher education and scientific research.Subjects A convenience sampling of 60 mechanically ventilated patients who were admitted to the previously mentioned settings and were selected based on Epi info statistical program.The sample was divided into two equal groups, 30 patients in each as follow: Control group: They received routine hospital eye care which included eye irrigation with sterile normal saline and covered the eye with tape.Study group: They received a combination of polyethylene eye-cover and artificial teardrops with routine hospital eye care.

Tools of data collection
Three tools were used in this study:-Tool I: Critically Ill Patients Assessment This tool was developed by the researcher after reviewed the relevant literature (25)(26)(27)(28) (29) It was developed by the researcher, it was used to assess; mode of mechanical ventilation which included {controlled mandatory ventilation (CMV), assisted controlled ventilation (ACV), intermittent mandatory ventilation (IMV), synchronized intermittent mandatory ventilation (SIMV), positive end-expiratory pressure(PEEP), continuous positive airway pressure(CPAP)} , positive end expiratory pressure (PEEP), fraction of inspired oxygen (FiO2) and (SPO2) for ventilated patients.Part (c): Assessment of Glasgow Coma Scale (GCS): (30) It was developed by Steven M Green (2021) and adopted by the researcher to assess the level of consciousness of critically ill patient.It was divided into three main variables: eye opening response (4 items), verbal response (5 items), and motor response (6 items).The researcher checked the response of the subjects pertinent to the three variables of the GCS.

Scoring system
The level of consciousness was determined by the sum of the given score for each variable and classified as follows: -Score of 13-15 was considered mild level.
-Score of 9-12 was considered moderate level.
-Score of 3-8 was considered severe level.
Tool (II):-Richmond Agitation Sedation Scale (RASS): (31) This tool was developed by Sessler (2020) and adopted by the researcher.It was used to assess patient's anxiety and agitation.
-In addition to, sedation and muscles relaxants data used to assess effect of sedation and muscles relaxant on corneal exposure and eye closure on critically ill patients.It included drug names, dose and frequency.

Tool (ІІІ):-Clinical Indicators of Corneal Injury Assessment Tool
This tool was developed by the researcher after reviewed of the related literature (32) , Which divided into three parts:-Part (a): Physical assessment of eye: This part was used to assess patient's eyelids, conjunctiva, cornea, and pupil from the first day of admission for seven consequent days, and three times per day as following: -Assessment of eyelids for the presence of any Lesions, crusting, redness, swelling / bruising, and lacerations.
-It was used to assess the viability of the epithelium and provide extensive details about ocular surface injury.The Corneal Fluorescein Staining was specific in identifying corneal damage in ICU patients Vol. 31.No. 4 (Suppl 1) ,November 2023 as well as fluorescein testing considered to measure and classify the patients' corneal injury, it was used as the following.
-At the portable slit-lamp microscope with a blue filter, the cornea examined between four and eight minutes following the instillation of fluorescein by using the fluorescein strip.The patient's eyelid gently opened and closed a few times to spread the Fluorescein on the eye surface.
-The concentration and the breadth of the corneal staining provided valuable evidence to measure disease severity and to monitor the response to treatment .Epithelial Erosions counted and scored from zero to five.Scoring system -Severity 0: Lack of contact keratopathy.
-Severity 1: Incidence of lesion spots (pits resulting from loss of epithelium cells in one third of the lower epithelium layer of cornea. -Severity 2: Incidence of pits (small pits) in more than one third of lower epithelium layer of cornea.
-Severity 4: Turbidity of stroma layer despite epithelial defects of cornea.
-Severity 5: Incidence of scar in stroma layer.Part (c): -Eye Grading Guide : ( 34) This part was developed by Mercieca (2020) and it used to accurately assess the degree of eye exposure and closure for grading lagophthalmos from the first day of admission for seven consequent days, and three times per day.It consisted of three grades:--Grade 1: Lids completely closed.
-Grade 2: Any conjunctival exposure as shown by any white of the eye being visible, but no corneal exposure.
-Grade 3: Any corneal exposure, even a very tiny amount. .-Written informed consent was obtained from the responsible person for critically ill patients.
-Confidentiality and anonymity was maintained by the use of code number instead of name and the right of withdrawal is reserved.
-Privacy of the studied patients was maintained.
-The study didn't cause any harm to the critically ill patients.Care nursing and Biostatistics to ensure their validity and modifications was done.The current results revealed that more than two-third (73.33%) and the majority (93.33%) of study group patients have normal cornea in right and left eyes respectively from 1st to 7th days, and there was a statistical significant difference between control and study groups in right and left eyes (P = 0.001 and 0.00) respectively.As regard to corneal abrasion in right eye, it was observed that (60.00%) of patients in control group had corneal abrasion after 7th day of the study compared to (13.34%) of patients in the study group.Also, regarding corneal abrasion in left eye, it was observed that (60.00%) of patients in the control group had corneal abrasion after 7th day of the study compared to (6.67%) of patients in the study group.Regarding corneal ulcer in right eye, it was observed that small percentage (13.33%) of both control & study group had incidence of macro-epithelial defect after 7th day of the study.Also, regarding corneal ulcer in left eye, it was observed that (20.00%) of patients in control group had incidence of macro-epithelial defect after 7th day of the study compared to no one of any patients in the study group.-Statistical significant difference were observed among control and study groups regarding right eye which (P = 0.001, 0.000) respectively and left eye which (P = 0.000)  11.554 0.003* 0 0.00 0 0.00 2 6.67 0 0.00 0 0.00 0 0.00 0 0.00 2 6.67 6 66.67 0 0.00 6 20.00 5 16.67 0 0.00 2 6.67 2 6.67 0 0.00 0 0.00 0 0.00 0 0.00 0 0.00 2 6.67 0 0.00 4 13.33 6 20.00 0 0.00 0 0.00 0 0.00 0 0.00 0 0.00 6 20.00 0 0.00 0 0.00 0 0.00 .33 6 20.00 2 6.67 0 0.00 0 0.00 2 6.67 4 13.33 2 6.67 0 0.00 0 0.00 0 0.00 0 0.00 0 0.00 0 0.00 6 20.00 0 0.00 0 0.00 0 0.00

Discussion
Intensive care patients have a great possibility of developing adverse eye changes due to mechanical ventilation, and the use of medications, such as muscle blocking drugs, sedatives and diuretics that interfere with the cornea's protective mechanisms, interfering with effective eyelid closure and the production of tears. (35)ccording to the findings of the current study, less than half of the participant patients in both groups were between (50-60) years old.This could be explained by the fact that the majority of eye diseases are considered to be age-related disease because the prevalence of the eye diseases rises with age.This is consistent with the findings reported by Alvarenga et al (2021) who revealed that the average age was approximately 55.9 years. (36)In relation to sex, more than half of the participant patients were male.This might be explained by the fact that men are more prone to road and motor accident.
Similarly to Silva et al (2021) who reported that more than half of the patients were men. (37) The findings of current study revealed that all patients were unconscious.This result could be due to majority of patients admitted to ICU as a result of traffic accident, that may affect their level of consciousness and their spontaneous eye opening and the frequency of blinking was limited so that increase risk for corneal complications as corneal abrasion and corneal ulcer.This result was in line with de França.etal(2023) who documented that altered level of consciousness has an impact on the protective mechanisms of the eye and increase risk of OSDs, such as corneal dehydration, abrasion, and ulceration. (41)n the current study, the majority of patients in the study group had normal eye assessment (eye lid and conjunctiva) after 7 th day of the study compared to less than half of patients in the control group had normal eye assessment.It might be due to the use of eye care protocol (polyethylene eye-cover and artificial teardrops with routine eye care such as eye irrigation with sterile normal saline in the study group, which created a moist chamber and provided a barrier against tear-film evaporation.This result is in line with Dawson, (2020) who documented that the use of polyethylene covers is an effective method in preventing eye complications. (42)egarding Corneal Fluorescein Staining (CFS) in the current study, it was revealed that more than two-third and the majority of study group patients have normal cornea in right and left eyes from 1st to 7th days.It might be due to the use of eye care protocol (polyethylene eye-cover and artificial teardrops with routine eye care in the study group.Similarly to Ehsani et al. (2020), who reported that the use of three methods of eye care including the use of polyethylene cover, liposic ointment, and artificial tear drops were more effective than washing the eye with normal saline alone. (43)egarding eye grading guide in the current study, the result revealed that more than half of the participant patients in the control and study groups had grade II and III.This indicated to the presence of incomplete eyelid closure.It might be explained by the majority of patients were unconscious, sedated and reported severe level of GCS that lead to corneal abrasion and ulceration.These findings were supported with Mc Call.et al. (2019) who showed that incomplete eyelid closure and prolonged intensive care stay are risk factor for corneal surface disorders development. (44)he findings of current study revealed that the studied patients were on sedation and the majority of them reported sever level of GCS and more than two-third were unarousable that leading to lagophthalmos which lead to corneal complication.This result is in line with Med Pregl,(2022) who documented that critically ill patient unable to maintain normal eye protective mechanisms such as eyelid closure and an intact blink reflex because the use of sedation and muscle relaxants were more susceptible to corneal complications. (45)oncerning Corneal Fluorescein Staining (CFS) in relation to eye grading guide, it was observed that eye grading guide had statistically significant positive relation with the incidence of corneal abrasion and ulcer among control and study groups either in right or left eye.In the current study, the participant patients were unconscious so that those patients did not have spontaneous eye opening, incomplete eye lid closure and the frequency of blinking was limited leading to increase risk for corneal complications as corneal abrasion and corneal ulcer.This result is in line with Andrea et al., (2020) who found that altered levels of consciousness has an impact on the protective mechanisms of the eye that increase risk of eye injury, such as corneal dehydration, abrasion, and ulceration. (46)Also Fiona et al., (2022), found that mechanically ventilated patients who are unconscious considered high risk group who are dependent on eye care to maintain eye integrity.These patients are susceptible to corneal dehydration, abrasions and ulcer as a result of impairment of basic eye protective measures. (47)n the current study, it was found that patients on sedation and muscle relaxants medications were more susceptible to incomplete eye lid closure that contributing to development of corneal complications.This results are agreed with Andrea et al., (2020), who found that critically ill patients were unable to maintain normal eye protective mechanisms such as eyelid closure and an intact blink reflex because the use of sedation and muscle relaxants are more susceptible to corneal complications. (46)

Conclusion
The current study showed that using eye care protocol reduced the occurrence of keratitis, conjunctivitis, dry eye, and corneal ulcers in mechanically ventilated patients.Additionally, this study showed that polyethylene cover and artificial teardrops were effective in preventing corneal injury in critically ill patients.

Method 1 .
Official permission.It was obtained from the responsible authorities at Faculty of Nursing, Tanta University to the director of Emergency Hospital, teaching hospital to carry out the study.2. Ethical Consideration -Approval of scientific research ethical committee was obtained and code No was 30/1/2022 and the code number of Faculty of Medicine was 35244 /1/22.

3 . 4 .
The tool (I) part (a,b) was developed by the researcher after reviewing related literature, part (c) was developed by Steven M Green (2021).Tool (II) was developed by Sessler (2020) and adopted by researcher.And tool (III) part(a) was developed by the researcher to conduct the study, part (b, c) was developed by Pellegrini M (2021) and Mercieca (2020) respectively and adopted by researcher.Tool validity: The content validity of the developed tool tested for clarity and applicability by seven experts in Critical Vol. 31.No. 4 (Suppl 1) ,November 2023

): Illustrates distribution of the studied patients according to Glasgow Coma Scale (GCS) throughout periods of
5. The reliability was done on the tools by Cronbach`s Alpha test.-Cronbach's Alpha for tool I is 0.850 for 14 items applied on 6 patients.-Cronbach's Alpha for tool II is 0.981 for 1 item applied on 6 patients.-Cronbach's Alpha for tool III is 0.808 for 8 items applied on 6 patients.-Cronbach's Alpha for the studied sheet in total is 0.950 for 6 patients.6. Pilot study: A pilot study was carried out to assess the feasibility and applicability of the tools and the needed modifications was done, a pilot study was done on 10% (6) patients and excluded from the study.
7. The study was conducted at four phases which include assessment, planning, implementation and evaluation phase.8. Data was collected within six months from 20-4-2022 to 20-10-2022 Results Table (1): Illustrates distribution of the studied patients according to their demographic characteristics.In this results, it was observed that less than half (46.67%) of control group and more than one quarter (26.67%) of the study group were between 50-60 years old, with a mean age of 43.8712.401 in control group and 40.6711.127 in study group.In relation to sex, more than half of the patients in control and study groups (53.33% and 66.67%) were male respectively.

Table ( 9): Percent distribution of the studied patients regarding eye grading guide as an indicator of corneal injury throughout periods of study.
The result revealed that more than one third of the patients in control and study groups in relation to eye grading guide in right eye had grade I (46.67%, 46.67%) respectively.No significant changes were observed between the three times of data collection (on admission, 4th day of admission and 7th day of admission) in right eye among both control & study group (P value > 0.05 ).On the other hand, about half of study group (53.33%) had grade II throughout period of the study.-Significant changes were observed between control and study groups in left eye (P value = 0.040).

Table ( 10): Represents comparison between Glasgow Coma Scale (GCS) of the studied patients and their eye grading guide as an indicator of corneal injury at 7th day of intervention.
In this table, it was observed that near to half (46.67%) of the control group and more than one third (40.00%) of study group had sever level of GCS reported grade I of eye grading guide in the right eye.Also, less than half (46.67%) of control group and one third (33.33%) of study group had sever GCS reported grade I of eye grading guide in left eye.No significant difference was observed among study group in both right & left eye.

of the studied patients and their eye grading guide as an indicator of corneal injury at 7th day of intervention.
Regarding right eye, it was observed that about one third (33.33%) of control group who are un arousal reported grade II of eye grading guide compared to more than one quarter (26.67%) in study group.Also, regarding left eye, it was observed that about more than one quarter (26.67%) of control group who are un arousal reported grade II of eye grading guide compared to near to half (46.67%) in study group.

On Admission 4 th day of admission 7 th day of admission On admission 4 th day of admission 7 th day of admission
-Group 2: Study group.

Table ( 12): Percent comparison between Corneal Fluorescein Staining (CFS) of the studied patients among groups and their eye grading guide as indicator of corneal injury at 7 th day of intervention.
Concerning diagnosis, more Vol.31.No. 4 (Suppl 1) ,November 2023 The following suggestions are made in light of the study's findings: -It is necessary to disseminate protocols and guidelines for eye care in ICU patients to reduce the risk of corneal injury.-Eye care should be standardized as a basic part of nursing care provided to all critically ill patients in ICU with impaired conscious level.-Emphasize the importance of eye physical assessment for critically ill patients in relation to eyelids, conjunctiva, cornea, and pupil for early detection of any eye problem.-Assess the ability of critically ill patients' ability to maintain eyelid closure by Eye Grading Guide should be performed daily in intensive care units.-Applying polyethylene eye cover should be standardized in ICU as a moist chamber method of eye care instead of routine eye cover with tap.-Apply the present study to large probability sampling with impaired of conscious level.