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The surface of the eye needs to stay well lubricated or it can lead to vision-threatening complications in the ICU


  • Normal ocular surface protective mechanisms include tear production, intact corneal sensation, blinking, and complete eyelid closure

  • Impaired protective mechanisms result in corneal exposure and drying

  • Corneal “dryness” (subclinical epithelial breakdown) may progress to corneal abrasion, ulceration, infection, scarring, thinning, and/or perforation if untreated


  • Risk factors for corneal exposure include loss of protective mechanisms due to deep sedation, neurologic impairment, or eyelid abnormality; overhead warmers; treatments causing air to blow over the eyes

  • Risk increases with poor eyelid closure: Low risk with eyelids that close completely, increasing with white sclera showing, highest with cornea or underlying iris showing

  • Eye exam may reveal conjunctival redness or swelling, corneal haze or opacity, blunted red reflex


  • Slit lamp biomicroscope exam and fluorescein staining may reveal punctate erosions, corneal abrasion, opacity (ulcer), thinning, or perforation


  • Prophylaxis for at-risk patients (e.g., intubated and sedated) is critical:

    • ✓ Lubricating eye ointment (Lacri-lube ointment which consists of mineral oil and white petrolatum) with frequency according to eyelid position

    • ✓ Closed lids every 6–8 hours, sclera showing every 4–6 hours, cornea showing every 2–4 hours; the frequency of ointment administration may be reduced if the eye and ointment are then covered with a piece of non-sticky plastic wrap (e.g., saran wrap) to form a “moisture chamber”

    • ✓ Artificial tear drops evaporate quickly and are not useful

  • Prompt ophthalmology consultation for red conjunctiva, corneal haze or opacity, or if the cornea is visible due to incomplete eyelid exposure in an at-risk patient

  • Antibiotic ophthalmic ointment (erythromycin, polysporin) if there is corneal epithelial staining with fluorescein

  • Complicated cases may require tarsorrhaphy (suturing of eyelids), bandage contact lens, corneal gluing, or emergent corneal transplantation


The cornea should always be clear with visible iris details and a bright red reflex, and any opacity, whether diffuse or focal, is a sign of serious eye disease.

Glaucoma is irreversible optic nerve damage due to increased intraocular pressure.


  • Trauma: Forceps injury, corneal perforation with amniocentesis

  • Infection: Syphilis, rubella, HSV, bacterial ulcer

  • Infantile glaucoma: Associated with enlarged eye (buphthalmos)

  • Corneal or limbal dermoid, associated with Goldenhar syndrome

  • Anterior segment dysgenesis: Peters anomaly (central corneal opacity), sclerocornea

  • Corneal dystrophy: Congenital hereditary endothelial dystrophy (CHED), congenital hereditary stromal dystrophy (CHSD)

  • Metabolic: Mucopolysaccharidoses (Hurlers, MPS IH; Type IV, mucolipidoses), cystinosis, tyrosinemia


Primary Glaucoma

  • Primary infantile glaucoma (congenital glaucoma): 1:10,000–1:15,000; 90% sporadic

  • Caused by developmental defect in ...

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