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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.

Clinical Manifestations

  • Risk factors for corneal exposure include loss of protective mechanisms due to deep sedation, neurologic impairment, or eyelid abnormality; overhead warmers; and 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, or blunted red reflex.


  • Slit lamp biomicroscopic 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); frequency determined according to eyelid position

    • ✓ Closed lids every 12 hours, sclera showing every 6 hours, cornea showing every 2 hours; the frequency of ointment administration may be reduced if the eye and ointment are then covered with a piece of nonsticky 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. Any opacity, whether diffuse or focal, is a sign of serious eye disease. Glaucoma is irreversible optic-nerve damage due to increased intraocular pressure.

Differential Diagnosis of Corneal Clouding in an Infant

  • Trauma: Forceps injury, corneal perforation with amniocentesis

  • Infection: Syphilis, rubella, herpes simplex virus (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, congenital hereditary stromal dystrophy

  • Metabolic: Mucopolysaccharidoses type I. (Hurler syndrome) [MPS -IH]; T type IV, mucolipidoses), cystinosis, tyrosinemia

Epidemiology and Etiology

Primary Glaucoma

  • Primary infantile glaucoma (congenital glaucoma): 1 in 10,000 to 1 in ...

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