Ocular Lubricant Linked With Lower Rates of Exposure Keratopathy

keratopathy bullous condition in eye of elderly patient
keratopathy bullous condition in eye of elderly patient before penetrating keratoplasty
For patients on mechanical ventilation, ocular surface lubrication can prevent the development of corneal damage.

In patients who have been managed using invasive ventilation, the prevalence of exposure keratopathy is significantly higher for those who did not use scheduled ocular surface lubricants compared with those who did, according to a report published in Ocular Surface.

Researchers retrospectively assessed the prevalence and severity of exposure keratopathy in patients who were on active mechanical ventilation with and without scheduled ocular surface lubrication. 

They reviewed the charts of all adult patients on active ventilatory support, defined as endotracheal intubation at the time of ophthalmology consultation, extubation within 3 days of consultation, or transition to tracheostomy during the same admission, at Duke Health hospitals between 2013 and 2021. The team defined exposure keratopathy as the presence of punctate epithelial erosions, corneal abrasions, or corneal ulceration in at least 1 eye and severe disease as the presence of 2 or more punctate epithelial erosions, an epithelial defect, or ulceration in the cornea in 1 or both eyes.

The team evaluated whether or not ocular lubricants were initiated within 3 days of intubation by the primary inpatient team and admission and ophthalmology consultation reasons. They compared the prevalence of exposure keratopathy between patients using surface lubricants prior to ophthalmology evaluation with that of patients not using surface lubricants.

A total of 205 patients (78.5% men and 21.5% women) met study inclusion criteria. Of those, 12.2% were started on any ocular surface lubricants within 3 days of intubation, while 87.8% were not on surface lubricants. The mean age of patients at time of admission was 56.9±14.3 years. No patients had lid taping or polyethylene covers at the time of ophthalmology evaluation. 

Most (71.2%) patients had active endotracheal intubation or were extubated within 3 days of ophthalmology evaluation, while 28.3% patients had a tracheostomy. The researchers found that the most common reasons for ophthalmology consultation were to rule out ocular involvement of fungemia (42.4%), evaluate for exposure-related corneal disease (18.0%), or determine ocular findings after stroke (7.8%).

The team found that 54.6% of patients had any degree of exposure keratopathy, and of those, 51.7% had severe exposure keratopathy. Most (85.7%) patients had bilateral disease. Among all patients with exposure keratopathy (n=112), 26.8% were consulted by the primary service due to concern for exposure keratopathy. 

The prevalence of any degree of exposure keratopathy was significantly higher in patients not on surface lubricants than in those on surface lubricants (58.9% vs 24.0%, P =.001). The proportion of patients with severe keratopathy was not significantly different between the groups. 

“There is currently no standard recommendation for surface lubrication in mechanically-ventilated patients, although the importance of preventing exposure keratopathy is well-understood. Implementation of prophylactic surface lubrication in all mechanically ventilated patients is a low-risk, high-reward initiative that should be automatically included in ventilation order sets in Electronic Medical Record systems,” researchers report.

Limitations of the study included the single-center, retrospective design, the difficulty associated with characterization of corneal findings during a bedside examination in critically ill patients, and lack of information on additional risk factors that could contribute to exposure keratopathy


Aggarwal S, Snyder AJ, S Gabriel R, Kim T. Exposure keratopathy in patients undergoing invasive ventilation: Prevalence, severity, and the role of surface lubrication. Ocul Surf. Published online May 2, 2022. doi:10.1016/j.jtos.2022.04.010