Protecting More Than Lungs: New ICU Eye Care Plan Tackles Hidden Risks of Prone Ventilation

A patient placed face-down in an intensive care unit may be receiving prone position ventilation. Because this position can improve lung expansion and oxygenation, the same treatment can put the eyes under pressure for many hours while sedation weakens natural protective responses such as blinking and complete eyelid closure. A new study titled 'Construction and application of an eye care plan for ICU patients receiving prone position ventilation: a quasi-experimental study, published in Frontiers in Health Services, examined whether a structured, evidence-based nursing plan could protect these vulnerable patients from eye complications and dangerous changes in intraocular pressure.

The researchers developed the care plan from published evidence and expert consultation, then tested it in ICU patients receiving prone position ventilation, finding a substantial reduction in overall eye complications during the one-week observation period.

Why Prone Ventilation Can Put the Eyes at Risk

Prone position ventilation, often shortened to PPV, uses gravity and body positioning to help expand the lungs and improve oxygenation in critically ill patients. Keeping someone face-down for prolonged periods can compress the tissues around the eyes, interfere with venous drainage and increase intraocular pressure. Sedative medications can also weaken eye-protection mechanisms, making problems such as chemosis, exposure keratitis, acute angle-closure glaucoma and orbital syndrome more likely. Earlier research cited by the authors suggested that ocular complications in prone patients may occur in roughly 23% to 60% of cases, meaning eye protection is not a small nursing detail but a potentially important part of critical care.

Existing guidance already recommends lubrication, avoiding direct compression and checking whether the eyes are exposed. The researchers found that practical, standardized protocols specifically designed for ICU patients receiving PPV were still limited, particularly in the Chinese clinical setting. Their response was to build a more detailed plan that nurses could follow before, during and after prone positioning, rather than relying only on general eye-care instructions.

The Care Plan Combined Research Evidence With Clinical Expertise

The development process began with a seven-member research team and a structured evidence search using the PIPOST framework and the '6S' evidence model, which guided the researchers toward high-level evidence before individual studies. They searched international guideline repositories, professional organizations, evidence databases and biomedical literature sources in both English and Chinese, covering material available up to November 2023.

Eight publications passed the screening and quality-assessment process: four guidelines, one expert consensus, one systematic review, one evidence summary and one randomized controlled trial. From these sources, the researchers extracted 23 pieces of evidence across five areas: organizational management, eye assessment and cleaning before PPV, nursing interventions during PPV, management after PPV, and staff training and education.

Seven specialists then reviewed the proposed plan, including an ICU doctor, ophthalmologist, ophthalmic nurse, traditional Chinese medicine physician, ICU nurses and an ICU nursing manager. Their feedback led to clearer assessment criteria, infection-control requirements, standardized emergency procedures and a practical schedule in which eye evaluation, cleaning and care were carried out every four hours.

The final intervention went well beyond basic wiping of the eyes: Before prone positioning, patients received a more complete eye assessment, lubrication with artificial tears or sterile petroleum-based ointment, acupoint massage and protective padding around the eyes. During PPV, nurses used a 30-degree head elevation, gel headrests or specially shaped foam supports to prevent direct eye pressure, cleaned oral and nasal secretions, used lubrication and watched for complications that required rapid multidisciplinary care. After PPV, patients received continued assessment, complication management, medication when needed, cleaning, lubrication and massage.

Eye Complications Fell From 27.6% to 6.8%

The clinical part of the research included 58 adult ICU patients, divided into two groups of 29. The control group received routine eye care between April and July 2024, while the intervention group received the structured plan between August and November 2024. Patients were observed for one week, and the two groups showed no statistically significant differences in their baseline characteristics, making the comparison more meaningful.

Eight of the 29 control patients developed ocular complications, producing a total incidence of 27.6%, compared with only two patients in the intervention group, an incidence of 6.8%. Chemosis fell from 13.8% to 3.4%, exposure keratitis dropped from 6.9% to 3.4%, and corneal injury fell from 6.9% to zero. The total difference reached statistical significance, even though individual complication categories did not all reach significance because of the small sample.

The authors linked the improvement to several parts of the programme working together: clearer identification of risk factors, fewer omissions during nursing care, regular screening, stronger quality control and faster involvement of multiple clinical specialties when a problem appeared. The results suggest that protecting the eyes of prone ICU patients may depend less on one isolated technique and more on creating a reliable system in which assessment, positioning, lubrication, monitoring and staff training are performed consistently.

Intraocular Pressure Improved After Eight Hours, Though Larger Studies Are Still Needed

The team also tracked intraocular pressure before PPV, after four hours, after eight hours and at the end of prone ventilation, measuring both eyes separately. The differences became clearer after eight hours, when pressure in both the left and right eyes of patients receiving the structured intervention was significantly lower than in the control group. The authors suggested that elevating the head by 30 degrees may support venous return, keeping the eyes free from direct pressure may prevent local compression, and acupoint massage may assist aqueous drainage, though the study was not designed to prove the individual contribution of each component.

The research was carried out at a single hospital, used convenience sampling, included only 58 patients and followed a quasi-experimental rather than randomized design. The researchers also could not separate the effect of each of the 18 individual care measures, meaning it remains unclear which elements contributed most strongly to the improvement. They recommend larger, multicentre studies that can test and refine the plan across different hospitals and patient populations.