Iranian Journal of Nursing and Midwifery Research

: 2018  |  Volume : 23  |  Issue : 6  |  Page : 492-

A response to: "A second look at the impact of normal saline on the incidence of exposure keratopathy"

Zohreh Davoodabady, Korosh Rezaei 
 Department of Nursing, Arak University of Medical Sciences, Arak, Iran

Correspondence Address:
Mr. Korosh Rezaei
Department of Nursing, School of Nursing and Midwifery, Arak University of Medical Sciences, Arak

How to cite this article:
Davoodabady Z, Rezaei K. A response to: "A second look at the impact of normal saline on the incidence of exposure keratopathy".Iranian J Nursing Midwifery Res 2018;23:492-492

How to cite this URL:
Davoodabady Z, Rezaei K. A response to: "A second look at the impact of normal saline on the incidence of exposure keratopathy". Iranian J Nursing Midwifery Res [serial online] 2018 [cited 2022 Jun 28 ];23:492-492
Available from:

Full Text

Dear Editor,

Unfortunately, there is no universally accepted protocol for eye care in the intensive care unit (ICU).[1] Some authors recommend the use of normal saline,[2] but the results of some studies have shown that it should not be used routinely.[3] Therefore, our study was designed to evaluate the effect of normal saline on the occurrence of Exposure Keratopathy (EK) in the ICU, considering a group that is only treated with normal saline, and does not receive usual treatments, not approved by the Ethics Committee. In addition, the authors believe that, despite the simultaneous use of conventional treatments and saline, any changes in occurrence of keratopathy are more valuable. The discontinuation of conventional treatments that their preventive role has been identified can be a major contributing factor to the analysis of information when one group receives only normal saline.

The existence of controversy over the use of normal saline shows that the need for a clinical trial study is necessary. The results of studies on the tear evaporation rate, may not be easily extended to occurrence of EK in patients in the ICU. In these studies, which are essentially laboratory, all conditions are under control and normal saline has been used as a placebo.[4] Whereas in critically ill patients, the conditions are quite different. These patients usually have severe and acute illnesses, and most often have one or more comorbidities. Critically ill patients often have lagophtalmos, chemosis, immune disorder, and reduced REM that increase the likelihood of keratopathy. Moreover, some medications may interfere with protective mechanisms of the eye.[3] Therefore, studying the effect of saline on the occurrence of keratopathy in these patients seems completely necessary.

The occurrence of EK on the 1st day in the total population was about 7% and it was increased in two groups, during the study. However, it should be noted that the number and severity of keratopathy in the intervention group were significantly increased. Although at the beginning of the study, the occurrence of keratopathy was similar in the two groups, but it would be better if they did not enter the study.

In this study, we used an artificial tear solution without a preservative, and containing methyl cellulose (0.3%). This solution was routinely used in ICUs.

Financial support and sponsorship


Conflicts of interest

Nothing to declare.


1Kam KYR, Haldar S, Papamichael E, Pearce KCS, Hayes M, Joshi N. Eye care in the critically ill: A national survey and protocol. JICS 2013;14:150-4.
2Urden LD, Stacy KM, Lough ME. Critical Care Nursing, Diagnosis & Management. 8th ed. Sunders Elsevier; 2018. p. 590-1.
3Grixti A, Sadri M, Edgar J, Datta AV. Common ocular surface disorders in patients in intensive care units. Ocul Surf 2012;10:26-42.
4Uchiyama ED, DiPascuale MA, Butovich IA, McCulley JP. Impact on ocular surface evaporation of an artificial tear solution containing Hydroxypropyl (HP) Guar. Eye Contact Lens 2008;34:331-4.