Eye Protection During Rapid Sequence Intubation
You should tape the eyes closed as soon as the ciliary reflex is lost and before intubation to prevent corneal abrasion, even during RSI. 1
The Evidence-Based Approach
The 2017 Anaesthesia guidelines provide a GRADE 1+ strong recommendation (the highest level) for systematic eyelid occlusion using adhesive strips during general anesthesia 1. Critically, Recommendation R1.2 specifically addresses RSI, stating that "apart from a rapid induction sequence, eyelid occlusion is recommended as soon as the ciliary reflex is lost and before tracheal intubation" 1.
Why This Matters
The guideline explicitly recognizes that corneal injuries can occur from direct trauma during intubation caused by objects used during the procedure—including the laryngoscope itself, as well as watches, badges, and stethoscopes 1. This risk is present even during the brief period of RSI.
The Timing Algorithm
Here's the specific sequence:
- Monitor for loss of ciliary reflex after administering your induction agent
- Immediately apply adhesive tape to close the eyelids completely
- Ensure complete occlusion by apposing upper and lower eyelids together
- Then proceed with laryngoscopy and intubation
The evidence shows that proper training on correct eyelid occlusion technique reduced corneal injury incidence by three-fold 1.
What NOT to Do
Do not leave eyes unprotected during RSI. Research from 1977 demonstrated a 44% incidence of corneal abrasion in patients whose eyes remained partly open during general anesthesia, compared to 0% in those with protected eyes 2. While this predates modern RSI protocols, the mechanism of injury remains identical.
Common Pitfall
The phrase "apart from a rapid induction sequence" in the guideline does NOT mean "skip eye protection during RSI." Rather, it acknowledges RSI as a special circumstance while still recommending protection once the ciliary reflex is lost—which occurs within seconds of induction agent administration, well before intubation begins.
Practical Implementation
Use adhesive strips alone (GRADE 1+)—this is superior or equivalent to ointments, lubricants, or other methods and has fewer adverse effects 1. The tape application takes 2-3 seconds and does not meaningfully delay intubation in true RSI scenarios.
For standard RSI in emergency or ICU settings, the brief time required to tape eyes closed after induction does not compromise the "rapid" nature of the sequence, as you're still waiting for neuromuscular blockade to take full effect before laryngoscopy anyway.