What are the guidelines for patching an eye that doesn't close after a stroke, also known as (Cerebrovascular Accident, CVA)?

Eye Protection for Stroke Patients with Impaired Eye Closure

Eye protection should be implemented for stroke patients with impaired eye closure to prevent corneal damage, using a combination of lubricating drops, ointments, and moisture chambers or taping at night, with proper patient instruction to avoid complications. 1

Assessment of Eye Closure Problems After Stroke

• Incomplete eye closure (lagophthalmos) after stroke can result from:

  • Upper eyelid retraction
  • Lower lid ectropion
  • Failure of the lacrimal pump mechanism
  • Decreased blink and tear production
  • Loss of the corneal "squeegee effect" 1

• Warning signs requiring immediate attention:

  • Burning, itching, eye irritation
  • Changes in vision
  • Eye pain 1

Complications of Impaired Eye Closure

Without proper management, patients may develop:

• Foreign particle deposition in the eye
• Corneal abrasions
• Exposure keratitis
• Corneal ulcerations 1

Evidence-Based Management Approach

First-Line Interventions

1. Ocular Surface Hydration:

   • Lubricating ophthalmic drops: Provide hydration but require frequent application 1
   • Ophthalmic ointments: More effective for moisture retention but may blur vision; better for nighttime use 1

2. Moisture Chambers and Eye Protection:

   • Moisture chambers using polyethylene covers: Particularly effective at night 1
   • Eye patching or taping: Effective when properly executed, especially at night 1

Important Considerations for Eye Patching/Taping

• Patient Education: Careful instruction in proper execution is essential to avoid corneal damage 1
• Technique: Ensure the eye is properly closed before applying tape or patch 1
• Timing: Most beneficial during sleep/nighttime 1

Second-Line Interventions (for patients who fail first-line treatments)

• Detailed ophthalmologic evaluation 1
• Botulinum toxin injections: Can improve eyelid closure for months 1
• Surgical options:
  • Temporary or permanent tarsorrhaphy
  • Upper eyelid weighting 1

Special Considerations

For Visual Field Deficits

• Yoked prisms may help patients compensate for visual field cuts (Class IIb, Level B evidence) 1
• Compensatory scanning training may improve functional deficits after visual field loss (Class IIb, Level B evidence) 1

For Patients with Hemispatial Neglect

• Right half-field eye patching may improve neglect symptoms but has shown limited improvement in functional independence 2

Implementation Algorithm

1. Initial Assessment:

   • Evaluate degree of eye closure
   • Check for signs of corneal irritation
   • Assess blink reflex and tear production

2. Daytime Management:

   • Frequent lubricating eye drops (every 1-2 hours)
   • Consider sunglasses for additional protection 1

3. Nighttime Management:

   • Apply lubricating ointment before sleep
   • Use moisture chamber or properly applied eye taping/patching 1

4. Follow-up and Escalation:

   • Monitor for signs of corneal damage
   • If first-line treatments fail, refer for ophthalmologic evaluation
   • Consider botulinum toxin or surgical interventions for persistent cases 1

Common Pitfalls to Avoid

• Improper eye patching technique: Can cause corneal damage if the eye is not properly closed first 1
• Relying solely on one intervention: A combination approach is more effective 1
• Inadequate patient/caregiver education: Proper technique is essential for safety 1
• Insufficient monitoring: Regular assessment for corneal damage is necessary 1

By following these guidelines, healthcare providers can effectively prevent ocular complications in stroke patients with impaired eye closure, improving patient comfort and preventing potentially serious eye damage.