Globe rupture should be managed by covering the eye with a shield, elevating the head of the bed, updating the tetanus vaccine, and starting antibiotics. In eyes that have had previous intraocular surgery, the rupture is often at the prior incision site. After chemical exposure, patients often complain of moderate to severe pain, photophobia, blurred vision, and sensation of a foreign body. [25][26], If there is a perforating injury that affects that eye posteriorly, further surgical intervention may be necessary. Although rare, CRAO also can occur in association with syphilis or sickle cell disease. In an office setting, the eye can be irrigated using an intravenous tube, nasal cannula, or Morgan Medi-flow lens. An acceptable antibiotic regimen for an adult is intravenous cefazolin (Kefzol; brand not available in the United States) 1 g given every eight hours, plus intravenous ciprofloxacin (Cipro) 400 mg every 12 hours. The location you tried did not return a result. The anterior chamber is located behind the cornea and in front of the Iris and pupil. Venkatesh R, Bavaharan B, Yadav NK. [14] Seidel testing is contraindicated in cases of obvious globe rupture. Once a scratch passes Bowmans layer, the probability of scaring increases significantly. Yuan WH, Hsu HC, Cheng HC, Guo WY, Teng MM, Chen SJ, Lin TC. More than 1 million people worldwide have vision loss bilaterally secondary to trauma. Interpretation: Findings suggestive of Globe Rupture (Positive Seidel Test) Fluorescein dye diluted by aqueous fluid Darker, diluted Fluorescein dye streams from Globe Rupture site Bright green concentrated dye surrounds leak site (above and to side) VII. Am J Ohthalmol. Anteriorly at the limbus, the sclera is continuous with the cornea. Find a doctor near you. Grdal C, Erdener U, Irke M, Orhan M. Incidence of sympathetic ophthalmia after penetrating eye injury and choice of treatment. [6][7][8], Globe rupture is more common in males than in females. This book is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits use, duplication, adaptation, distribution, and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, a link is provided to the Creative Commons license, and any changes made are indicated. . Wong TY, Klein BE, Klein R. The prevalence and 5-year incidence of ocular trauma. Open globe laceration Open globe laceration refers to a penetrating injury to the eye by a sharp object or projectile and is further subclassified as penetrating (entry wound but no exit wound) or perforating (entry and exit wounds) [ 1 ]. The streaming is sometimes described as a waterfall by some with more brisk leaks. Succinylcholine has been found to raise the intraocular pressure, although this is reducible with subsequent remifentanil administration. Antiemetics, pain control, and bed rest with elevation of the head of the bed to 30 degrees will aid in this process. Blast trauma: the fourth weapon of mass destruction. Narang S, Gupta V, Gupta A, Dogra MR, Pandav SS, Das S. Role of prophylactic intravitreal antibiotics in open globe injuries. Gender differences in etiology and outcome of open globe injuries. -, Aghadoost D. Ocular trauma: an overview. [13]The pupil should be examined for reactivity and shape, taking note of any irregularities in the roundness of the pupil. If globe rupture is suspected or confirmed, an eye shield (Figure 1) should be immediately placed over the affected eye and further direct examination should be deferred to avoid putting pressure on the eye. He used the test to evaluate leakage in the postoperative patient but later expanded its use to other causes or anterior chamber leakage.[3]. a thorough clinical history (the side of injury and type of foreign body) and pertinent information from the ophthalmic right occipital subgaleal hematoma exam (visual acuity, presence of an. Copyright 2022 American Academy of Family Physicians. The sclera is a fibrous, opaque, white of the eye, the structure that provides support and protection to the deep structures of the eye. Li X, Zarbin MA, Bhagat N. Pediatric open globe injury: A review of the literature. Asymptomatic retinal breaks and lattice degeneration (i.e., focal thinning in the periphery of the retina) are risk factors for retinal detachment. In this situation, given a history of high-velocity trauma, immediate referral to an ophthalmologist is recommended irrespective of the physical findings during examination.8. Before A thorough evaluation of ocular injuries is critical in identifying injuries in an attempt to preserve vision. When it becomes diluted, it turns green under cobalt blue light. To decrease the risk of sympathetic ophthalmia, several sources recommend enucleation or evisceration within two weeks of an open globe injury if the visual prognosis is poor. This leakage is from a defect in the cornea or sclera from multiple causes, including trauma, post-surgical leak, corneal perforation, and corneal degeneration. Community eye health. Indications for a vitrectomy include signs of developing transvitreal detachment, the presence of moderate to severe vitreous hemorrhage, phacoanaphylactic uveitis, and damage to other tissue requiring repair. [3] In indirect trauma, the most common location of rupture is at the superior-nasal quadrant close to the limbus. The https:// ensures that you are connecting to the Scleral wounds may be closed with 7-0, 8-0, or 9-0 nonabsorbable sutures, and an attempt should be made to burry or cover these suture knots as well. The patient may report a history of amaurosis fugax (transient, painless unilateral vision loss) before presentation. Check out the new My Emergency Department app - a single source of truth for all your ED team's guidelines, policies and education content. In patients with negative results on carotid ultrasonography, transesophageal echocardiography should be considered to exclude a cardiac origin of the embolus.15,21 Minimization of risk factors with diet and lifestyle modifications and treatment of hypercholesterolemia, hypertension, and diabetes may help prevent CRAO. Department of Ophthamology, University of California, San Francisco. A Seidel sign may also be present when performing fluorescein staining of the cornea and sclera as a stream of clear aqueous fluid originating from the globe wound site, although the globe can be . Ophthalmologic visits account for about 3% of emergency department visits annually. The physical exam on patients with potential globe rupture requires a detailed ophthalmologic assessment. Koo L, Kapadia MK, Singh RP, Sheridan R, Hatton MP. Classic teaching revolves around Seidel's sign; it is not sensitive, but it is specific. However, the fluid is clear and hard to identify. A slit-lamp examination should be performed to assess the anterior portion of the globe and the anterior chamber. About 38 to 52% of these visits are for ocular trauma. Maneuvers that will increase intraocular pressure should be avoided (i.e., tonometry, lid retraction, or ocular ultrasound). Le Fort fractures; Skull fracture (peds) Auricular hematoma; Nasal fracture. This leakage is from a defect in the cornea or sclera from multiple causes, including trauma, post-surgical leak, corneal perforation, and corneal degeneration. Ruptured globe: what are the symptoms: irregularly shaped pupil, afferent pupillary defect, subconjunctival hemorrhage, decreased extra ocular motion, decreased visual acuity, extravasation of the iris through the globe defect prep you got wrong View this set What are symptoms of a ruptured globe? Computed tomography of the head and orbits (coronal and axial views) is recommended to evaluate for open globe injury, intraocular foreign body, or orbital wall fractures.6. Treasure Island (FL): StatPearls Publishing; 2022 Jan. Would you like email updates of new search results? MS, PhD, AND SANAZ A. LOFTUS, MD. Indicators of globe rupture include moderate to severe pain, decreased vision, hyphema (blood in the anterior chamber), loss of anterior chamber depth, or deviation of the pupil toward the laceration (Table 2). Etiologic Causes and Epidemiological Characteristics of Patients with Intraocular Foreign Bodies: Retrospective Analysis of 1340 Cases over Ten Years. Penetrating eye injury from a very small object at high speed may be detected as only a small corneal defect by fluorescein staining. If vision loss is acute, transient, and bilateral, other causes such as migraine auras, heart failure, and hypertensive emergencies should be suspected. This is known as the Seidel sign or a positive Seidel test.4,5 Any pressure on the eye must be avoided to prevent extrusion of intraocular tissue. Treasure Island (FL): StatPearls Publishing; 2022 Jan. Clinical practice and cases in emergency medicine. [20]Although no specific prophylactic antibiotic regimen exists, preservative-free, topical antibiotic drops before surgery can be given prophylactically to theoretically decrease the risk of endophthalmitis. Once pH is stabilized, a cycloplegic agent (0.25% scopolamine [Isopto Hyoscine] eye drops) and a broad-spectrum antibiotic (ciprofloxacin, ofloxacin [Ocuflox], gentamicin, or tobramycin [Tobrex]) should be applied. Contributed by Diane Wang, MD. The patient may present with sudden eye pain and vision loss after a potentially penetrating injury. This activity reviews the role of the Seidel test, its indications, and highlights the interprofessional team's role in the evaluation of orbital trauma. "Full-thickness" means all layers of the eye are disrupted. One test that helps evaluate ocular trauma is the Seidel test. The Seidel test is named after the German ophthalmologist Erich Seidel (1882-1948). 2014 Jun [PubMed PMID: 25147781], Cain W Jr,Sinskey RM, Detection of anterior chamber leakage with Seidel's test. Risk factors for CRAO include age older than 70, atherosclerosis, diabetes, endarteritis, glaucoma, high cholesterol levels, hypertension, hypercoagulable states, and migraine.1517 CRAO may occur in younger patients with systemic disease, such as collagen vascular diseases, hypercoagulopathies, or cardiac valvular disease. If antimicrobial therapy is necessary, an infectious disease board-certified pharmacist can be an invaluable resource, assisting with agent selection based on the latest antibiogram data available. Bethesda, MD 20894, Web Policies Once globe rupture is suspected, urgent ophthalmologic consultation is required. For children < 12 years, cefazolin 25-50 mg/kg/day in three divided doses, and gentamicin 2 mg/kg iv q8h. Topical anesthetics (e.g., tetracaine [Pontocaine]) help to relieve pain and thus facilitate eye irrigation. If acute angle-closure glaucoma is not treated immediately, damage to the optic nerve and significant and permanent vision loss can occur within hours. These injuries range from simple abrasions to catastrophic globe rupture. 2015; [PubMed PMID: 26682179]. Prepare the room for evaluation and obtain all necessary equipment and medications. The pupil may be dilated with sluggish reaction to light (Table 2). Conditions that should raise suspicion for potential trauma and ocular leak including but are not limited to: Contraindications to the Seidel test include several conditions, such as: The Seidel test does not require significant resources, but specific components are required to obtain an accurate analysis include: The Seidel test can be performed by any medical provider that can instill the dye and interpret the results. Up to 10 liters of an irrigant may be necessary to achieve neutral pH.12 If pH paper is not available, the eye should be irrigated with at least 1 to 2 liters of eyewashing solution or for at least 30 minutes. Before closure, incarcerated uvea must be reposited or excised, and prolapsed vitreous should be excised from the wound. and transmitted securely. The tear film covering the ocular surface is also a transparent layer. Irrigation should be continued until a neutral pH level (7.0) is achieved and maintained for at least 30 minutes. During an acute attack, medical therapy is initiated to lower the increased intra-ocular pressure. Lorch A, Sobrin L. Prophylactic antibiotics in posttraumatic infectious endophthalmitis. These injuries range from simple abrasions to catastrophic globe rupture. Careful evaluation of the patients baseline visual acuity is critical. Jindal A, Pathengay A, Mithal K, Jalali S, Mathai A, Pappuru RR, Narayanan R, Chhablani J, Motukupally SR, Sharma S, Das T, Flynn HW. Thevi T, Abas AL. Classic teaching revolves around Seidel's sign; it is not sensitive, but it is specific. Globe rupture involves compromised integrity of the cornea or sclera; it should always be considered in a patient with an eye injury. If globe rupture is suspected or confirmed, an eye shield ( Figure 1) should be. [19]In patients who are awake and alert, it is recommended to reduce stressors that may increase intraocular pressure. If the affected eye looks white after exposure to an alkali, it could be an indication of a particularly severe eye injury with ischemia of the conjunctival and scleral vessels. Direct ophthalmoscopic examination aids in the diagnosis of retinal detachment (Figure 3). Orbit fractures: Identifying patient factors indicating high risk for ocular and periocular injury. Behind the iris and pupil lies the posterior chamber, which includes multiple structures out of the scope of this discussion.[5]. They are uniform in size and are stacked parallel to one another in bundles called lamellae. Globe rupture. Image of a globe rupture just posterior to the lateral rectus muscle insertion site. Diagnostic performance of isolated orbital CT scan for assessment of globe rupture in acute blunt facial trauma. Agrawal R, Rao G, Naigaonkar R, Ou X, Desai S. Prognostic factors for vision outcome after surgical repair of open globe injuries. Learn vocabulary, terms, and more with flashcards, games, and other study tools. Zhang Y, Zhang MN, Jiang CH, Yao Y, Zhang K. Endophthalmitis following open globe injury. In adult males under 40 years of age, assault and workplace injuries are the most common causes of globe rupture. In: StatPearls [Internet]. [3], If there is a strong suspicion for a globe rupture and the Seidel test is negative, the next set in evaluation is to obtain an orbital CT scan, which can evaluate for a flat anterior chamber and may demonstrate an intraocular foreign body.[7]. . Management of acute ocular pain requires a coordinated interprofessional effort between nursing staff, ER clinicians, pharmacists, and ophthalmologic specialists to coordinate an accurate and prompt diagnosis that will result in appropriately directed management and treatment. Once globe ruptureis safely ruled out, otherpotential causes of acute ocularpain, including corneal abrasions or ulcerations,can undergo an evaluation and the patient appropriately treated. The differential diagnosis for globe rupture should include:[3], The most important factor influencing the patient's final visual acuity following globe rupture is the patient's presenting visual acuity. Globe Rupture. Severe subconjunctival hemorrhage involving the area 360 degrees around the cornea is also highly suspicious for globe rupture. Describe the technique of performing the Seidel test. A positive test indicates a full-thickness corneal or scleral injury. The test was first described in 1921 by Dr. Erich Seidel (1882-1948), a German ophthalmologist, for which the test is named. Because the Valsalva maneuver or pressure on the globe may lead to extrusion of intraocular contents, appropriate analgesia and antiemetics should be provided on a scheduled basis. The most important factor influencing the patient's final visual acuity following globe rupture is the patient's presenting visual acuity. An attack of acute angle-closure glaucoma in predisposed persons can occur as a result of dim lighting or use of certain medications (e.g., dilating drops, anticholinergics, antidepressants). Emerg Med Clin North Am. [11], Globe rupture can either occur due to an object penetrating the ocular tissues or by blunt trauma. When there is any suspicion of a globe rupture, it requires an ophthalmology consult. The epithelium has a high turnover rate and is replaced entirely over about 7 days. [5]Other potential etiologies of globe rupture include gunshots, sporting injuries,stab wounds, and blast wounds. Yalcin Tk O, Tok L, Eraslan E, Ozkaya D, Ornek F, Bardak Y. Prognostic factors influencing final visual acuity in open globe injuries. . Coles WH, Haik GM. A primary care physician can manage conjunctival lacerations smaller than 1 cm by using a topical antibiotic and close follow-up. LIST YOUR PRACTICE ; Dentist ; Pharmacy ; Search . Start studying Med Final: HEENT. Patients with this condition typicallypresentto the emergency department, and it is important that the triage team recognize the emergent nature of this presentation and immediately activate a trauma assessment. Coming into contact with a gas or liquid is a common way by which an eye is exposed to a chemical. Andrews BT, Jackson AS, Nazir N, Hromas A, Sokol JA, Thurston TE. 2022 Jul 12. After acute management of CRAO, carotid ultrasonography to evaluate for stenosis or plaque formation may identify the cause of CRAO. The recognition of globe rupture is a challenge for all providers. Acid should not be used to neutralize a base, and vice versa.14 Sweeping the conjunctival fornices with a moist cotton swab after instilling topical anesthetic may help to neutralize the pH by removing crystallized particles of the chemical. Definition The test is used to reveal leaks from the cornea, sclera, or conjunctiva following injury or surgery. When possible, systemic antibiotics should be started within six hours of the injury. official website and that any information you provide is encrypted suture peak first, at least 1 mm from each side of laceration, 80%+ depth. [23][24][45] [Level 5]Thus, repair of open globe injuries should be undertaken within 24 hours if at all possible. They may also obtain medications and equipment needed for further patient evaluation. Treasure Island (FL): StatPearls Publishing; 2022 Jan. Bower T, Samek DA, Mohammed A, Mohammed A, Kasner P, Camoriano D, Kasner O. Its rationale and its indications and limitations. Globe rupture should be a consideration whenever a patient presents with blunt or penetrating facial trauma. If possible, physical examination of the eye should include the eyelids, globes, orbits, forehead, and cheeks; evaluation of extraocular motility; and pupillary reflex visual field testing (i.e., the confrontation visual field examination). [23][24]Initial surgical management of a globe rupture includes microsurgical corneal and/or scleral wound repair. Risk factors for acute angle-closure glaucoma include anterior placement of the lens, hyperopia, myopia, narrow angle, and shallow anterior chamber. Exp Eye Res. Accessibility Of the patients who irrigated their eyes, 76 percent had a minimal grade 1 injury, whereas 86 percent of patients who did not irrigate their eyes had a more severe grade 2 injury. Search doctors, conditions, or procedures . Patients with CRAO describe painless and sudden loss of vision in one eye. Mean healing time was eight days for the patients who irrigated and 29 days for those who did not.13. [37][38]Sympathetic ophthalmia is another devastating complication where there is a diffuse bilateral granulomatous panuveitis following immune system sensitization to the intraocular contents of the traumatized eye. Examination with a slit lamp and fluorescein dye helps to differentiate between a conjunctival laceration and a globe rupture. In: StatPearls [Internet]. Streptococcus species, Staphylococcus aureus, and Staphylococcus epidermidis are among the most common causes of endophthalmitis. The epithelium is about 5 to 7 cells thick that provides the eye with a smooth surface for the tears to form a film. Corneal lacerations can be closed with 10-0 nylon interrupted sutures. Deep or shallow anterior chamber compared to fellow eye, full thickness scleral or corneal laceration, severe subconjunctival hemorrhage (especially involving 360 degrees of bulbar conjunctiva, often bulbous), peaked or irregular pupil, iris transillumination defect, lens material or vitreous in the AC, foreign body tract or new cataract in the lens, limitation of extraocular motility (greatest in the direction of rupture), intraocular contents may be outside of the globe, Seidel's sign - do not perform this test if suspect open globe, May be falsely negative if scleral rupture is small. Prompthistory, physical exam, and visual acuitywillgive the physician some initial guidance and directionbefore consulting ophthalmology or considering CT imaging. Following surgical repair, patients will start on topical antibiotics covering the most common pathogens for endophthalmitis following globe rupture - Bacillus cereus and gram-negative organisms. In case of injury from organic material (e.g., hay, leaves, grains), infection from gram-negative bacteria and fungi also should be treated with antibiotics.7 The patient should be given nothing by mouth, and an emergent referral to an ophthalmologist should be sought for further evaluation and surgical repair. Once the diagnosis of a ruptured globe is made, further examination should be DEFERRED until the time of surgical repair in the operating room. Start studying EXAM 3: DISORDERS RESULTING FROM TRAUMA TO THE ANTERIOR SEGMENT. Laryngoscope. Agrawal R, Wei HS, Teoh S. Prognostic factors for open globe injuries and correlation of ocular trauma score at a tertiary referral eye care centre in Singapore. Ocular injury from high-velocity trauma or from chemicals may be easily misdiagnosed. Prompt recognition and appropriate treatment of ocular emergencies are essential in the primary care setting when the outcome may depend on timely management. Arch Ophthalmol. Axial computed tomography of the orbits demonstrating an abnormal posterior globe contour and loss of globe volume, consistent with a posterior globe rupture. Post-traumatic endophthalmitis involving Clostridium tetani and Bacillus spp. In patients with severe visual impairment, acuity evaluation is by the patient's ability to count fingers (CF), see a moving hand (HM), or flashes of light (LP). A pharmacist will also be involved in care not only during the acute setting but also on an outpatient. Principle Aqueous in the anterior chamber is a clear fluid. Lacerations larger than 1 cm should be referred to an ophthalmologist for possible suture placement. Eye injury, retinal detachment, and central retinal artery occlusion (CRAO) are among the most common ocular emergencies seen in the emergency department.1 It is estimated that about 2 million eye injuries occur every year in the United States, a significant number of which lead to vision loss.2,3. International journal of ophthalmology. An embolus in a retinal vessel may be seen (Figure 215). Kawashima M, Kawakita T, Shimmura S, Tsubota K, Shimazaki J. Characteristics of traumatic globe rupture after keratoplasty. Ocular trauma and other catastrophes. [32][33][34][35]For providers wanting to predict the functional outcome following a serious eye injury, the Ocular Trauma Score was created in 2002 to use for prognostic purposes. He used the test to evaluate leakage in the postoperative patient but later expanded its use to other causes or anterior chamber leakage. government site. 2011:152:66-73, Libonati MM, Leahy JJ, Ellison N: The use of succinylcholine in open eye surgery. Definitive treatment for primary acute angle-closure glaucoma is laser iridotomy. Nasal septal hematoma; Zygomatic arch fracture; Zygomaticomaxillary (tripod) fracture . Medications such as sulfa derivatives and topiramate (Topamax) can cause swelling of the ciliary body and secondary angle closure.22 If a tonometer is available, intraocular pressure should be measured to see if it has increased. Nursing will assist both during the evaluation period, as well as during any operative procedures, providing clinician support, administering medications, and answering patient questions. [3][4]A large study from China found that if the patient has a penetrating or perforating injury with an intraocular foreign body, it is most commonly due to an explosive in patients under ten, and more likely due to a foreign body if over ten years of age. No pressure must be applied to the globe during evaluation; this means tonometry and eversion of the lids should not be part of the initial assessment. 10% Discount on All E-Books through IGI Global's Online Bookstore Extended (10% discount on all e-books cannot be combined with most offers. A maxillofacial computed tomography (CT) scan can aid in the management of globe rupture, although it should never replace an ophthalmic evaluation. It is essential that clinicians have a high index of suspicion for globe rupture when treating patients with ocular trauma. Patients will often have decreased visual acuity, and this can be assessed using a Snellen chart or near card. identify extent of K laceration, find center or peak. 1981 Nov; [PubMed PMID: 7295152], Watson PG,Young RD, Scleral structure, organisation and disease. Campaigners receive awards at Nobel Peace Prize ceremony. A penetrating injury is when an object penetrates the eye, but the object does not go all the way through the eye. If a slit lamp is available, a moistened fluorescein dye strip can be gently applied directly to the site of the injury. The Seidel test assesses for the presence of aqueous humor leakage from the anterior chamber. Li X, Zarbin MA, Langer PD, Bhagat N. POSTTRAUMATIC ENDOPHTHALMITIS: An 18-Year Case Series. Romaniuk VM. [14]Seidel testing is contraindicated in cases of obvious globe rupture. Rocuronium has been found not to raise the intraocular pressure as much as succinylcholine and is suitable as a muscle relaxer in ruptured globe cases. The cornea is composed of five layers that include from superficial to deep; the corneal epithelium, Bowmans layer, corneal stroma, Descemets membrane, and corneal endothelium. Anesthesiology 1985; 62:637-640, This page was last edited 23:38, 16 December 2020 by, http://www.icoph.org/dynamic/attachments/resources/rupturedglobeico.pdf, https://www.wikem.org/w/index.php?title=Globe_rupture&oldid=289061, Is a full thickness disruption of sclera or cornea, Evert lids with paperclips or eyelid retractors, Suspect globe penetration with any puncture or laceration of eyelid or periorbital area, More commonly associated with objects from metal on metal, lawn mower, drills, grinders. Inspect lids, lashes, cornea, sclera, and pupils. Yeh S, Colyer MH, Weichel ED. [15][16] A CT scan is the preferred imaging technique to assess for the presence of intraocular foreign bodies. Blair K, Alhadi SA, Czyz CN. The history of patients presenting with globe rupture should focus on the etiology of the ocular and/or periocular trauma. The patient should receive education in the use of proper eye protection and avoidance of potentially harmful lifestyle choices that may increase their chances of ocular injury. Canadian family physician Medecin de famille canadien. CT can also help in making the diagnosis. The patient must be placed in a room promptly evaluated by a physician who is familiar with the patient's presentationand chief complaint. Positive Seidel test on fluorescein stain exam Globe rupture can be identified by a positive Seidel test on fluorescein stain exam. The anterior chamber should also be reformed and repressurized to an appropriate IOP. He X, Hahn P, Iacovelli J, Wong R, King C, Bhisitkul R, Massaro-Giordano M, Dunaief JL. Experimental eye research. Contributed with Permission by Michael Mohseni, MD. Singh S, Sharma B, Kumar K, Dubey A, Ahirwar K. Epidemiology, clinical profile and factors, predicting final visual outcome of pediatric ocular trauma in a tertiary eye care center of Central India. Dim the lights in the room as much as possible to ensure patient comfort and improving the evaluation. Outline the indications for the Seidel test. The Seidel's test is used to detect difficult to visualize corneal injuries that allows leaking of aqueous humor from the anterior chamber. Funduscopic examination after CRAO reveals interrupted columns of blood within the retinal vessels (sometimes referred to as boxcarring) and retinal pallor secondary to retinal edema, with a characteristic cherry-red spot at the fovea and attenuation of the retinal arteries. All five layers combined are approximately 550 microns or just over half a millimeter thick. MeSH Kuhn F, Maisiak R, Mann L, Mester V, Morris R, Witherspoon CD. Precautions Do not apply pressure to eye during test (risk of eye tissue extrusion) VIII. The eye is an incredibly complex organ; multiple components and intricate mechanisms must collaborate for the eye to function correctly. for cornea, 10-0 nylon preferred, make 2 nd throw 90 deg away, tension. If funduscopic examination reveals either of these risk factors, laser demarcation of these areas may be considered to prevent future retinal detachment and vision loss. 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