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Clinical Ophthalmology (Auckland, N.Z.) 2021A typical oculocardiac reflex (OCR) is a moderate trigemino-vagal bradycardia elicited by tension on an extraocular muscle (EOM) during strabismus surgery; however, many... (Review)
Review
BACKGROUND
A typical oculocardiac reflex (OCR) is a moderate trigemino-vagal bradycardia elicited by tension on an extraocular muscle (EOM) during strabismus surgery; however, many other orbital stimuli can elicit cardiac slowing including retinopathy of prematurity examination.
METHODS
World literature related to trigeminovagal and oculocardiac reflex covering over 15,000 patients including 51 randomized clinical trials and case reports are analyzed and reviewed. Under an ongoing observational trial in Alaska, anesthetic, patient and surgical influences on routine strabismus surgery using prospective, uniform EOM tension are compared seeking sufficient sample size to characterize this individually widely variable cardiac response.
RESULTS
With adequate sample size, and emphasizing clinical studies controlling type of EOM, muscle tension amount and duration, anticholinergic and opioid medications, the following augment OCR; rapid-acting opioids and dexmedetomidine while OCR is reduced in older patients, the right eye, less EOM tension, deeper inhaled agents, hypocarbia, anticholinergic medications and orbital block. In re-operations, the former are relatively poor predictors of subsequent OCR.
CONCLUSION
Profound bradycardia can occur in almost 10% of strabismus surgery cases without anticholinergic preventive measures, but reliable prediction of OCR remains elusive. With foreknowledge and careful anesthetic monitoring of the patient before EOM manipulation, residual adverse sequelae from OCR are fortunately very rare. Despite well over a century of experience, the teleology for this occasionally dramatic cardiac response to eye surgery is still not known.
PubMed: 34194223
DOI: 10.2147/OPTH.S317447 -
The Journal of Craniofacial SurgeryThe oculocardiac reflex is initiated by a pressure stimulus to the orbit or periorbital structures causing in bradycardia transmitted via the trigeminal-vagus nerve...
INTRODUCTION
The oculocardiac reflex is initiated by a pressure stimulus to the orbit or periorbital structures causing in bradycardia transmitted via the trigeminal-vagus nerve reflex arc. While this most frequently occurs with ophthalmologic surgeries, trauma to the orbit and periorbital structures can result in bradycardia and even in some cases, asystole. The aim of this case report and review of the literature is to identify and examine recent studies of the oculocardiac reflex related to facial trauma and to identify associated patient age, symptoms, and fracture patterns.
METHODS
A literature search was performed using the database within PubMed.gov using the term "oculocardiac." Results were reviewed for case reports or series related to facial trauma from the year 2000 to 2019. Studies were then evaluated for fracture pattern, presence of entrapment, patient symptoms, and age.
RESULTS
The initial search resulted in 109 articles. A total of 22 articles were case reports or series of trauma patients. Twenty articles met inclusion criteria. Median age was 22 years. Eleven patients sustained orbital floor fractures. Four patients sustained medial wall fractures. Three patients had concomitant orbital floor and zygomatic fractures, and 4 with concomitant orbital floor and medial wall fractures. The most common extracardiac symptom experienced was nausea and vomiting (15/23) followed by diplopia (10/23). Status of entrapment was available in 20 patients of which entrapment was reported in fourteen (14/20).
CLINICAL REPORT
A 26-year old male presents after blunt trauma to the face resulting in a left orbital floor, rim, and maxillary fractures. Extraocular movements were initially intact and the patient had no diplopia. He developed bradycardia to 30 to 40 bpm just prior to induction of anesthesia. He was found to have developed entrapment of the inferior rectus muscle. The orbital floor and rim were repaired with complete resolution of bradycardia.
CONCLUSION
Patients who sustain maxillofacial trauma involving the orbit are at risk of developing the oculocardiac reflex. Patients tend to be younger. The orbital floor is more commonly the site of traumatic injury. Nausea and vomiting are common encountered symptoms. The oculocardiac reflex, clinicians must recognize, is not static but may evolve over a patient's clinical course as seen in our patient.
Topics: Bradycardia; Diplopia; Humans; Male; Oculomotor Muscles; Orbital Fractures; Reflex, Oculocardiac; Young Adult
PubMed: 33186288
DOI: 10.1097/SCS.0000000000006995 -
Journal of AAPOS : the Official... Jun 2019This review presents updated recommendations, based on existing clinical research, for anesthetic management of strabismus surgery in children. In children, unlike... (Review)
Review
This review presents updated recommendations, based on existing clinical research, for anesthetic management of strabismus surgery in children. In children, unlike adults, eye surgery nearly always requires general anesthesia, even for brief procedures. Recommendations for preoperative anxiolysis, fasting guidelines, and management of upper respiratory infections are discussed. Airway considerations and the oculocardiac reflex are highlighted. The prevention of postoperative complications, including those related to opioid prescription therapy, is also addressed. Finally, given the 2016 warning from the Food and Drug Administration about anesthesia neurotoxicity in children, we discuss recent studies on anesthetic neurotoxicity in children undergoing general anesthesia.
Topics: Anesthesia, General; Child; Humans; Ophthalmologic Surgical Procedures; Practice Guidelines as Topic
PubMed: 30995517
DOI: 10.1016/j.jaapos.2018.10.017 -
Survey of Ophthalmology 2023One of the most common untoward occurrences during strabismus surgery at all ages is the oculocardiac reflex. Although typically easily treated, the sudden bradycardia... (Review)
Review
One of the most common untoward occurrences during strabismus surgery at all ages is the oculocardiac reflex. Although typically easily treated, the sudden bradycardia or cardiac arrest may add a few gray hairs to ophthalmologists and anesthesiologists alike as it can be potentially fatal. This updated review of the literature and novel detailed treatment algorithm may prevent patient morbidity and mortality through proper recognition of at-risk patients and rapid treatment through proper communication between surgical and anesthesia physicians/providers.
Topics: Child; Humans; Adult; Reflex, Oculocardiac; Bradycardia; Anesthetics; Strabismus
PubMed: 37116545
DOI: 10.1016/j.survophthal.2023.04.004 -
Current Opinion in Ophthalmology Sep 2017The current study reviews the recent literature on pediatric orbital blowout fractures and provides guidelines on their management. (Review)
Review
PURPOSE OF REVIEW
The current study reviews the recent literature on pediatric orbital blowout fractures and provides guidelines on their management.
RECENT FINDINGS
The most common problem among patients requiring surgical revision of a previously repaired orbital floor fracture is an improperly placed orbital floor implant, usually erroneously placed under the posterior bony ledge. Although the transconjunctival incision can be combined with a lateral canthotomy and cantholysis, excellent surgical exposure can be obtained without the need for these latter relaxing maneuvers. In surgically repaired pediatric orbital blowout fractures with preoperative diplopia (both trapdoor and nontrapdoor), approximately 85% of patients recover completely over time. Delayed orbital tissue atrophy may play a role in the development of late enophthalmos.
SUMMARY
Most cases of pediatric orbital fracture can initially be followed conservatively to determine if disabling diplopia, when present, resolves without surgery. A notable exception is the trapdoor fracture, in which herniated tissue becomes entrapped by a recoiled bone fragment, causing marked or complete reduction in motility and/or an oculocardiac reflex; we recommend that these fractures be repaired within 24 h from the time of diagnosis. Enophthalmos resulting from an orbital floor fracture does not need to be prevented with early surgery. Enophthalmos can be allowed to develop over time to determine if it is noticeable, and then repair undertaken, if necessary, at that time. When surgery is indicated, a simple transconjunctival incision is preferred over a cutaneous incision, and care should be taken to insure that the implant is placed on the bony ledge at the posterior edge of the defect. Many children with blowout fractures will not require surgery, and those that do usually have excellent outcomes provided the recommendations are closely followed.
Topics: Child; Fracture Fixation; Global Health; Humans; Incidence; Orbital Fractures; Orbital Implants; Tomography, X-Ray Computed; Trauma Severity Indices
PubMed: 28797015
DOI: 10.1097/ICU.0000000000000407 -
Journal of AAPOS : the Official... Feb 2019
Topics: Dexmedetomidine; Reflex, Oculocardiac
PubMed: 30445142
DOI: 10.1016/j.jaapos.2018.09.003 -
Medical Hypothesis, Discovery &... 2020Oculocardiac reflex (OCR) has been described to occur with mechanical manipulation of the eye, eyelids or orbit. There are no reports in the literature of OCR during...
Oculocardiac reflex (OCR) has been described to occur with mechanical manipulation of the eye, eyelids or orbit. There are no reports in the literature of OCR during intravitreal injection (IVI). This may be due to the fact that heart rate is not monitored during the procedure. We aimed to evaluate OCR during IVI. A total of 532 patients were enrolled in the study at Asociacion para Evitar la Ceguera en Mexico. Mexico City, Mexico. IVI was performed on one eye in every patient with diabetic retinopathy (DR), age related macular degeneration (AMD) or choroidal neovascularization (CNV) secondary to pathological myopia. Heart rate was monitored with a pulse oximeter before, during and after injection. OCR was defined as a 20% decrease or more of basal heart rate. The population enrolled included 270 females and 262 males with mean age of 63.8 years. A decrease in heart rate of 20% or more occurred in 18 patients during IVI (3.3%; 95% confidence interval 1.85% and 4.92%). OCR was asymptomatic in these patients. OCR occurred in 3.3% of our patients during IVI. Hence, OCR must be considered when performing IVI.
PubMed: 32490017
DOI: No ID Found -
Anesthesia and Analgesia Jun 2023
Topics: Reflex, Oculocardiac; Ice; Heart Rate; Hypothermia, Induced; Reflex
PubMed: 37205826
DOI: 10.1213/ANE.0000000000006496 -
Clinical Ophthalmology (Auckland, N.Z.) 2020Reducing physiologic stress including bradycardia during staging eye exams for retinopathy of prematurity (ROP) is desirable. We observed heart rate change during...
PURPOSE
Reducing physiologic stress including bradycardia during staging eye exams for retinopathy of prematurity (ROP) is desirable. We observed heart rate change during routine retinopathy of prematurity eye examinations and compared the response with our ongoing study of oculocardiac reflex (OCR) elicited by uniform EOM tension during strabismus surgery.
PATIENTS AND METHODS
Electrocardiograph was prospectively monitored during ROP exams featuring indirect ophthalmoscopy with Alfonso lid speculum and see-through scleral depressor without topical anesthesia. Clinical data were retrieved from ROP-Check software. OCR was defined as maximally changed heart rate (HR) as a percent of baseline. Strabismus surgery patients under general anesthesia served as controls.
RESULTS
From 10/2017 to 9/2020, 281 infants had ROP exams, and the median OCR was 55.9% of baseline HR (IQR 41.4% to 72.6%), the kurtosis 0.93 and skewness 1.01 representing a drop from HR 169 ± 16 bpm to 102 ± 39 bpm. In comparison, 1493 adult and pediatric strabismus surgery patients had less OCR median bradycardia 87.8% (IQR 72-98%), kurtosis 1.60 and skewness -1.18. ROP %OCR correlated with birth gestational age (%OCR = 2.5 (GA) - 11, r(279)=0.33, p<0.01) and with birthweight (%OCR = 0.02 (BW) + 38, r(279) =0.35, p<0.01). The duration of bradycardia induced by ROP exam averaged 92 ± 34 seconds (range 34-240 seconds).
CONCLUSION
Bradycardia is common during eye exams in the smallest premature infants with greater degree, more rapid onset and longer duration than OCR during strabismus surgery.
PubMed: 33324032
DOI: 10.2147/OPTH.S288043