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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 -
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 -
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 -
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 -
Journal of Maxillofacial and Oral... Dec 2014The purpose of this paper was to undertake a review of literature on trigeminocardiac reflex in oral and maxillofacial online data-base and discuss the pathophysiology,... (Review)
Review
PURPOSE
The purpose of this paper was to undertake a review of literature on trigeminocardiac reflex in oral and maxillofacial online data-base and discuss the pathophysiology, risk factor assessment, presentation of the reflex, prevention, management with emphasis on the role of the attending anaesthetist and the maxillofacial surgeon.
MATERIALS AND METHODS
The available literature relevant to oral and maxillofacial surgery in online data-base of the United States National Library of Medicine: Pubmed (http://www.ncbi.nlm.nih.gov/pubmed/) was searched. The inclusion criterion was to review published clinical papers, abstracts and evidence based reviews on trigeminocardiac reflex relevant to oral and maxillofacial surgery.
RESULTS
Sixty-five articles were found with the search term "trigeminocardiac reflex" in the literature searched. Eighteen articles met the inclusion criteria for this study. The relevant data was extracted, tabulated and reviewed to draw evidence based conclusions for the management of trigeminocardiac reflex.
CONCLUSIONS
Conclusions were drawn and discussed based on the reviewed maxillofacial literature with emphasis on the anaesthetist's and the surgeon's role in the management of this detrimental event in maxillofacial surgical practice.
PubMed: 26224999
DOI: 10.1007/s12663-013-0541-4 -
BMC Anesthesiology Mar 2019The oculocardiac reflex (OCR), bradycardia that occurs during strabismus surgery is a type of trigemino-cardiac reflex (TCR) is blocked by anticholinergics and enhanced...
BACKGROUND
The oculocardiac reflex (OCR), bradycardia that occurs during strabismus surgery is a type of trigemino-cardiac reflex (TCR) is blocked by anticholinergics and enhanced by opioids and dexmedetomidine. Two recent studies suggest that deeper inhalational anesthesia monitored by BIS protects against OCR; we wondered if our data correlated similarly.
METHODS
In an ongoing, prospective study of OCR/TCR elicited by 10-s, 200 g square-wave traction on extraocular muscles (EOM) from 2009 to 2013, anesthetic depth was estimated in cohorts using either BIS or Narcotrend monitors. The depth of anesthesia was deliberately varied between first and second EOM tested.
RESULTS
From 1992 through 2013, 2833 cases of OCR during strabismus surgery were monitored. Excluding re-operations and cases with anticholinergic, OCR from first EOM traction averaged - 20.2 ± 21.8% (S.D.) with a range from - 95 to + 25% in patients aged 0.2 to 90 (median 6.5) years. We did not find correlation between %OCR and brain wave for 97 patients with BIS monitoring and 91 with Narcotrend. With intra-patient controls between first and second muscle, the difference in brain wave did not correlate with difference in %OCR for BIS (r = 0.0002, 95% C. I -0.0002, 0.002, p = 0.30) or for Narcotrend (r = - 0.001, 95% C. I -0.004, 0.001, p = 0.32). Secondary multi-variable analysis demonstrated significant association on %OCR particularly with BIS monitor, opioid, propofol and nitrous oxide concentration in the second EOM tensioned. Sevoflurane concentration correlated better with BIS monitor in second and third EOM tension. %OCR correlated with younger age (p < 0.01). OCR with rapid onset was more profound than those with gradual onset (difference in means 18, 95% C. I 10, 26%).
CONCLUSIONS
We were unable to confirm a direct correlation between brain wave monitor and OCR when using multifactorial anesthetic agents. The discrepency with other studies probably reflects direct impact of inhalational agent concentration and less deliberate quantification of EOM tension. We found no level of BIS or Entropy EEG monitoring that uniformly prevents OCR.
TRIAL REGISTRY
NCT03663413.
DATA
http://www.abcd-vision.org/OCR/OCR%20Brainwave%20de-identified.pdf .
Topics: Adolescent; Adult; Aged; Aged, 80 and over; Anesthetics, Inhalation; Bradycardia; Brain Waves; Child; Child, Preschool; Consciousness Monitors; Female; Humans; Infant; Male; Middle Aged; Oculomotor Muscles; Prospective Studies; Reflex, Oculocardiac; Sevoflurane; Strabismus; Young Adult
PubMed: 30871507
DOI: 10.1186/s12871-019-0712-z -
Indian Journal of Ophthalmology Apr 2021This study compares the vital parameters and pain experienced during phacoemulsification under peribulbar and topical anesthesia to determine the incidence of OCR. (Randomized Controlled Trial)
Randomized Controlled Trial
PURPOSE
This study compares the vital parameters and pain experienced during phacoemulsification under peribulbar and topical anesthesia to determine the incidence of OCR.
METHODS
One hundred six patients are enrolled for phacoemulsification in a prospective and randomized study. Fifty-two patients undergo surgery in a peribulbar block (Group PB) and 54 in topical anesthesia (Group TA). Mean arterial pressure (MAP) and pulse rate are recorded during a preoperative check-up and at four other steps of surgery. Pain experienced during surgery and on a postoperative day, 5, is graded with a verbal analogue scale. OCR defined as a decrease in pulse rate by greater than 20% is calculated. Chi-square test, Fisher's exact test, paired t test and the comparison of means give the statistical analysis. A value of P < 0.05 was taken as significant.
RESULTS
MAP readings at baseline versus MAP at other steps of surgery show a trend towards rising with a P value of < 0.05 in both groups. Pulse rate measured at all steps of surgery versus baseline pulse rate in Group TA shows P < 0.05. OCR is present in nine patients in peribulbar block verses eleven patients in topical anesthesia with P value of 0.687. The pain scores using verbal analogue scale were higher in Group TA compared with Group PB with a P < 0.0001.
CONCLUSION
Oculocardiac reflex can occur during phacoemulsification under both peribulbar block and topical anesthesia, and the difference is not significant.
Topics: Administration, Topical; Anesthesia, Local; Anesthetics, Local; Humans; Lidocaine; Pain Measurement; Pain, Postoperative; Phacoemulsification; Prospective Studies; Reflex, Oculocardiac
PubMed: 33727460
DOI: 10.4103/ijo.IJO_1019_20 -
Indian Journal of Anaesthesia Feb 2020
PubMed: 32139942
DOI: 10.4103/ija.IJA_713_19 -
SAGE Open Medical Case Reports 2022Oculocardiac reflex is a phenomenon caused by traction applied to the extraocular muscles, or pressure on the globes. The afferent stimulus travels via the ophthalmic...
Oculocardiac reflex is a phenomenon caused by traction applied to the extraocular muscles, or pressure on the globes. The afferent stimulus travels via the ophthalmic branch of cranial nerve V, and the efferent stimulus travels via cranial nerve X, which can cause severe bradycardia and potentially hypotension, atrioventricular block, ventricular ectopy, and rarely asystole. Oculocardiac reflex is different from vasovagal syncope which has another pathway, and is triggered by pain or emotional upset, that results in failure of autoregulation of blood pressure. Ophthalmologists often observe oculocardiac reflex intraoperatively upon manipulation of extraocular muscles during strabismus surgeries. We report a case with a previously undescribed complication following pterygium autograft with fibrin glue stimulating oculocardiac reflex resulting in episodes of sudden bradycardia associated with light headedness and nausea.
PubMed: 36119665
DOI: 10.1177/2050313X221122459