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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 -
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 -
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 -
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 -
Indian Journal of Anaesthesia Feb 2020
PubMed: 32139942
DOI: 10.4103/ija.IJA_713_19 -
Middle East Journal of Anaesthesiology Jun 1986Oculocardiac reflex is one of the trigemino-vagal reflexes, and is frequently observed during anesthesia for pediatric strabismus surgery. The reflex is greatly... (Review)
Review
Oculocardiac reflex is one of the trigemino-vagal reflexes, and is frequently observed during anesthesia for pediatric strabismus surgery. The reflex is greatly exaggerated in the presence of hypoventilation, hypoxemia and acidosis. The reflex is important as a cause of cardiac arrest during eye surgery. Several related reflexes are known, such as blepharocardiac reflex, oculorespiratory reflex, and the sudden infant death syndrome. Although the reflex can be prevented by a retrobulbar block or the administration of parasympatholytic drugs, well conducted anesthesia and cooperation with the surgeon is much more important.
Topics: Anesthesia, General; Atropine; Bradycardia; Heart Arrest; Humans; Intraoperative Complications; Neural Pathways; Ophthalmologic Surgical Procedures; Postoperative Complications; Reflex; Reflex, Oculocardiac; Trigeminal Nerve; Vagus Nerve
PubMed: 3528796
DOI: No ID Found -
The British Journal of Ophthalmology Aug 1981
Topics: Humans; Methods; Oculomotor Muscles; Reflex; Reflex, Oculocardiac
PubMed: 7295624
DOI: 10.1136/bjo.65.8.589 -
Anesthesia and Analgesia Jun 2023
Topics: Reflex, Oculocardiac; Ice; Heart Rate; Hypothermia, Induced; Reflex
PubMed: 37205826
DOI: 10.1213/ANE.0000000000006496 -
Journal of the American Optometric... May 1982The oculocardiac reflex (OCR), which may result from traction or pressure on the globe, orbital contents, or extra ocular muscles, has been associated with cardiac... (Review)
Review
The oculocardiac reflex (OCR), which may result from traction or pressure on the globe, orbital contents, or extra ocular muscles, has been associated with cardiac arrests during ocular surgery. The pathways for this reflex have been established and several preventive methods including retrobulbar block and intravenous injection of atropine have been developed. These procedures, combined with recent advances in anesthesia, may have reduced the occurrence of fatal cardiac arrests caused by the elicitation of the reflex during ocular surgery, however, for numerous reasons, the reflex remains of optometric interest.
Topics: Animals; Atropine; Child; Child, Preschool; Heart Arrest; Humans; Infant; Nerve Block; Ophthalmologic Surgical Procedures; Reflex; Reflex, Oculocardiac; Surgical Procedures, Operative
PubMed: 7047626
DOI: No ID Found