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Indian Journal of Ophthalmology Dec 2021:To evaluate the outcomes of large-angle exotropia by single-stage adjustable strabismus surgery (SSASS) under monitored conscious anesthesia.
PURPOSE
:To evaluate the outcomes of large-angle exotropia by single-stage adjustable strabismus surgery (SSASS) under monitored conscious anesthesia.
METHODS
A prospective study was done in 33 patients above 14 years with ≥40 prism diopters (PD) of exotropia. All patients underwent SSASS under monitored conscious anesthesia (topical anesthesia plus intravenous sedation). For deviations of ≤55 PD, two horizontal rectus muscles, and for >55 PD, three rectus muscles were operated and a decision on adjustment/operating on an additional rectus muscle was taken after assessing the alignment. Monitored conscious anesthesia allowed us to check our results after surgery and plan further surgery/adjustment to achieve the desired alignment.
RESULTS
Mean preoperative deviation for distance was 52 ± 11.1 PD. The target alignment was achieved with the initial surgical plan in 10/21 patients with <55 PD exotropia and 4/12 patients with >55 PD exotropia, and one patient in each group needed adjustment. The remaining patients needed additional rectus muscle surgery. One patient with >55 PD exotropia needed both adjustment and additional rectus surgery. The success rate for distance correction was 85% at 6 months and 1 year. The overall success rate was 71% at 6 months. Percentage of patients with binocular single vision improved from 31% preoperatively to 78% by 6 months. Incidence of oculocardiac reflex was 6.1%.
CONCLUSION
SSASS under monitored conscious anesthesia is a viable option for large-angle strabismus correction with good patient comfort and safety.
Topics: Anesthesia, Local; Exotropia; Follow-Up Studies; Humans; Oculomotor Muscles; Ophthalmologic Surgical Procedures; Prospective Studies; Retrospective Studies; Strabismus; Suture Techniques; Treatment Outcome; Vision, Binocular
PubMed: 34827002
DOI: 10.4103/ijo.IJO_85_21 -
Brazilian Journal of Anesthesiology... 2021The most common cause of oculocardiac reflex (OCR) is traction of the extraocular muscles. Therefore, strabismus surgery is highly risk for the development of this... (Observational Study)
Observational Study
BACKGROUND AND OBJECTIVES
The most common cause of oculocardiac reflex (OCR) is traction of the extraocular muscles. Therefore, strabismus surgery is highly risk for the development of this complication. This study aimed to investigate whether an association exists between the occurrence of OCR and the type of extraocular muscle manipulated during strabismus in a pediatric population.
METHODS
A total of 53 pediatric patients who were operated for strabismus under sevoflurane anesthesia were enrolled in this prospective study. The association between surgical techniques and the occurrence of OCR was investigated.
RESULTS
This study included 30 (56.6%) males and 23 (43.4%) females, with a mean age of 8.4 years. Overall, 83 eyes with 93 extraocular muscles were operated. Surgery was performed most frequently on the medial (44.6%) and lateral (36.1%) recti. OCR occurred in 33 (62.3%) patients. OCR was found to be significantly higher in the first operated muscle compared with the second muscle, regardless of muscle type, as identified in the statistical analysis based on the sequence of the operated muscles.
CONCLUSIONS
The manipulation of the first extraocular muscle has a higher risk of OCR in the pediatric population undergoing two-muscle surgery for strabismus.
Topics: Child; Female; Humans; Male; Oculomotor Muscles; Prospective Studies; Reflex, Oculocardiac; Sevoflurane; Strabismus
PubMed: 34715994
DOI: 10.1016/j.bjane.2020.12.015 -
Journal of Clinical Medicine Sep 2021The intraprocedural immobilization of selected subsets of patients undergoing pars plana vitrectomy (PPV) requires the performance of general anesthesia (GA), which...
The intraprocedural immobilization of selected subsets of patients undergoing pars plana vitrectomy (PPV) requires the performance of general anesthesia (GA), which entails the intraoperative use of hypnotics and titration of opioids. The Adequacy of Anesthesia (AoA) concept of GA guidance optimizes the intraoperative dosage of hypnotics and opioids. Pre-emptive analgesia (PA) is added to GA to minimize intraoperative opioid (IO) usage. The current additional analysis evaluated the advantages of PA using either COX-3 inhibitors or regional techniques when added to AoA-guided GA on the rate of presence of postoperative nausea and vomiting (PONV), oculo-emetic (OER), and oculo-cardiac reflex (OCR) in patients undergoing PPV. A total of 176 patients undergoing PPV were randomly allocated into 5 groups: (1) Group GA, including patients who received general anesthesia alone; (2) Group T, including patients who received preventive topical analgesia by triple instillation of 2% proparacaine 15 min before induction of GA; (3) Group PBB, including patients who received PBB; (4) Group M, including patients who received PA using a single dose of 1 g of metamizole; (5) Group P, including patients who received PA using a single dose of 1 g of acetaminophen. The incidence rates of PONV, OCR, and OER were studied as a secondary outcome. Despite the group allocation, intraoperative AoA-guided GA resulted in an overall incidence of PONV in 9%, OCR in 12%, and OER in none of the patients. No statistically significant differences were found between groups regarding the incidence of OCR. PA using COX-3 inhibitors, as compared to that of the T group, resulted in less overall PONV ( < 0.05). Conclusions: PA using regional techniques in patients undergoing PPV proved to have no advantage when AoA-guided GA was utilised. We recommend using intraoperative AoA-guided GA to reduce the presence of OCR, and the addition of PA using COX-3 inhibitors to reduce the rate of PONV.
PubMed: 34575281
DOI: 10.3390/jcm10184172 -
Acta Ophthalmologica Jun 2022To evaluate the tolerability and usability of topical anaesthesia in single rectus muscle recession for strabismus caused by Graves' orbitopathy (GO). To compare the...
PURPOSE
To evaluate the tolerability and usability of topical anaesthesia in single rectus muscle recession for strabismus caused by Graves' orbitopathy (GO). To compare the perioperative pain score and surgical outcome between GO patients and non-GO patients.
METHODS
A retrospective comparative study of consecutive single rectus muscle recession performed under topical anaesthesia was carried out. All patients scheduled for one-stage single rectus muscle recession under topical anaesthesia were included. Numerical visual analogue pain score scale (NVAS) points, rates of motor success (horizontal deviation < 8 prism diopters (PD) and vertical deviation ≤ 6 PD) and sensory success (no diplopia without prisms), complications and postoperative adjustment frequencies were compared between GO and non-GO patients.
RESULTS
A total of 111 patients were included. The mean perioperative pain scores were 2.3 (SD ± 1.3) in GO and 1.6 (SD ± 1.1) in non-GO patients (p = 0.06 adjusted for gender). The postoperative mean alignments in GO and non-GO patients were 2 versus 3 PD horizontally and 1 versus 1 PD vertically respectively. Both motor and sensory success rates were 98% in GO patients and 94% versus 93% in non-GO patients. Adjustments as a second procedure the day after surgery was performed in 10% of the GO patients and 15% of the non-GO patients. The oculocardiac reflex was not triggered in any of the GO patients.
CONCLUSION
Topical anaesthesia in single muscle recession for GO is safe, well-tolerated and gives comparable surgical outcomes to those achieved in non-GO patients.
Topics: Anesthesia, Local; Graves Ophthalmopathy; Humans; Oculomotor Muscles; Ophthalmologic Surgical Procedures; Pain; Retrospective Studies; Strabismus; Treatment Outcome
PubMed: 34532987
DOI: 10.1111/aos.15024 -
Journal of the Korean Association of... Aug 2021The oculocardiac reflex is a trigeminal-vagal reflex that manifests as cardiac arrythmias, most often bradycardia. The reflex can be triggered by manipulation of...
The oculocardiac reflex is a trigeminal-vagal reflex that manifests as cardiac arrythmias, most often bradycardia. The reflex can be triggered by manipulation of periorbital structures and unintended pressure on the bulbus oculi maxillofacial procedures. In this brief communication, we describe an unusual trigger of the oculocardiac reflex during maxillofacial surgery that resulted in severe bradycardia. This case highlights the need for careful securement of medical devices and attention to surgical technique to avoid undue pressure on draped fascial structures.
PubMed: 34462391
DOI: 10.5125/jkaoms.2021.47.4.335 -
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 -
Dermatologic Surgery : Official... Jun 2021
Topics: Aged; Carcinoma, Basal Cell; Cardiopulmonary Resuscitation; Eye Neoplasms; Female; Heart Arrest; Humans; Intraoperative Complications; Male; Middle Aged; Mohs Surgery; Neoplasm Invasiveness; Neoplasm Recurrence, Local; Orbit Evisceration; Reflex, Oculocardiac; Treatment Outcome
PubMed: 34029252
DOI: 10.1097/DSS.0000000000002767 -
A&A Practice Jan 2021Incontinentia pigmenti (IP) is a rare X-linked dominant disorder. We present a case of an infant with IP who was brought to the operating room for panretinal diode...
Incontinentia pigmenti (IP) is a rare X-linked dominant disorder. We present a case of an infant with IP who was brought to the operating room for panretinal diode photocoagulation under general anesthesia. The anesthesia team was unable to obtain intravenous access even with instruments such as a vein finder and ultrasound. Anesthesia for IP patients also poses challenges such as prevention of the oculocardiac reflex, obesity and airway management, and preemptive measures for intravenous access due to skin manifestations. Patients with IP may present with many challenges for the anesthesiologist during all phases of anesthetic management.
Topics: Anesthetics; Child; Humans; Incontinentia Pigmenti; Infant
PubMed: 33986197
DOI: 10.1213/XAA.0000000000001384 -
Medicine May 2021Intravenous dexmedetomidine (DEX) has been used to prevent emergence agitation (EA) in children. The aim of this meta-analysis was to evaluate whether DEX decreases EA... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Intravenous dexmedetomidine (DEX) has been used to prevent emergence agitation (EA) in children. The aim of this meta-analysis was to evaluate whether DEX decreases EA incidence without augmenting oculocardiac reflex (OCR) in pediatric patients undergoing strabismus surgery.
METHODS
We searched PubMed, EMBASE, Chinese National Knowledge Infrastructure (CNKI), Wan Fang, and the Cochrane Library to collect the randomized controlled trials (RCTs) investigating the effects of intraoperative DEX in children undergoing strabismus surgery from inception to October 2019. Postoperative Pediatric Agitation and Emergence Delirium (PAED) score, postoperative EA, extubation or laryngeal mask airway (LMA) removal time, postanesthetic care unit (PACU) stay time, OCR, and postoperative vomiting (POV) were evaluated.
RESULTS
11 RCTs including 801 patients were included in this study. Compared with control group, intravenous DEX significantly reduced postoperative PAED score (WMD, 3.05; 95% CI: -3.82 to -2.27, P = .017) and incidences of postoperative EA 69% (RR, 0.31; 95% CI: 0.17 to 0.55, P < .00) and POV (RR, 0.28; 95% CI: 0.13 to 0.61, P = .001). Furthermore, the use of DEX significantly delayed extubation or LMA removal time (WMD, 2.11; 95% CI: 0.25 to 3.97, P < .001). No significant difference was found in the incidence of ORC and PACU stay time.
CONCLUSION
Intravenous DEX reduced the incidences of EA without increasing OCR in pediatric patients undergoing strabismus surgery. Meanwhile, DEX infusion decreased the incidence of POV in children.
Topics: Anesthesia, General; Dexmedetomidine; Emergence Delirium; Humans; Incidence; Injections, Intravenous; Ophthalmologic Surgical Procedures; Perioperative Period; Randomized Controlled Trials as Topic; Reflex, Oculocardiac; Strabismus; Treatment Outcome
PubMed: 33950954
DOI: 10.1097/MD.0000000000025717 -
Plastic and Reconstructive Surgery.... Apr 2021"Trap door" orbital floor fractures are usually seen in children. In the linear fracture type, a break occurs in the bones of the orbital floor that permits orbital...
BACKGROUND
"Trap door" orbital floor fractures are usually seen in children. In the linear fracture type, a break occurs in the bones of the orbital floor that permits orbital tissue to prolapse into the fracture site during fracture formation. The bony fragments of the fracture then return to their original position, entrapping the prolapsed orbital tissue. In the hinged fracture type, the fractured part of the floor is minimally displaced into the maxillary sinus and acts as the hinge of a "swinging door" entrapping the orbital tissue.
METHODS
We report on a series of 10 adult patients with hinged orbital floor fractures.
RESULTS
The mean patient age was 35 years. Seven patients had a pure orbital floor fracture and the remaining 3 patients had fractures of both the orbital floor and the inferior orbital rim. All 10 patients had diplopia in the upgaze. None of the patients had signs of the oculocardiac reflex. None of the CT scans showed a "tear-drop" sign. However, the sagittal CT scans showed evidence of entrapment of the inferior rectus. All patients had a small area of a slightly depressed orbital floor at the site of entrapment, without a bony defect. All patients underwent surgery through an infraorbital incision and a titanium mesh was used in all patients. There were no postoperative complications. All patients regained full range of motion of the globe.
CONCLUSION
This is the first series in the literature that reports on the characteristics and outcome of trap door orbital floor fractures in adults.
PubMed: 33868879
DOI: 10.1097/GOX.0000000000003537