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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 -
PloS One 2020Common complications of pediatric strabismus surgery, including emergence agitation (EA), postoperative nausea and vomiting (PONV), and postoperative pain, may be... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Common complications of pediatric strabismus surgery, including emergence agitation (EA), postoperative nausea and vomiting (PONV), and postoperative pain, may be prevented using dexmedetomidine, which is an anxiolytic and analgesic. This systematic review and meta-analysis assessed the effects of dexmedetomidine in patients who had undergone pediatric strabismus surgery.
METHOD
Five databases were searched for randomized controlled trials published from database inception to April 2020 that compared dexmedetomidine use with placebo or active comparator use and evaluated EA, PONV, or postoperative pain incidence (main outcomes) in patients who had undergone pediatric strabismus surgery. Oculocardiac reflex (OCR) incidence and postanesthesia care unit (PACU) stay duration were considered as safety outcomes. All meta-analyses were performed using a random-effects model.
RESULTS
In the nine studies meeting our inclusion criteria, compared with placebo use, dexmedetomidine use reduced EA incidence [risk ratio (RR): 0.39; 95% confidence interval (CI): 0.25-0.62, I2 = 66%], severe EA incidence (RR: 0.27, 95% CI: 0.17-0.43, I2 = 0%), PONV incidence (RR: 0.33, 95% CI: 0.21-0.54, I2 = 0%), analgesia requirement (RR: 0.38, 95% CI: 0.25-0.57, I2 = 0%), and pain scores (standardized mean difference: -1.02, 95% CI: -1.44 to -0.61, I2 = 75%). Dexmedetomidine also led to lower EA incidence in the sevoflurane group than in the desflurane group (RR: 0.26 for sevoflurane vs. 0.45 for desflurane). Continuous dexmedetomidine infusion (RR: 0.19) led to better EA incidence reduction than did bolus dexmedetomidine infusion at the end of surgery (RR: 0.26) or during the peri-induction period (RR: 0.36). Compared with placebo use, dexmedetomidine use reduced OCR incidence (RR: 0.63; I2 = 40%). No significant between-group differences were noted for PACU stay duration.
CONCLUSION
In patients who have undergone pediatric strabismus surgery, dexmedetomidine use may alleviate EA, PONV, and postoperative pain and reduce OCR incidence. Moreover, dexmedetomidine use does not affect the PACU stay duration.
Topics: Analgesics, Non-Narcotic; Anesthesia Recovery Period; Child; Child, Preschool; Dexmedetomidine; Female; Humans; Hypnotics and Sedatives; Infant; Male; Postoperative Complications; Randomized Controlled Trials as Topic; Reflex, Oculocardiac; Strabismus
PubMed: 33045022
DOI: 10.1371/journal.pone.0240553 -
The Journal of International Medical... Aug 2020To determine (1) how the specific muscle undergoing surgical treatment affects the occurrence of the oculocardiac reflex (OCR) and oculorespiratory reflex (ORR) and (2)...
Oculocardiac reflex and oculorespiratory reflex during strabismus surgery under general anesthesia using the laryngeal mask airway with maintenance of spontaneous respiration: A retrospective study.
OBJECTIVE
To determine (1) how the specific muscle undergoing surgical treatment affects the occurrence of the oculocardiac reflex (OCR) and oculorespiratory reflex (ORR) and (2) whether the depth of anesthesia influences the occurrence of the OCR and ORR in patients undergoing strabismus surgery with a laryngeal mask airway with maintenance of spontaneous respiration.
METHODS
The medical records of patients who underwent strabismus surgery on the lateral rectus (LR) and medial rectus (MR) muscles from January 2017 to December 2017 were retrospectively reviewed.
RESULTS
The incidence of the OCR was not significantly different between LR and MR operations in either pediatric or adult patients. The incidence of the ORR as indexed by the tidal volume (TV) was significantly higher during MR than LR surgery in pediatric patients (29.3% vs. 10.1%, respectively). The change in TV during muscle traction and the bispectral index were significantly correlated in both pediatric and adult patients (r = 0.034 and 0.058, respectively).
CONCLUSIONS
The OCR was not influenced by the specific muscle undergoing surgery or the depth of anesthesia. The incidence of the ORR as indexed by the TV was higher during MR surgery in pediatric patients and was positively correlated with the depth of anesthesia.
Topics: Adult; Anesthesia, General; Child; Humans; Laryngeal Masks; Reflex; Reflex, Oculocardiac; Respiration; Retrospective Studies; Strabismus
PubMed: 32787487
DOI: 10.1177/0300060520945158 -
Anaesthesia and Intensive Care Jul 2020Strabismus correction surgery is the most common eye operation in children. Adults have approximately a 4% lifetime risk of developing strabismus. Current treatment...
Strabismus correction surgery is the most common eye operation in children. Adults have approximately a 4% lifetime risk of developing strabismus. Current treatment options include pharmacological injection of botulinum toxin or bupivacaine, conventional corrective surgery, adjustable suture surgery and minimally invasive surgery. Repeated surgery is common as each operation has a 60%-80% chance of successful correction. The benefits of early surgical correction in large-angle strabismus in children outweigh the risks of anaesthesia. General anaesthesia is suitable for patients of all age groups, for complicated or repeated surgery, and bilateral eye procedures. Regional ophthalmic block reduces the incidence of oculocardiac reflex and emergence agitation, and provides postoperative analgesia, but requires a cooperative patient as many experience discomfort. Topical anaesthesia has been used in pharmacological injection, minimally invasive surgery, uncomplicated conventional strabismus surgery and some adjustable suture strabismus surgery. Its use, however, is only limited to cooperative adult patients. Prophylactic antiemesis with both ondansetron and dexamethasone is recommended, especially for children. A multimodal analgesia approach, including paracetamol, intravenous non-steroidal anti-inflammatory drugs, topical local anaesthetic and minimal opioid usage, is recommended for postoperative analgesia, while a supplementary regional ophthalmic block is at the discretion of the team.
Topics: Adult; Anesthesia, Local; Anesthetics; Bupivacaine; Child; Humans; Ophthalmologic Surgical Procedures; Strabismus
PubMed: 32777929
DOI: 10.1177/0310057X20937710 -
Paediatric Anaesthesia Oct 2020Anesthesia providers are familiar with the oculocardiac reflex, one type of trigeminocardiac reflex. While less common, arrhythmias associated with manipulation of other...
Anesthesia providers are familiar with the oculocardiac reflex, one type of trigeminocardiac reflex. While less common, arrhythmias associated with manipulation of other trigeminal nerve branches can occur. We report the presentation and management of bradycardia and asystole from stimulation of the mandibular branch of the trigeminal nerve during temporomandibular joint reconstruction.
Topics: Bradycardia; Heart Arrest; Humans; Reflex; Reflex, Oculocardiac; Temporomandibular Joint; Trigeminal Nerve
PubMed: 32741014
DOI: 10.1111/pan.13984 -
Pediatric Emergency Care Oct 2021The oculocardiac reflex has been well described in the literature and was first defined in 1908 by Aschner. The phenomenon involves the afferent limb of the ophthalmic...
The oculocardiac reflex has been well described in the literature and was first defined in 1908 by Aschner. The phenomenon involves the afferent limb of the ophthalmic division of the trigeminal nerve as well as the efferent pathway involving the vagal nerve leading to negative chronotropic effects. It results in a decrease in heart rate and oftentimes a decrease in blood pressure associated with compression of the eye or traction of the extraocular muscles. This reflex has clinical significance in both the operating room during ophthalmic procedures and in the emergency department in patients having sustained craniofacial trauma. The typical dysrhythmia described in literature is sinus bradycardia. Our patient, however, had a ventricular escape rhythm with a complete left bundle branch block pattern.
Topics: Adolescent; Bradycardia; Heart Rate; Hematoma, Epidural, Cranial; Humans; Orbital Fractures; Reflex, Oculocardiac
PubMed: 32701866
DOI: 10.1097/PEC.0000000000002191 -
Annals of the Royal College of Surgeons... Nov 2020The trigeminovagal reflex is a phenomenon that occurs rarely during maxillofacial surgery. Previously described as the oculocardiac reflex, this reflex can occur during...
The trigeminovagal reflex is a phenomenon that occurs rarely during maxillofacial surgery. Previously described as the oculocardiac reflex, this reflex can occur during ocular and periocular surgery. To be more anatomically precise, it was renamed the trigeminocardiac or trigeminovagal reflex, since stimulation of any part of the trigeminal nerve can elicit this reflex arc. We describe a case of asystole during mobilization of a maxilla following a Le Fort 1 osteotomy.
Topics: Heart Arrest; Humans; Intraoperative Complications; Male; Maxilla; Middle Aged; Osteotomy, Le Fort; Reflex, Trigeminocardiac; Risk Factors; Trigeminal Nerve
PubMed: 32513016
DOI: 10.1308/rcsann.2020.0126 -
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 -
American Journal of Otolaryngology 2020The purpose of this study is to determine whether bradycardia associated with the oculocardiac reflex is a significant source of morbidity in the post injury period...
PURPOSE
The purpose of this study is to determine whether bradycardia associated with the oculocardiac reflex is a significant source of morbidity in the post injury period following orbital floor fractures in children.
MATERIALS/METHODS
A retrospective review of all pediatric patients who presented to our emergency department with an orbital floor fracture from May 1, 2016 to June 1, 2018 were included. Basic demographic data was collected as well as mechanism of injury, presence of bradycardia, and time to operating room. Morbidity was based on the need for medications to treat bradycardia.
RESULTS
Thirty-five pediatric patients with orbital floor fractures were reviewed. 6 (17.1%) patients had post injury bradycardia, with one patient requiring medication to stabilize their heart rate. There was no statistically significant difference in sex, race/ethnicity, or age in patients with or without bradycardia (p > 0.05) however there was a significant relationship between bradycardia and need for operative repair (X = 7.88, df = 1, p = 0.005). The most common mechanism of injury was motor vehicle collision (45.7%). The average time to the operating room was 145 h (6.04 days).
CONCLUSIONS
While activation of the oculocardiac reflex is a legitimate concern in the post injury period, there is unlikely to be significant morbidity due to bradycardia, and the greater concern should be for the ischemic muscle injury incurred from the fracture.
Topics: Accidents, Traffic; Adolescent; Bradycardia; Child; Female; Humans; Male; Morbidity; Orbital Fractures; Reflex, Oculocardiac; Retrospective Studies; Time Factors
PubMed: 32485298
DOI: 10.1016/j.amjoto.2020.102553 -
Chinese Medical Journal Apr 2020Ophthalmic ambulatory surgery is preferred to be performed under general anesthesia either by total intravenous anesthesia (TIVA) or by inhalational anesthesia to... (Randomized Controlled Trial)
Randomized Controlled Trial
Desflurane anesthesia compared with total intravenous anesthesia on anesthesia-controlled operating room time in ambulatory surgery following strabotomy: a randomized controlled study.
BACKGROUND
Ophthalmic ambulatory surgery is preferred to be performed under general anesthesia either by total intravenous anesthesia (TIVA) or by inhalational anesthesia to increase the patient comfort. However, anesthesia-controlled time (ACT) can cause increased non-operative operating room (OR) time which may adversely affect the ORs efficiency. This study was aimed to compare the ACT of desflurane with that of propofol-remifentanil in strabismus ambulatory surgery.
METHODS
From November 2016 to December 2017, a total of 200 strabismus patients (aged 18-60 years old, and scheduled for elective ambulatory surgery at Zhongshan Ophthalmic Center) were randomly assigned to receive either propofol-based TIVA (group TIVA) or desflurane anesthesia (group DES) for maintenance of anesthesia. The primary outcome was the extubation time. Secondary outcomes included surgical time, anesthetic time, OR exit time, and Phase I and II recovery time. The intraoperative incidences of hypotension, bradycardia and oculocardiac reflex (OCR), and the incidences of any post-operative complications were recorded. Mann-Whitney U test and Chi-square or Fisher exact tests were used to compare the two groups.
RESULTS
We found that the extubation time (5.5 [3.9-7.0] vs. 9.7 [8.5-11.4] min, P < 0.001) and the incidence of prolonged time to extubation (0 vs. 6%, P = 0.029) in the DES group were significantly decreased compared with those in the TIVA group. The patients in the DES group displayed shorter OR exit time as compared with that in the TIVA group (7.3 [5.5-8.7] vs. 10.8 [9.3-12.3] min, P < 0.001). The patients using desflurane exhibited more stable hemodynamics during surgery than the patients using propofol-based TIVA, as demonstrated by lower incidences of hypotension (1% vs. 22%, P < 0.001), bradycardia (2% vs. 13%, P = 0.002), and OCR (17% vs. 44%, P < 0.001).
CONCLUSION
DES enhanced the ophthalmic OR efficiency by reducing the extubation time and OR exit time, and provided more stable hemodynamics intra-operatively than TIVA in patients undergoing strabismus ambulatory surgery.
TRIAL REGISTRATION
ClinicalTrials.gov, No. NCT02922660; https://clinicaltrials.gov/ct2/show/NCT02922660?id=NCT02922660&draw=2&rank=1.
Topics: Adolescent; Adult; Ambulatory Surgical Procedures; Anesthesia, General; Anesthesia, Intravenous; Anesthetics, Inhalation; Anesthetics, Intravenous; Desflurane; Female; Humans; Male; Middle Aged; Operating Rooms; Operative Time; Propofol; Remifentanil; Strabismus; Young Adult
PubMed: 32149764
DOI: 10.1097/CM9.0000000000000728