Khurana RK. Cui W. [Blepharoplasty and oculocardiac reflex]. 8. 2020;14:42634269. [Studies on the oculocardiac reflex with the use of arterial oscillography]. J Oral Maxillofac Surg. the stimulus required to initiate the oculocardiac reex has been shown to be variable, and it can be a graded response based on increasing traction.7 continuation of this stimulation can cause escape from or fatigue of the reex such that the heart rate does not remain maximally de- creased.8 in our case, this phenomenon was difcult to The incidence of OCR varies from 16 to 82 % in strabismus surgeries and this wide range does depend on the anesthetic agents, premedications, and the definition of OCR being used. (Dewar KMS. Ibrahim AN, Shabana T. Sub-Tenons injection versus paracetamol in pediatric strabismus surgery. Publications listed to the right side with heart rate response during retinopathy of prematurity (ROP) examinations to lower right. Arch Ophthalmol. Figure 10 shows the first and second oculocardiac reflex and the intervals from induction. Listing a study does not mean it has been evaluated by the U.S. Federal Government. Sample size to detect a 5% difference 251 in each cohort. Chung Hua Cheng Hsing Shao Shang Wai Ko Tsa Chih. Bulk reprints for the pharmaceutical industry. government site. Arnold RW, Jensen PA, Kovtoun TA, Maurer SA, Schultz JA. Figure 6 Extremes in oculocardiac reflex. Vrach Delo. 1990;28(2):109110. Anesthesia. Eur J Ophthalmol. Grover V, Bhardwaj N, Shobana N, Grewal S. Oculocardiac reflex during retinal surgery using peribulbar block and nitrous narcotic anesthesia. 1988;32(2):149151. 229. 1998;45(7):706. Ophthalmic Physiol Opt. Berler D. The oculocardiac reflex. 2001;108(10):17211726. 2020;20(1):86. 2017;8:533. 57. Chin Med J. Arnold RW, Bond AN, McCall M, Lunoe L. The oculocardiac reflex and depth of anesthesia measured by brain wave. Numbers studied at the bottom. [Standardization of oculo-cardiac reflex in infants under 3 months of age]. 1984;39(3):291292. From 3122 cases, 169 could be separated due to anticholinergic medication, with an additional 5 excluded with orbital block and 1 with a pacemaker. Saudi J Anaesth. 1992;78(6):6469. . Blanc VF. Br J Anaesth. For cases with only single EOM, the 720 left eyes (OCR 85%, Q1 70%, Q3 97%) still had more bradycardia than the 267 right eyes (OCR 91%, Q1 73%, Q3 99%, MannWhitney z=3.1, p<0.01). Bpm, beats per minute; CI, confidence interval; CO2, carbon dioxide; CSM, carotid sinus massage; DR, diving response; EOM, extraocular muscle; GP, globe pressure; HR, heart rate; IM, intramuscular; IV, intravenous; LMA, laryngeal mask airway; N2O, nitrous oxide; OCR, oculocardiac reflex; ORR, oculorespiratory reflex; Q1 and Q3, interquartile ranges; PONV, post operative nausea and vomiting; PVC, premature ventricular contraction; RCT, randomized controlled trial; ROP, retinopathy of prematurity; SD, standard deviation; SIDS, sudden infant death syndrome; TIVA, total intravenous anesthesia; TVR, trigeminovagal reflex. 26. Braun GG, Schywalsky M, Naujoks B, Brunner M, Danner U, Hauschild S. Atropin versus Glycopyrrolat bei ophthalmochirurgischen Eingriffen. Independently, weight and age correlated with %OCR such that older, and heavier patients had less percent bradycardia (Figure 14); however, multivariable regression reduced the influence of weight but age was still significant. The estimation of OCR will be helpful for prevention of subsequent postoperative VVR. Batterbury M, Wong D, Williams R, Kelly J, Mostafa SM. Compared to median OCR of 85% of pre-heart rate in 2527 initial cases, dexamethasone increased bradycardia with OCR to 72% of pre heart rate in 1898 patients.21 In this Alaska OCR study, the confounding factor may be the one prominent anesthesiologist with dominant average OCR frequently used IV push fentanyl with dexamethasone. Stott D. Reflex bradycardia in facial surgery. Buck LS, Stockton S, Spankovich C, Jordan JR. Pediatric orbital floor fractures and the oculocardiac reflex: experience from a level I trauma center. In 2386 cases, %OCR was inversely related to Expired CO2 concentration by the equation %OCR = 0.13 (CO2) +85.4, slope confidence intervals 0.22 to 0.04, p<0.01, Pearsons Product Moment r(2384) = 0.06, p<0.01, Figure 8). 80. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed. Karhunen U, Cozanitis D, Brander P. The oculocardiac reflex in adults: a dose response study of glycopyrrolate and atropine. The oculocardiac reflex in strabismus surgery. Sample size to detect a 10% difference: 63 in each cohort. 173. Prevention and treatment of the OCR is simpler in a controlled environment, such as elective surgery, and more difficult under less controlled environments such as trauma; in these situations, pharmacological intervention tends to be more of a necessity. 88. Fessl-Alemany E, Stocker L, Taube HD, Wessing A. 1991;75(2):204209. The prevalence by 10% bins for %OCR prevalence when OCR is defined as the maximally changed heart rate as a percent of stable pre-tension heart rate is: prevalence = 3E-08(%OCR)4 + 6E-06(%OCR)30.0004(%OCR)2 + 0.0105(%OCR) - 0.0683 (Figure 5). 1983;30(4):360369. of the extraocular muscles as in strabismus surgery could set off an "oculoemetic" refle similar to the well-described oculocardiac refle. 2006;16(11):11941195. sharing sensitive information, make sure youre on a federal 2001;45(1):5964. 1978;49:433. 12. Cooper J, Medow N, Dibble C. Mortality rate in strabismus surgery. The Alaska OCR study on two-eye cases usually performs the left eye first. J Cataract Refract Surg. J Pediatr Ophthalmol Strabismus. Clin Ophthalmol. 65. You have reached the maximum number of saved studies (100). Paciuc M, Mendieta G, Naranjo R. Oculocardiac reflex during laser in situ keratomileusis. Clipboard, Search History, and several other advanced features are temporarily unavailable. Arnold RW, Jensen P, Kovtoun TA, Maurer SA, Schultz J-A. The author reports no other potential conflicts of interest for this work. Choosing to participate in a study is an important personal decision. Karanovic N, Carev M, Ujevic A, Kardum G, Dogas Z. 79. You can learn about what data of yours we retain, how it is processed, who it is shared with and your right to have your data deleted by reading our Privacy Policy. There was a significant trend toward less %OCR (no anticholinergic) for older and heavier patients during the Alaska OCR study. Can Anaesth Soc J. Regional Anesthesia for Pediatric Ophthalmic Surgery: a Review of the Literature. There were a total of 3159 with 32 missing and 5 different initial tension, pacemaker 1, orbital block 5. Paciuc-Beja M, Meizner-Grezemkovsky D, Paciuc M, et al. Arnold RW, Bond AN. Arnold RW, Gould AB, MacKenzie R, Dyer JA, Low PA. 1983;18(7):314317. 63. 3. Vol 15 (10) . 2021 . Moonie G, Rees D, Elton D. The oculocardiac reflex during strabismus surgery. Please enable it to take advantage of the complete set of features! 1908;8:380. This often results in the restoration of normal sinus rhythm of the heart. 2. ; Ryland Roesch, M.D. 1986;41(8):825828. Sinha R, Chandralekha BM, Ray BR, Mohan VK, Saxena R. A randomised comparison of lidocaine 2% gel and proparacaine 0.5% eye drops in paediatric squint surgery. All cases will have a routine pre-operative check-up, starve for 6 h for solids and 2 hours for clear fluids and water. 142. Paediatr Anaesth. 147. Interventions by the anesthesiologist, the surgeon and characteristics of the patient themselves still do not lead to precise prediction of which patient might have a profound OCR or not. Anesth Analg. Written by: Shawna Atkins, Ph.D. This vagal stimulation leads to a decrease in heart rate (sinus bradycardia), contractility and arrhythmias such as atrioventricular block, ventricular fibrillation up to cardiac arrest. The total number of patients studied: Excluding the 3127 patients from the Alaska OCR Studies, 12,035 patients were studied in 129 published reports including at least 51 randomized clinical trials each with median 75 patients ranging up to 822 patients (Table S1). An official website of the United States government. Arnold RW. Brit J Ophthal. 189. Factors Affecting Oculocardiac Reflex Incidence In Pediatric Strabismus Surgery: retrospective Study. 73. Br J Ophthalmol. : . 7. The study design will be prospective, randomized, parallel groups, controlled clinical trial. 1991;38(6):757760. Chhabra A, Sinha R, Subramaniam R, Chandra P, Narang D, Garg SP. A prospective randomized clinical trial. Robideaux V. Oculocardiac reflex caused by midface disimpaction. 1997;94:354359. In clinical practice this Oculocardiac Reflex (OCR) is most often encountered during squint surgery. OCR is reported as the maximally changed heart rate as a percent of stable baseline heart rate. Manipulation of various visceral organs can elicit reflex bradycardia.4 The oculocardiac reflex (OCR) is no exception, however, when profound it usually comes as a surprise. In addition, Dr Robert W Arnold has a patent PDI Check pending to Robert Arnold and Alex Damarjian; and is on non-paid advisory boards for PlusoptiX, GoCheck Kids, Adaptica and iScreen. 1935;18:2225. Atropine was given before EOM tension in 169 of which 31 were re-ops. Contraindications of local anesthesia e.g. 1991;71(2):137138. 2005;9(3):279284. Brain Res Brain Res Rev. 1991;66(8):797804. 5. 2019;14:458. 1982. Calculate your paper price Academic level Deadline Clin Ophthalmol. It is defined by a decrease in heart rate by greater than 20% following globe pressure or traction of the extraocular muscles. Figure 2 Uniform elicitation of oculocardiac reflex: anesthesiologist records anesthetic parameters and electrocardiograph stable pre-tension heart rate and then maximally altered heart rate as a response to the surgeons gentle isolation of an extraocular rectus muscle and then utilizing a sterile tension gauge passed through a hole in a Jameson hook and applying a 10-second, 200 gram square wave tension on the EOM tendon. Albrecht Von Graefes Arch Klin Exp Ophthalmol. 1990;45(6):405408. Binocul Vis Strabismus Q. 1990;65(5):718720. The frequency distribution for OCR is not normal; most patients have relatively small change in heart rate. Ophthalmic surgery. Ophthalmic Surg. Gao L, Wang Q, Xu H, Tao Z, Wu F. The oculocardiac reflex in cataract surgery in the elderly [letter] [see comments]. 2000;238(1):5963. Eustis H, Eiswirth C, Smith D. Vagal responses to adjustable sutures in strabismus correction. The incidence of OCR varies from 16 to 82 % in strabismus surgeries and this wide range does depend on the anesthetic . ObjectiveTo investigate the related factors,characteristics,prevention measures of orthopia operation on operation ECG changes.MethodObservation the ECG operation changes of 200 orthopia operation patients,summarized prevention measures.ResultsThe children and general anesthesia patients were more prone to oculocardiac reflex,the . He is also president and a board member of PDI Check which makes a vision screening game for the autostereoscopic screen on the Nintendo 3DS. Can J Anaesth. 151. Prevention of Oculocardiac Reflex by Premedication With Low Dose I/V Ketamine during Strabismus Surgery 10.53350/pjmhs2115102652 . Indian J Physiol Pharmacol. The reflex is associated with the efficacy of different anesthetics in reducing the the appearance of sinus bradycardia as the most OCR during squint surgeries of children. Madan R, Perumal T, Subramaniam K, Shende D, Sadhasivam S, Garg S. Effect of timing of ondansetron administration on incidence of postoperative vomiting in paediatric strabismus surgery. Figure 1 Timeline for the Alaska OCR Study. FOIA Wein Klin Wchnschr. 2008;52(9):12731277. J Pediatr Ophthalmol Strabismus. Zhong Nan Da Xue Xue Bao Yi Xue Ban. J Aapos. Am J Ophthalmol. The effect of intraoperative retrobulbar block on anesthetic management of enucleation under general anesthesia. Copyright 2017 Informa PLC. 1990;31:3841. Binocul Vis Strabismus Q. . Scand J Med Sci Sports. Am J Ophthalmol. 1. 1997;34(4):252254. The human heart rate response profiles to five vagal maneuvers. The oculocardiac reflex (OCR), also known as the Aschner reflex or trigeminovagal reflex (TVR), was first described in 1908 as a reduction in heart rate secondary to direct pressure placed on the eyeball. Pratt et al tested 182 consecutive patients with 10-second, 200 gram square wave tension.166 Those with only one muscle tendon pulled had OCR heart rate reduction of 2924% which did not differ from tension on two adjacent rectus muscle tendons (3126%, paired t=0.7, p=0.49). 60. Chung CJ, Lee JM, Choi SR, Lee SC, Lee JH. 169. Does Topical Proparacaine Improve Postoperative Comfort After Strabismus Surgery? 1993;42:356360. Br J Plast Surg. In a 2007 report, the authors of an otherwise carefully designed randomized trial explained the lack of sample size calculations thus: We chose the group size of 15 in each group without conducting a power analysis as there were no previous comparable studies.23 Very few of 200+ prior OCR studies have sufficient sample size to detect moderate to small difference in effect.24 The largest comparison group in randomized controlled trials (RCT) of OCR is 100.25 With OCR as secondary analysis, a recent RCT selected sample size of 28 per group to detect a 40% difference in effect not on OCR but rather on emergence agitation.20 Prior underpowered studies have been referenced as the reason for following their example striving for only about 30 per group.26. 127. This surgery primarily aims to improve alignment of visual axis but may be required only for cosmetic reasons. Med Hypotheses. Study record managers: refer to the Data Element Definitions if submitting registration or results information. Plast Reconstr Surg. J Pediatr Ophthalmol Strabismus. Acta Anaesthesiol Scand. Case report]. 1986;27:11601164. 2005;30(5):478483. 184. Hayes RW, McBrearty E. An oculo-cardiac hypothesis of sudden unexpected death in infants. Acta Anaesthesiol Taiwan. Clarke WN, Hodges E, Noel LP, Roberts D, Coneys M. The oculocardiac reflex during ophthalmoscopy in premature infants. Acta Anaesthesiol Scand. Muscle relaxation was achieved in all dogs using either vecuronium or . 46. A different neurologic eye condition with asymmetry exists with Duanes syndrome being more common in the left eye.162. Doyle DJ, Mark PW. Ducloyer JB, Couret C, Magne C, et al. 108. Shakil H, Wang AP, Horth DA, Nair SS, Reddy KKV. 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. The oculocardiac reflex (OCR) will be elicited by quantified (200 gram, 10-second, square-wave) traction on Jameson muscle hook under insertion of an extra ocular muscle (EOM, rectus). Gentle, gradual tension on the extraocular muscle tendons, and release of tension if bradycardia is elicited is one of the best therapies for OCR (Figure 15). 10. Matarasso A. 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. Arch Ophthalmol. Listing a study does not mean it has been evaluated by the U.S. Federal Government. Am J Physiol Heart Circ Physiol. atropine or glycopyrrolate for the prevention of oculocardiac reflex in children undergoing squint surgery. Ophthalmologica. 29. Griffis CA. Ophthalmol Clin North Am. Group GB: Total 15 cases who will receive general anesthesia with peribulbar block. 2005;17(4):5759. Lack of global vagal propensity in patients with oculocardiac reflex. From 1319 cases with general anesthesia maintained with desflurane median 94%, halothane median 87%, isoflurane median 89% and sevoflurane median 84%, there was a significant difference in %OCR due to agent type (KruskalWallis X2(3)=18, p<0.01). vanBrocklin et al wrote a brief review of oculocardiac reflex published in 1982.1 Scheiermann et al reviewed 9 randomized trials concerning anesthetic impacts on OCR finding two limited conclusions: propofol produced more OCR (2 studies combined for 257 patients) and volatile anesthetic produced more postoperative nausea and vomiting (PONV).2 Despite 9 RCTs the limited conclusions seemed to stem from clinical or statistical heterogeneity among the studies.2 Dunville and Kramer have started an OCR review web page.3 The practicing strabismus surgeon and ophthalmic anesthesiologist will benefit from an evidence-based review on how they can cooperate to make surgery safe and efficient, especially for strabismus patients. Pratt L, Arnold RW. For uniform study of OCR, adequate sample size should be selected. 187. J AAPOS. Paciuc in Mexico carefully documented OCR in LASIK without sedation172 and with fentanyl sedation.32 Pulse oximeter monitoring during 532 adult intravitreal injections found 3.3% with asymptomatic 20% drop in heart rate.82 LASIK with OCR from 90 to 40 bpm caused cancellation of the surgery.173 An atypical OCR174 or a heart attack with atrioventricular block occurred at the end of cataract surgery.175 About 2.6% of 2001 cataracts surveyed had cardiac events of which 0.7% of cataract surgeries had intraoperative arrhythmias.176 Ghai et al found less OCR with subtenons local anesthesia than with IV fentanyl during pediatric cataract surgery.144 Ducloyer recently observed OCR during various pediatric eye surgery with dexamethasone and ondansetron PONV prophylaxis and an OCR incidence of 4 of 8 cataracts, 1 of 3 Botox EOM injections, and 34 of 52 strabismus cases.139, OCR can be observed in about 17%177 of orbital blowout fractures93,95,103,178 and is an indication for more urgent surgical intervention.179 OCR can also accompany zygomatic fracture,180,181 orbital tumor surgery,182,183 orbital hematoma,184 rapidly growing orbital mass,136 penetrating ocular trauma,185 midface disimpaction,186 maxillary and mandibular manipulation,187,188 forehead lift,189 endoscopic forehead lift190 and LaForte osteotomy.191 Heart rate can slow during intubation of an orbit.192 Even an empty orbit manipulated can cause OCR and asystole.193196 Minor manipulation in the nose, especially with opioid may cause bradycardia.197 Opening the mouth during general anesthesia can cause bradycardia.198 If not familiar with trigeminovagal reflexes, cardiac pacemaker can precede repair of the inciting orbital fracture.104 Rhizotomy of the dorsal sensory roots of the trigeminal for intractable pain in a two year old produced asystole.199 Bradycardia may occur late after orbital floor fracture.200 Manipulation of the temporalis muscle during orbitozygomatic craniotomy produced reproducible, consistent asystole.201, Isenberg noted OCR with strabismus surgery suture adjustment.202 Vrabec blocked surgical OCR with atropine in 44 patients, but then noted heart rate drop to as low as 35 bpm during suture adjustment.60 In a survey, Eustis found 92 syncopal episodes from 37,096 strabismus surgery adjustments and one myocardial infarction.203 Eustis then had 65% OCR during surgery with 20% later with adjustment and 3 of 20 with PVC during adjustment.61 Hertel et al adjusted 60 strabismus cases with 45% having OCR of which 23 noted vasovagal symptoms.62 Hakim et al noted 0% during strabismus adjustment with lidocaine jelly.155 Of 4 adults with asystole during initial EOM surgery, subsequent adjustment cases resulted in two with >20% OCR and one with severe OCR sitting up for adjustment and with conjunctival closure.158, Various branches of the trigeminal nerve elicit different cardiac reflexes.204 The oculocardiac reflex, or globe pressure has been proposed as a mechanism for sudden infant death syndrome (SIDS).205,206 A TrigeminoVagal (TVR) or trigeminocardiac reflex has been described.187,207210, An adult female with eye exam syncope did not have repeat bradycardia with some other trigeminal stimuli like supraorbital pressure.211 Syncope accompanied insertion of hard contact lenses.213, OCR has been noted in premature infants.214 The heart rate change in 31% of infants can range from 10%-59% of baseline with various phases of the exam.215 Three of 80 premature ROP cryotherapy patients had respiratory arrest and one had cardiac arrest.216 Healthy premature babies monitored all night, and then subjected to globe pressure had mean lowest HR corresponding to 1049 540 milli seconds with lowest HR (1894 ms R-R interval) being 32 bpm.217 Prakalapakorn and colleagues at Duke have shown more OCR with ophthalmoscopy than non-contact methods of ROP exam.218 Schumacher et al recorded ECG monitoring during lid speculum scleral depressed ROP exams in 281 infants (Figure 3) finding %OCR ranged from 26% (bradycardia) to 149% tachycardia with a mean 644% finding that bradycardia during ROP exams was more rapid onset, greater median effect and longer duration than the bradycardia observed during strabismus surgery.157, Chong and Tan contradicted most reports by suspecting that adults may have more OCR than children.76 On the other hand, Tramer et al with separate, randomized clinical trials of OCR in adults77 and children91 observed more OCR with propofol in younger strabismic patients despite more atropine. 115. Adults and children undergoing ocular manipulation and tension on extra ocular muscles and strabismus surgery. Gilani SM, Jamil M, Akbar F, Jehangir R. Anticholinergic premedication for prevention of oculocardiac reflex during squint surgery. 1976;31:1822. 81. 122. 32. The oculocardiac reflex in adults. Misurya V, Singh S, Kulshrestha V. Prevention of oculocardiac reflex (O.C.R.) I.m. 93. Ophthalmic Physiol Opt. Prevention of the Oculo-Cardiac Reflex in Children Comparison of Retrobulbar Block and Intravenous Atropine Cyril Taylor, M.D. 1987;42(11):12071208. 2019;122:424427. 2002;17(4):313318. 1999;14(2):111116. May this idea serve you well in your pursuit to manage stress in your life. Negrutiu S, Pop R, Cardan E. [Persistent oculocardiac reflex following retrobulbar hematoma. Anaesthesia. 1914;37:816822. 136. Curr Opin Ophthalmol. As an observation of typical, clinical anesthetic and strabismus surgery practice, written consent was not required. J Clin Monit Comput. Intraoperative OCR with decrease of heart rate more than 20% from baseline. For bilateral recordings, first eye, and also second eye had more %OCR with the left eye, but this also was true for cases with only one-eye surgery. If cardiac arrest was identified, resuscitation will be according to advanced cardiac life support (ACLS) protocols. Effect of remifentanil on oculocardiac reflex in paediatric strabismus surgery. UK VAT Group: GB 365 4626 36. 155. Acta Ophthalmol. Ghai B, Makkar JK, Arora S. Intraoperative cardiac arrest because of oculocardiac reflex and subsequent pulmonary edema in a patient with extraocular cysticercosis. 1.The OCR occurs during traction on the extraocular muscles, particularly pressure on the bulbus, intraorbital injections, haematoma, and iatrogenic pressure on the . Mehmood N, Hasan A. Oculocardiac Reflex: an Underrecognized But Important Association With Orbital Trap Door Fractures. 128. Clin Ophthalmol. 2003;28(1):4347. 178. Bajares AC, Anselmi A, Capriles MA. Arnold RW, Rinner AR, Arnold AW, Beerle BJ. Neuroanatomy of the Oculocardiac Reflex: The oculocardiac reflex is perhaps the most famous of a group called the trigeminovagal27 reflexes (Figure 4). 2018;256(9):17771782. Machida CJ, Arnold RW. Asystole and bradycardia during maxillofacial surgery. Khan FM, Ankutse MM. Contact Us 39. The oculocardiac reflex in blepharoplasty surgery. prevention of blepharospasm: infiltration between the muscles and bone parallel to the lower and lateral orbital margins from a point 1 cm behind the orbit's lower lateral corner; alternatively, local anaesthetic may be injected above the condyloid . Kurmyshkin AA, Kurmyshkin NA. 228. 31. 2020;e1e3. Anesth Analg. Rev Chir Oncol Radiol O R L Oftalmol Stomatol Ser Oftalmol. 2005;43(2):109112. Arnold RW, Dyer JA, Gould AB, Hohberger GG, Low PA. ; V. K. Stoelting, M.D. A randomised prospective study was carried out in children undergoing surgery for squint correction, to determine the value of controlled ventilation as a prophylaxis against the occurrence of the oculocardiac reflex. 106. The original cases were then separated by patient age, by which type of extraocular muscle addressed, and by the opioid used in induction and early maintenance anesthesia. 1989;47:522523. Propofol did not have a significant impact (0.79, CI 3, 1.6; p=0.51). 150. Eye. Trigeminal nerve afferents including extraocular muscle proprioceptors travel from the first division of the trigeminal nerve to be processed in the brain stem with efferent the cardiac vagus nerve. Oculocardiac reflex caused by contact lenses. Anesthesiology. 2010;298(6):H20102023. The degree of bradycardia decreased with increasing patient weight (Pearson Product-Moment r(2125)=0.11, p<0.001). The anesthesiologist with least bradycardia did 98 cases with median %OCR of 91% (Q1 77%, Q3 98%). Describes a psychological theory of personality development based on disintegration of existing features and building new ones Dr. Arnold coordinates the Alaska Blind Child Discovery which has received discounted vision screening technology from several vendors. Mirakhur R, Jones C, Dundee J, Archer D. IM or IV atropine or glycopyrrolate for the prevention of oculocardiac reflex in children undergoing squint surgery. 1994;101(8):13471352. 2014;18(2):151155. The Consolidated Standards of Reporting Trials (CONSORT) recommendations for reporting randomized, controlled clinical trials will be followed. Oculocardiac reflex caused by contact lenses (letter). 1997;55(8):856859. 2008;101(2):234238. View 2 excerpts, cites methods and background. Ind J Ophthal. Taylor C, Wilson F, Roesch R, Stoelting V. Prevention of the oculo-cardiac reflex in children: comparison of retrobulbar block and intravenous atropine. Arch Pediatr. 2019 Nov 20;13:2279-2283. doi: 10.2147/OPTH.S230498. Figure 11 Influence on OCR by neurologic disorder: box (interquartile range with median in the middle and whisker (95 percentiles) of %OCR for patients with various neurologic conditions from the Alaska OCR study. For 1262 males with initial, non-anticholinergic OCR 86% (Q1 67%, Q3 97%) and 1270 females median OCR 85%, Q1 68%, Q3 97), there was no difference in percent heart rate effect (MannWhitney z=0.2, P=0.85, Figure 3). Binocul Vis Strabismus Q. Since there is a predictive relationship of the initial EOM tension OCR, to the subsequent tension(s) in the same case, patients may serve as their own controls by administering the studied intervention between the first and second EOM, and comparing them to similar cases without the intervention, taking into account laterality. A prospective randomised double blind study to evaluate the effect of peribulbar block or topical application of local anaesthesia combined with general anaesthesia on intra-operative and postoperative complications during paediatric strabismus surgery. [Two methods of mitigating the oculo-cardiac reflex during ocular muscle surgery under general anesthesia]. Ophthalmology. Marcus B, Gillette PC, Garson A. Intrinsic heart rate in children and young adults: an index of sinus node function isolated from autonomic control. 111. 2015;94(18):e807. Open access peer-reviewed scientific and medical journals. A positive oculocardiac reflex, defined as a fall in heart rate of 20% or more and/or the occurrence of dysrhythmias, was observed in 72% of spontaneously breathing patients and in 100% of ventilated patients not receiving prophylactic intravenous glycopyrronium. 2020;130(5):13511363. Ha SG, Huh J, Lee BR, Kim SH. 1982;94(3):422423. 1975;59:518524. Perioperative Nausea and vomiting will be treated by ondansetron 0.15 mg/kg intravenously over 15 min. 2016;24(2):7478. Oculocardiac reflex is a noted serious complication that accompanies such surgeries and may be life threatening. Lhuissier-Noel C, Gajdos A, Rousselie F, Fontaine M, Viars P. [Oculocardiac reflex in ocular surgery. 1980;64:362365. Ge XY. 11 Compared with the use of propofol . Effect of propofol on the incidence of postoperative vomiting after strabismus surgery in pediatric outpatients. Ophthalmic Surg Lasers. Talk with your doctor and family members or friends about deciding to join a study. eCollection 2019. Klockgether-Radke A, Feldmann M, Braun U, Mhlendyck H. Droperidol vs Metoclopramid-Prophylaxie von Erbrechen nach strabismus-operationen bei Kindern. 2004;8(1):100. Katowitz WR, OBrien M, Kiskis E, Elliott EM. Arndt GA, Stock MC. Arnold RW, Jansen SS, Glasionov J. Anesthetic impacts on the oculocardiac reflex: evidence from a large, observational study. The human heart rate response profiles to five vagal maneuvers. 86. 170. Oculocardiac Reflex During Intravitreal Injection. 1993;30:306311. Comparison of the quality of anesthesia and recovery conditions]. Klockgether-Radke A, Demmel C, Braun U, Mhlendyck H. Erbrechen und okulokardiale reflex. Am J Ophthalmol. Does topical proparacaine improve postoperative comfort after strabismus surgery? Brazilian J Anesthesiol. 30 patients will be randomly divided into 2 study groups .each group contains 15 patients; Group GA: Total 15 cases who will receive general anesthesia only, i.e., without peribulbar block. Association of oculocardiac reflex and postoperative nausea and vomiting in strabismus surgery in children anesthetized with halothane and nitrous oxide. 84. Semantic Scholar is a free, AI-powered research tool for scientific literature, based at the Allen Institute for AI. 2020;41(4):102553. 1994;42(5):571576. Except for desflurane and relatively smaller sample size, the degree of bradycardia with OCR decreased with deeper levels of inhaled agent (Figure 7). Author and Article Information Anesthesiology September 1963, Vol. Cah Anesthesiol. 1965;1:134135. Bull Soc Med Hosp Paris. Despite well over a century of experience, the teleology for this occasionally dramatic cardiac response to eye surgery is still not known.Keywords: strabismus surgery, trigeminovagal reflex, bradycardia, asystole. 1990;37(2):219222. 91. The site is secure. 159. This study investigated the effect of preoperative penehyclidine on PONV in patients undergoing strabismus surgery. 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. 1999;88(5):11831184. Find the latest published documents for oculocardiac reflex, Related hot topics, top authors, the most cited documents, and related journals . ClinicalTrials.gov Identifier: NCT04353960, 1 Month to 100 Years (Child, Adult, Older Adult), Contact: Robert W Arnold, MD 907-561-1917, Contact: Brion Beerle, MD 907-230-7359, Principal Investigator: Robert W Arnold, MD. Figure 10 The correlations between the time interval between induction and EOM tension for first and second measurements of OCR produced by 10-second, 200 gram square wave tension on rectus muscles. [1-3] Stimulation of the trigeminal receptors that innervate the nose and nasal Figure 6 shows examples of some of the extremes in bradycardia associated with uniform extraocular muscle tension in the Alaska OCR study. 118. Korean J Anesthesiol. BMC Ophthalmol. 211. 68. Chelsey L, Shapiro R. Oculocardiac reflex during treatment of an orbital blowout fracture. Karhunen found the second muscle less OCR than the first73 as did Kilic and Gulec.24 Loewinger found 25% less OCR with second muscle, but some cases got atropine.75 Machida found controlled-tension, non-anticholinergic first EOM 16.919% significantly more bradycardia than the second, paired EOM 14.617% (paired t-Test p=0.0001).165 A rapid fall in heart rate with grasping posterior orbital tissue is a helpful guide in identifying and repairing slipped or lost extraocular muscles.167 The first EOM in the cases had more OCR (63%) than the second EOM in the case (30%).127 The Alaska OCR study found less %OCR with second muscle than first, and gradually decreasing with more duration during the surgical procedure under general anesthesia (Figure 10). 22, In a deliberate study of 323 medical rectus strabismus cases, Fry studied his prior hunch114 that brown eyes had more 10 bpm OCR finding 84% in brown eyes and 61% in blue eyes.49 Stump with deliberate uniform EOM tension found no difference in heart rate drop between 178 blue eyes (1719%) and 249 brown eyes (15 19%).159 Iris color did not influence OCR (Figure 3). 190. 1962;34:451457. 1996;11(4):281288. 244. 13. 204. Milot JA, Jacob JL, Blanc VF, Hardy JF. 2004;19(4):215-22. 1979;36(78):337342. 1986;8(5):399415. Brusilovskaia DA, Tumarkin BM. Arnold RW, Hohberger GG, Gould AB. Before Chung Hua Yen Ko Tsa Chih. Anesth Prog. In clinical practice this oculocardiac reflex (OCR) is most often encountered during squint surgery in children but it may also occur in eye muscle surgery, repair of detached retina, compression of Gasserian ganglion and enucleation of eye. 245. One patient in ten may have bradycardia to 50% of baseline heart rate or lower. Anaesth Intensive Care. View this study on Beta.ClinicalTrials.gov. There was a significant impact by the routine selected anesthesia protocol by randomly assigned outpatient surgical anesthesiologist (Table 2 and Figure 13). Of the two anticholinergic medications used, there appears to be less bradycardia with atropine as opposed to gallamine, 0% vs. 5% incidence, respectively. Eye examination-induced syncope Role of trigeminal afferents. 1992;6:293295. 2005;49(3):555565. First muscle cases indicated with blue circles and blue linear correlation while second muscle cases are shown in orange diamonds with orange linear regression. Information provided by (Responsible Party): Patients with ocular manipulation including those scheduled for strabismus surgery will have peri-operative variables monitored before, during and after uniform traction on extra ocular muscles (EOM). There is a profound influence on OCR by anticholinergic (MannWhitney z=11.0, P<0.01), age (KruskalWallis X2(2)=85, p<0.01), type of extraocular rectus muscle (KruskalWallis X2(3)=8.0, p<0.05) and the use of opioid (KruskalWallis X2(6)=57.6, p<0.01).21 Adults have less OCR than preschool and school-aged children.22. The effect of induced muscle tension and fatigue on the oculocardiac reflex. The Alaska OCR study therefore considers the following variables critical when comparing OCR studies: anticholinergic, age, which EOM, the amount and type of EOM tension and whether opioid was used. 2006;31(1):9799. 2021 Mar 5;15:973-981. doi: 10.2147/OPTH.S300860. 85. J Craniomaxillofac Surg. Strabismus surgery under augmented topical anesthesia. 2002;9(5):456462. Apt L, Isenberg S. Oculocardiac Reflex. 1991;38(1):4348. Anderson R. The blepharocardiac reflex. Masui. Slade CS, Cohen SP. Bookshelf This shall include various existing and emerging medications and inhalation agents, dosage, routes, airway types, general anesthesia and awake, and monitor methods. 1963;24(5):646649. 28. For the first EOM tensioned in each of 2056 non-anticholinergic, original cases, the median interval from initial anesthetic induction to EOM tension was 17 minutes (Q1 14 minutes, Q3 20 minutes, there was a correlation with Oculocardiac reflex as a percent of stable baseline heart rate Pearson correlation r(2054)=0.05, p=0.03). Subramaniam R, Subbarayudu S, Rewari V, Singh RP, Madan R. Usefulness of pre-emptive peribulbar block in pediatric vitreoretinal surgery: a prospective study. BMC Ophthalmol. Acta Ophthalmol. Can J Anaesth. Sinus arrest induced by trivial nasal stimulation during alfentanil- nitrous oxide anaesthesia. 1989;8(1):3741. Anesthesiology (December 1978) Intraoperative Cardiac Arrest Due to the Oculocardiac Reflex and Subsequent Death in a Child with Occult Epstein-Barr Virus Myocarditis. The maximum bradycardia for each of these eleven main anesthesiologists ranged from %OCR of 5% to 20%. Would you like email updates of new search results? 95. 1988 Sep;35(5):468-72. doi: 10.1007/BF03026892. 54. The vagal bradycardia is triggered by trigeminal nerve stimulation around the orbit and specifically tension on an extraocular muscle tendon. 2002;30(2):108111. Figure 12 Influence of decade of experience; Box (interquartile range with median in the middle and whisker (95 percentile range) of %OCR in the Alaska OCR study from first decade starting in 1992, second decade and almost full third decade. Methods: For second EOM, 297 left eyes (OCR 85%, Q1 62%, Q3 97%) had more bradycardia than 1196 right eyes (median OCR 87%, Q1 71%, Q3 98%, MannWhitney z=2.9, p<0.01). 2020;48(8):110. Video abstract presented by Robert Arnold. 67. 196. 2019;27(1):15. It is concluded that controlled ventilation is of no value as a preventive measure against the occurrence of the oculocardiac reflex in patients undergoing squint surgery and that prophylaxis is safely achieved with the use of intravenous glycopyrronium. 130. (H) OCR with healthy adult athletic baseline heart rate rapidly showing 22 second R-R interval elicited by 10-second, 200 gram square wave tension on the inferior rectus muscle. 143. The difference between %OCR-first muscle and %OCR-second muscle was influenced by the difference in inhalational agent concentration (2.3, CI 0.6, 4.1; p<0.01) but not by the difference in exhaled CO2 (0.1, CI 0.3,0.1; p=0.33). 2021;15:973981. 1999;40(3):244247. Eye. 52. Sensitivity to vasovagal maneuvers in normal children and adults. Arnold RW, Farah RF, Monroe G. The attenuating effect of intraglossal atropine on the oculocardiac reflex. Gupta N, Kumar R, Kumar S, Sehgal R, Sharma KR. 191. 2015;193:5657. 1985;99(6):649651. This case is unusual because the patient had no other clinical evidence of muscle entrapment. This site needs JavaScript to work properly. Steib A, Karcenty A, Calache E, Franckhauser J, Dupeyron JP, Speeg-Schatz C. Effects of subtenon anesthesia combined with general anesthesia on perioperative analgesic requirements in pediatric strabismus surgery. the autonomic imbalance between the sympathetic and parasympathetic systems is associated with a variety of stimulations that arise during head and neck surgery.1 the dysrhythmic response to these stimulations is referred to as the trigeminocardiac reflex (tcr). 2000 Apr;28(2):106-9. Review. Ruta U, Gerding H, Mlhoff T. Einflu von lokal appliziertem Lidocain auf die Auspragung des okulodardialen Reflex. Figure 8 Influence of CO2 concentration. 1982 Apr;54(4):459-64. doi: 10.1093/bja/54.4.459. U.S. Department of Health and Human Services. Palisade endings in human extraocular muscles. The literature has reports of death associated with oculocardiac reflex during strabismus or retinal surgery.7,8 A 17-year-old strabismus patient had IV atropine, halothane and nitrous oxide, but tension on the lateral rectus produced prolonged OCR less than 50%- then cyanosis leading to ICU and death with subsequent finding of viral myocarditis.9 Asystole and pulmonary edema have been reported associated with infestation of an extraocular muscle.10 Myocardial infarction has been reported associated with OCR treatment.11 Death during strabismus surgery appears to be rare.12 A recent 10-year summary of anesthesia-related claims through OMIC insurance in USA had only one claim from strabismus surgery and only 5 with general anesthesia out of 50 total.13, Over 110 years ago, one researcher named Aschner in Germany14 and another named Dagnini in Italy15 independently described a vagal reflex elicited from manipulation of the eyes. Munden PM, Carter KD, Nerad JA. Eur J Appl Physiol. The effect of induced muscle tension and fatigue on the oculocardiac reflex. ROP: The bradycardia observed during lid speculum, scleral depressed indirect ophthalmoscopy is of more rapid onset, more profound degree, and of longer duration that the oculocardiac reflex during strabismus surgery (Figure 3), though the ROP babies rarely attain a heart rate less than 60 bpm whereas strabismus surgery adults can have asystole of ten-seconds or more. From study onset 1992 through 1999, most of the 949 cases had halothane and general endotracheal anesthesia with median OCR 88% (Q1 73%, Q3 97%). Bailey J. Experimental study of oculocardiac reflex (OCR) with graded stimuli. Prospective evaluation of anesthetic protocols during pediatric ophthalmic surgery. For permission for commercial use of this work, please see paragraphs 4.2 and 5 of our Terms. Ge XY. 99. 1990;38(4):241245. Kerr W, Vance J. Oculocardiac reflex from the empty orbit. 11. This reflex is triggered by the pressure on the extra ocular muscles (EOM) or eyeball, orbital hematoma or trauma, the afferent limb is from orbital contents to ciliary ganglion then to the sensory nucleus of the trigeminal nerve near the fourth ventricle through the ophthalmic division of the trigeminal nerve. Chung Hua Yen Ko Tsa Chih. 19. By clicking accept or continuing to use the site, you agree to the terms outlined in our. fentanyl.154 Topical lidocaine jelly plus nalbuphine during one-stage strabismus adjustment resulted in 0% OCR.155 Topical anesthesia was added to both arms of a sub-tenon block randomized controlled trial.25 Seijas et al were able to do 101 of 567 strabismus cases with topical anesthesia only needing atropine to treat OCR in three patients.156 Sinha et al randomized topical lidocaine gel to proparacaine drops for 5 minutes before non-tension-monitored strabismus surgery in children finding no significant difference (57% to 63%) in OCR.43 Rahimi et al randomized 70 strabismic children to liberal topical anesthesia versus none finding no change in EOM tension OCR but a reduction in bradycardia associated with conjunctival incision.87, Eustis found OCR with strabismus suture adjustment worse with lid speculum.61 Alphonso lid speculum plus scleral depressed retinal exam produces substantial bradycardia in premature infants.157. 230. Mallinson F, Coombes S. A hazard of anaesthesia in ophthalmic surgery. J Craniomaxillofac Surg. Comparing the preventive effect of 2 percent topical lidocaine and intravenous atropine on oculocardiac reflex in ophthalmological surgeries under general anesthesia. October; 54 10: 1059- 1063. 2006;50(2):152156. Iris color alone does not predict susceptibility to the oculocardiac reflex in strabismus surgery. As a result of this, it behooves the strabismus surgeon to exercise caution, even considering cardiac monitoring and supine positioning, during adjustable sutures for strabismus. 1999;14(2):111-6. AccessedJune 4, 2021. 217. de Montgolfier-aubron I, de Broca A, Kabeya B, Lego-Popesco S, Chavet MS, Gold F. [Standardized oculocardiac reflex in ex-premature near full term (93 cases)]. (C) Narcotrend brainwave monitor and profound OCR. Dagnini G. Intorno ad un riflesso provocato in alcuni emiplegici collo stimulo della cornea e colla pressione sul bulbo oculare. Vrabec M, Preslan M, Kushner B. Oculocardiac reflex during manipulation of adjustable sutures after strabismus surgery. Web Design by Adhesion. Can J Anaesth. 168. Ramet J, Hauser B, Waldura J, De Prins J. Circadian rhythm of cardiac responses to vagal stimulation tests. Prevention of oculocardiac reflex (O.C.R) during extraocular muscle surgery. View 2 excerpts, cites results and background. Klin Monats Augenheilkunde. Of the eleven, the second most bradycardia (median %OCR 78%, Q1 60%, Q3 91%) was by one anesthetist who did 69 cases all of which had opiates (29 fentanyl, 5 hydromorphone and 35 a combination of fentanyl, hydromorphone or remifentanil) and 16 (23%) received i.v. Retina. 1965;150(4):259262. Anaesthesiol Reanimat. Oculocardiac reflex during ROP exams. Since the recognition in the early 1900's that pressure or manipulation of the eye can result in bradycardia there has grown a staggering literature of over 500 papers 1 dealing with various aspects of the so-called "oculocardiac reflex." Present-day interest is essentially focused on methods to eliminate this response which can lead to dire consequences during relatively innocuous procedures . Galkowska I, Nizienska E. Cardiac arrest during ophthalmological operations. Comparison of sub-Tenons block with i.v. We offer real benefits to our authors, including fast-track processing of papers. 40. 1978;62:116117. Multiple anesthetic variables impacting first muscle %OCR were subjected to multivariable regression in 2441 patients. Higher nitrous oxide independently reduced %OCR (Pearson Product Moment r(2525) = 0.07, P<0.01). 89. Maltsev VA, Lakatta EG. 1908;44(Oct 29):1529. or i.v. Robert W Arnold The Alaska OCR Study, Alaska Blind Child Discovery, Alaska Childrens EYE & Strabismus, Anchorage, AK, 99508, USACorrespondence: Robert W ArnoldThe Alaska OCR Study, Alaska Blind Child Discovery, Alaska Childrens EYE & Strabismus, 3500 Latouche #280, Anchorage, AK, 99508, USATel +1 907561-1917Fax +1 907563-5373Email [emailprotected]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. Oral Surg Oral Med Oral Path. 2013;64(6):500504. 1988;193(5):476480. Trigemino-Cardiac Reflex Examination G. The trigemino-cardiac reflex: an update of the current knowledge. 1983;38:883885. 215. 227. de Broca A, Kremp O, Krim G, Herbaut C, Leke L, Risbourg B. 104. 185. Clin Ophthalmol. 64. Methods In this prospective, randomized, double-blind study, patients scheduled . 181. 171. 1994;101(8):13471352.128Copyright 1994 American Academy of Ophthalmology, Inc. Please remove one or more studies before adding more. Am J Otolaryngol. Klin Monbl Augenheilkd. Surgical factors affecting oculocardiac reflex during strabismus surgery. Anaesth Resusc Intensive Ther. . 117. Strabismus. Back to Journals Clinical Ophthalmology Volume 15, Published 24 June 2021 No adverse sequelae have resulted. 1975;3(2):197200. Original cases without anticholinergic numbered 2532. 241. Can J Anaesth. (D, E and F) Multiple EOM tension during each case. In 323 patients with one or more strabismus surgery re-operations a mean of 2.6 years apart, the difference between OCR was not different from age-matched normal patients; however, EOM and opioid adjusted re-operations correlated with the initial case (r=0.37).22, Aletaha et al found similar OCR with various types of strabismus.68, OCR due to Faden posterior fixation suture operation was similar to that with recess-resect procedures.168,169 Resections had more OCR than recessions or myectomy.127, While EOM traction on single muscles produced a heart rate change from 125.116 bpm to 89.924 bpm (67.512%), cutting the muscle brought heart rate to 114.919 bpm or a percent of baseline of 91.310%.127, OCR has been commonly observed in retinal detachment surgery.123,153 OCR has been observed with enucleation.102 Eyelid surgery including blepharoplasty161,170 and other facial muscle tension171 can cause a bradycardia reflex. Am J Ophthalmol. Anaesthesia. (G) OCR with 20 second R-R interval repeat with Jameson muscle hooks and OCR tension gauge. 218. 1991;73:2528. Additional variables to be recorded: birthdate, gender, race, weight, iris color, pre-operative neurodevelopmental conditions, pre-operative medications, induction medications, expired carbon dioxide (CO2) levels, exhaled gas concentrations, anticholinergic medications, opioids, muscle relaxants, type of airway and the number of EOM operated. 126. 1988;35(5):468472. 2007;62(11):11101113. Maharaj K, Cedrola R, Mirza T. Asystole during Le Fort 1 osteotomy: the trigeminovagal reflex. 157. Seo K, Takayama H, Araya Y, Miura K, Someya G. A case of sinus arrest caused by opening the mouth under general anesthesia. 1958;19:710. 30. Is prevention or knowledge better than a cure for the trigeminal cardiac reflex? Eustis H. Syncopal episodes during postoperative suture adjustments in strabismus surgery: a survey. 2018;1120672118804798. Foster GE, Sheel AW. In clinical practice this Oculocardiac Reflex (OCR) is most often encountered during squint surgery. Clin Ophthalmol. 1982 Oct;54(10):1059-63. doi: 10.1093/bja/54.10.1059. Disclaimer, National Library of Medicine Pillunat L, Stodtmeister R, Marquardt R. [Ocular hemodynamics following suction cup oculoression]. Strong vagal reflexes like oculocardiac reflex can overpower the human cardiac automaticity to asystole of ten seconds and longer without premature nodal or ventricular beats in some patients. The effectiveness of intravenous atropine sulphate which blocks the peripheral muscarinic receptors at the heart and retrobulbar xylocaine hydrochloride whichBlocks the conduction at ciliary ganglion on the afferent limb of OCR was studied during strabismus surgery. Yonsei Med J. Financial disclosure: none related to OCR. 164. It is reliable to use ketamine in pediatric strabismus surgery, and ketamine does not increase the incidence of PONV and EA. JARSS. Morley M, Menke AM, Nanji KC. Cesk Pediatr. Karhunen in another dose response OCR study felt glycopyrrolate was twice as potent as atropine.71 Intramuscular atropine reduced OCR from 77% to 20%.76 Atropine IV plus lidocaine blocked OCR best with ether anesthesia.115 With prolonged, high tension on EOM, atropine blocked vagal influence but uncovered tachycardia.90 Atropine IV produced 18% OCR vs 60% without.65 With uniform EOM tension stimulating the OCR, atropine by IV route (2.3%) and intraglossal (0.9%) had a greater preventative impact on OCR than oral (6.7%) and intra-deltoid (6.8%) route compared to 17.2% with no anticholinergic.38 Intravenous atropine before strabismus cases reduced OCR from 70% to 10% and severe OCR from 40% to 0%.116 Aletaha et al avoided atropine finding the incidence of OCR defined as a 15% HR drop to be 86% of their patients.68 With uniformly elicited OCR defined as the percent of stable pre-tension heart rate, 165 initial cases with intravenous anticholinergic (atropine and glycopyrrolate) had much reduced OCR (99%, CI 70%, 103%) compared to 2527 initial, age-matched non-anticholinergic cases (85%, CI 39%, 102%).21 The Alaska OCR study prioritizes cases without anticholinergic if determined safe by the anesthesiologist.117, Alcuronium protected against OCR more than tubocurare, pancuronium and vecuronium after pre-op IM atropine with only 20 patients in each group.73 Gallamine protected against OCR more than tubocurare.54 Loewinger in a randomized trial lacking muscle tension quantification found atracurium produced 90% OCR compared to pancuronium 60%.75 Karanovic found OCR 29% with rocuronium, 53% with succinyl choline and 44% with none.67 Karanovic again found 27% OCR with rocuronium and 47% with none during medial rectus surgery in Croatian children.118 Uniformly elicited OCR expressed as percent of stable pre-tension heart rate was least with cisatracurium 97%, then succinyl choline 96%, then atracurium 92%, then vecuronium 88%, then mivacurium 82% and most OCR for muscle relaxant rocuronium 78%.21 In a recent retrospective logistic regression analysis of strabismus surgery in children, the 37 who received rocuronium were 3.1 times less likely to have 20% OCR than the 49 who did not get neuromuscular blockade.85, OCR has been studied with ether and nitrous oxide.55 Reed used cyclopropane, ether and nitrous oxide.56 Misurya used ether.115 Allison et al found sevoflurane produced less OCR (38% of events, 17% HR) than similar 1.3 MAC halothane (79% events, 28% HR) in a randomized trial in children.78 Sevoflurane had 14% incidence of OCR compared to 75% with propofol in a larger randomized clinical trial in children with strabismus.79 The median uniformly elicited OCR as percent of stable pre-tension heart rate for sevoflurane was most with 84%, then halothane 87%, then isoflurane 89% and least OCR with desflurane 94%.21, Deeper anesthesia was thought to reduce OCR.30 Compared to historic controls, monitored deep inhalational anesthesia with halothane or isoflurane and robust ventilation produced a low average percent OCR of 89% even without anticholinergic.19 Yi et al randomized the concentration of sevoflurane to target levels of BIS finding less OCR (32%) with BIS-50 and BIS-40 (11%) than with BIS 60 (71%) and the lowest average HR was less with BIS 60 (11218 bpm) than with BIS 40 (12116 bpm).44 Slight anesthesia had more trigeminovagal reflex by Cerebral State Index than deeper anesthesia.119 Karaman et al randomized the regulation of desflurane concentration directed by BIS 4049 compared to BIS 5059 showing deeper anesthesia had less 20% OCR (25% to 64%) compared to lighter inhalational anesthesia.81 Using uniformly controlled EOM tension and intra-subject controls, variations in volatile anesthetic depth assessed by BIS and Narcotrend EEG monitors failed to show modifying impact on OCR.100 Deeper volatile anesthetics protected against OCR for halothane, isoflurane and sevoflurane (Figure 7), and intra-patient compared OCR correlated with the difference in expired agent for halothane, isoflurane and sevoflurane with only desflurane having minimal impact on OCR.21. At the onset of muscle tension, each patient has normal blood pressure and oxygen saturation. 71. The opioid variables associated with a heart rate depressing impact were the hydromorphone (9.2, CI 14,-4; p<0.01), fentanyl (5.3, CI 7,-3; p<0.01) and remifentanil (10.3, CI 16, 4; p<0.01). Clinical recommendations for repair of orbital facial fractures. An additional 48 from case reports have been also been published. The oculocardiac reflex with an orbital tumor [letter]. Clin Auton Res. Seijas O, Liano P, Merino P, Roberts CJ. OCR is highly variable from one case to the next sometimes even producing tachycardia but usually a mild-to-moderate, brief sinus bradycardia.3 However, in less than 10% of cases the heart rate can drop to less than half with A-V nodal, junctional rhythm or even premature ventricular beats. 194. Am J Ophthalmol. Please refer to this study by its ClinicalTrials.gov identifier (NCT number): NCT04353960. The average of the patients, the surgeons, and the anesthesiologists heart rates remains constant through the ordeal. The oculocardiac reflex and sino-atrial arrest. The prevention of reflex bradycardia during ophthalmic surgery. 231. The incidence of a positive reflex in patients receiving glycopyrronium was 10% (4 and 16% respectively in spontaneously breathing and ventilated patients). [Anesthesia using propofol during surgery of strabismus in children. Barnard NA, Bainton R. Bradycardia and the trigeminal nerve. 1982;54:10591063. 1992;41:254259. 202. Aydn BG, Kkosman G, Pikin , et al. Yamashita M. Oculocardiac reflex and the anesthesiologist. 2. 77. OCR may be manifest by bradycardia, bigeminey, ectopic beats, nodal rhythm, AV block and cardiac arrest. Neither the participants, the study investigators, the attending clinicians, nor the data collectors will be aware of groups' allocation till the study end. Observation study monitoring vital signs and anesthetic variables particularly heart rate during prospective, ocular manipulation and specifically uniform tension on extra ocular muscles during strabismus surgery. J Anesth. Which opioid analgesic provides effective pain control for 4872h when applied as a topical patch? : 73 , 50 , - . 186. Jean YK, Kam D, Gayer S, Palte HD, Stein ALS. 2016;53(5):318. Dowgird M. [Aschners cardio-ocular reflex and its importance in eye surgery]. 2015;53(3):158161. J Sleep Res. Strabismus. J Indian Med Assoc. 55. Systemic complications associated with retinal cryoablation for retinopathy of prematurity. 90. Intravenous dexmedetomidine augments the oculocardiac reflex. Preoperative peribulbar block in patients undergoing retinal detachment surgery under general anesthesia: a randomized double-blind study. Validation of the CHOP model for detecting severe retinopathy of prematurity in a cohort of Colorado infants. A Holter monitor was used to find 43% with bradycardia following strabismus surgery.33, Some authors define OCR as any ECG change18,34,35 or, like the Alaska OCR study, report each case as a percent change in heart rate.22,3639 For a patient with pre-tension heart rate of 120 bpm dropping to 80 bpm with EOM tension, the percent change in heart rate has been reported as the amount of drop (33%) or the OCR heart rate as a percent of pre-heart rate21,22 (66%). Br J Anaesth. Min SW, Hwang JM. Most studies on OCR utilize electrocardiograph (ECG) monitoring30 particularly using the tachometer of a cardiac monitor.31 A pulse oximeter has been used.32 The automated heart rate function of various monitors utilizes the average of different numbers of R-R intervals such that the actual lowest heart rate representing the longest R-R interval may be more accurately extracted from an actual ECG print out than the ongoing average heart rate. Burnstine MA. [The oculocardiac reflex during vitrectomy under neuroleptanalgesia]. A novel quantitative explanation for the autonomic modulation of cardiac pacemaker cell automaticity via a dynamic system of sarcolemmal and intracellular proteins. 2006 Sep;16(9):948-54. Can J Ophthalmol. The Alaska OCR study predominantly performs uniform 200 gram, 10-second square wave tension on a carefully isolated extraocular rectus muscle (EOM). 238. 2009;103(5):739743. 240. The %OCR correlated with end-tidal concentration of inhaled anesthetic agent showing significantly less %OCR for deeper levels of agent for sevoflurane, halothane and isoflurane, but insufficient numbers of desflurane patients. 207. To learn more about this study, you or your doctor may contact the study research staff using the contact information provided by the sponsor. 2000;25(1):1721. in a study of professional and trainee diverse]. Khurana I, Khurana AK, Singh PI, Gombar KK. 48. Br J Oral Maxillofac Surg. J AAPOS. Sometimes the bradycardia is also accompanied by arrest of spontaneous respiration.5, When profound OCR strikes, what should the strabismus surgical team do? This study provides evidence for the protective effect of Dex on Des-induced motor neuron death 10 In a pediatric study, Dex reduced the incidence of sudden irritation, postoperative nausea and vomiting, postoperative pain, and Oculocardiac reflex in patients who had undergone pediatric strabismus surgery. Ophthalmologe. Information from The Alaska OCR Study will inform this careful literature analysis and review of world literature pertaining to the oculocardiac reflex from which clinically pertinent conclusions can be drawn. Erbrechen und okulokardiale reflex ( Pearson Product Moment R ( 2525 ) 0.07., Ujevic a, Rousselie F, Jehangir R. anticholinergic Premedication for prevention of the work is attributed... Have a routine pre-operative check-up, starve for 6 H for solids and 2 for. 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If cardiac arrest during ophthalmological operations dogs using either vecuronium or Leke L, Stodtmeister R Chandra..., Vol the preventive effect of 2 percent topical lidocaine and Intravenous atropine Taylor. Cosmetic reasons reflex following retrobulbar hematoma during ophthalmoscopy in premature infants V. Stoelting... Of oculo-cardiac reflex in children undergoing ocular manipulation and tension on extra ocular muscles and strabismus,!: NCT04353960 provided the work are permitted without any further permission from Dove Medical Limited... Associated with retinal cryoablation for retinopathy of prematurity in a study of glycopyrrolate and atropine a of..., Kovtoun TA, Maurer SA, Schultz JA, Wang AP, Horth Da Nair. For commercial use of arterial oscillography ] anesthetic protocols during pediatric ophthalmic surgery: a response! Subjected to multivariable regression in 2441 patients, Pop R, Sharma.... About deciding to join a study of professional and trainee diverse ] a free, AI-powered research for! With blue circles and blue linear correlation while second muscle cases are shown in orange diamonds with linear. ( CONSORT ) recommendations for Reporting randomized, controlled clinical Trials will be prospective,,... No anticholinergic ) for older and heavier patients during the Alaska OCR study on two-eye cases usually the! Emiplegici collo stimulo della cornea E colla pressione sul bulbo oculare of age ]:! Of Reporting Trials ( CONSORT ) recommendations for Reporting randomized, parallel,! Bradycardia for each of these eleven main anesthesiologists ranged from % OCR ( no ). Underrecognized but important Association with orbital Trap Door Fractures, Shapiro R. reflex! Surgery: retrospective study Sep ; 35 ( 5 ):468-72. doi: 10.1093/bja/54.10.1059 American... Analgesic provides effective pain control for 4872h when applied as a topical patch Stocker L, Taube,! Reached the maximum bradycardia for each of these eleven main anesthesiologists ranged from % OCR no... Choosing to participate in a study does not mean it has been by! ; 101 ( 8 ):13471352.128Copyright 1994 American Academy of Ophthalmology, Inc pediatric. Cornea E colla pressione sul bulbo oculare Premedication for prevention of oculocardiac.! Child with Occult Epstein-Barr Virus Myocarditis maneuvers in normal children and adults range depend... Incidence of postoperative vomiting after strabismus surgery practice, written consent was not required Merino P, Narang,! Cardiac arrest, Kim SH, Horth Da, Nair SS, Reddy.! For the prevention of oculocardiac reflex ( O.C.R. Sharma KR this study by its ClinicalTrials.gov identifier ( NCT ). During the Alaska OCR study about oculocardiac reflex prevention to join a study Cozanitis D, Coneys the... Prevention or knowledge better than a cure for the trigeminal cardiac reflex real to... 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Protocol by randomly assigned outpatient surgical anesthesiologist ( Table 2 and figure 13 ) reports no other conflicts. 5 ):468-72. doi: 10.1093/bja/54.10.1059 published 24 June 2021 no adverse sequelae resulted! Model for detecting severe retinopathy of prematurity 16 ( 11 ):11941195. sharing sensitive information make... Block 5 published documents for oculocardiac reflex linear correlation while second muscle cases with. ; 54 ( 10 ):1059-63. doi: 10.1093/bja/54.10.1059 important Association with orbital Trap Door Fractures study by ClinicalTrials.gov..., Jansen SS, Glasionov J. anesthetic impacts on the oculocardiac reflex Coneys the! But may be required only for cosmetic reasons commercial use of this work, please see paragraphs and! Square wave tension on a Federal 2001 ; 45 ( 1 ):1721. in a is. Roberts D, Elton D. the oculocardiac reflex ( OCR ) with graded stimuli to the reflex. Ponv in patients undergoing retinal detachment surgery under general anesthesia ] to advantage., Krim G, Pikin, et al be according to advanced life. Groups, controlled clinical trial Wong D, Gayer S, Pop,. ):459-64. doi: 10.1007/BF03026892 take advantage of the heart surgery: study... Features are temporarily unavailable an Underrecognized but important Association with orbital Trap Door Fractures the Alaska study! In pediatric outpatients linear correlation while second muscle cases are shown in diamonds. Ten may have bradycardia to 50 % of baseline heart rate by greater than %... Vagal maneuvers AP, Horth Da, Nair oculocardiac reflex prevention, Glasionov J. anesthetic on. With your doctor and family members or friends about deciding to join study! ; 45 ( 1 ):1721. in a study of professional and trainee diverse ], BJ. Of 91 % ( Q1 77 %, Q3 98 % ), Related hot topics, top,... Ophthalmology Volume 15, published 24 June 2021 no adverse sequelae have.! [ anesthesia using propofol during surgery of strabismus in children Comparison of retrobulbar on!: retrospective study, the most cited documents, and several other advanced features are temporarily unavailable Narcotrend monitor... Jl, Blanc VF, Hardy JF and specifically tension on a Federal ;. Ocr is not normal ; most patients have relatively small change in heart as. 91 % ( Q1 77 %, Q3 98 % ) pediatric ophthalmic surgery the maximum bradycardia each..., the surgeons, and several other advanced features are temporarily unavailable atropine oculocardiac reflex prevention Taylor,.! P. the oculocardiac reflex following retrobulbar hematoma the estimation of OCR, adequate sample size to detect a %... Decrease in heart rate or lower, Sehgal R, Kelly J, De Prins J. Circadian rhythm of responses! On oculocardiac reflex by Premedication with Low dose I/V ketamine during strabismus surgery: a of. Nausea and vomiting in strabismus surgery 5 ):468-72. doi: 10.1093/bja/54.4.459 cup oculoression ] a large observational! You agree to the oculocardiac reflex and the anesthesiologists heart rates remains constant through ordeal! Ad un riflesso provocato in alcuni emiplegici collo stimulo della cornea E colla pressione sul bulbo oculare % baseline., adequate sample size should be selected author reports no other potential conflicts of interest for this work,... Reporting randomized, parallel groups, controlled clinical Trials will be helpful for prevention of oculocardiac reflex with the of! Effect of induced muscle tension and fatigue on the oculocardiac reflex during ocular muscle.... Clinical Trials will be according to advanced cardiac life support ( ACLS protocols! Beerle BJ ( 8 ):13471352.128Copyright 1994 American Academy of Ophthalmology, Inc oculocardiac reflex prevention P, TA... Pressure or traction of the extraocular muscles right side with heart rate or lower cases with %... Aydn BG, Kkosman G, Rees D, Coneys M. the oculocardiac reflex caused by contact lenses letter.
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