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Yue Z, Liu S, Zhu Y, Shen Y, Zeng C, Li J, Chen Y, Wei R. The role of surgical factors eliciting oculocardiac reflex of patients undergoing orbital tumor surgery: a retrospective study. Graefes Arch Clin Exp Ophthalmol 2024; 262:1295-1303. [PMID: 37950752 DOI: 10.1007/s00417-023-06311-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Revised: 08/18/2023] [Accepted: 11/02/2023] [Indexed: 11/13/2023] Open
Abstract
PURPOSE Orbital tumors are an interdisciplinary disease, and surgery is one of the main treatment methods. The oculocardiac reflex (OCR) is a condition of surgery for orbital tumors. The aim of this study was to investigate whether there is an association between many surgical factors and the incidence of OCR in orbital tumor surgery. METHODS Comparisons were made between patients with and without OCR using the Mann-Whitney test, Fisher's exact test, and Chi-square test. When comparing multiple groups (groups > 2), to explain which two groups had differences, post hoc testing was used for analysis, and the differences between groups were judged according to the adjusted standardized residuals. RESULTS The results showed that the incidence of intraoperative OCR was different based on the different exposed operative field locations (p = 0.021). The OCR incidence in those with lesions involving the orbital apex and lesions adhering to extraocular muscles was higher than that of others (p < 0.001 and p = 0.003). In addition, multivariate logistic regression analysis revealed that orbital apex involvement and extraocular muscle adhesion were highly associated with a higher incidence of OCR (p < 0.001 and p = 0.013), while the operative field located in the lateral-superior orbit was highly associated with a lower incidence of OCR (p = 0.029). CONCLUSION In orbital tumor surgery under general anesthesia, lesions involving the orbital apex and lesion adhesion to the extraocular muscles were independent risk factors for OCR, and an operative field located in the lateral-superior orbit was a protective factor for OCR.
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Affiliation(s)
- Zifan Yue
- Department of Ophthalmology, Changzheng Hospital of Naval Medical University, Shanghai, China
| | - Siyu Liu
- Department of Ophthalmology, Changzheng Hospital of Naval Medical University, Shanghai, China
- Department of Ophthalmology, Naval Medical Center of PLA, Shanghai, China
| | - Yanfei Zhu
- Department of Ophthalmology, Changzheng Hospital of Naval Medical University, Shanghai, China
| | - Ya Shen
- Department of Ophthalmology, Changzheng Hospital of Naval Medical University, Shanghai, China
| | - Chengcheng Zeng
- Department of Ophthalmology, Changzheng Hospital of Naval Medical University, Shanghai, China
| | - Jian Li
- Department of Ophthalmology, Changzheng Hospital of Naval Medical University, Shanghai, China
| | - Yuqing Chen
- Department of Ophthalmology, Changzheng Hospital of Naval Medical University, Shanghai, China
| | - Ruili Wei
- Department of Ophthalmology, Changzheng Hospital of Naval Medical University, Shanghai, China.
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Abstract
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.
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Affiliation(s)
- Robert W Arnold
- The Alaska OCR Study, Alaska Blind Child Discovery, Alaska Children’s EYE & Strabismus, Anchorage, AK, 99508, USA
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Arnold RW, Bond AN. Does Topical Proparacaine Improve Postoperative Comfort After Strabismus Surgery? Clin Ophthalmol 2019; 13:2279-2283. [PMID: 31819352 PMCID: PMC6875500 DOI: 10.2147/opth.s230498] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Accepted: 11/06/2019] [Indexed: 01/28/2023] Open
Abstract
Background Strabismus surgery is often performed on children and adults as a quick-turnover, outpatient procedure under general anesthesia. Ideal methods to reduce post-operative pain and nausea are not yet perfected. We postulated that a simple topical anesthetic drop after surgery might help. Methods In a prospective study of oculocardiac reflex (OCR) and strabismus surgery, a cohort of ongoing patients either received proparacaine immediately post-op, or none. Co-variables were Intraoperative opioid and OCR, patient age, type of surgery. Several post-operative recovery outcome variables were prospectively monitored. Results Sixty strabismus surgery patients (age 15±22 years) received proparacaine 1% while another 80 (16.5±22 years) received none; both received topical antibiotic-steroid ointment. Pain and nausea (Likert scale) were not impacted by covariables complexity of case, age less than 3.5, OCR >33% drop, intraoperative opioid or neuro-status. Immediate post-op heart rate was lower if OCR >33% and if opioids used. Time until discharge was shorter in younger patients. Proparacaine did not impact outcome variables, except in patients younger than 3.5 years when post-op pain was worse. Conclusion Post-op topical anesthetic either produced no difference, or worsened post-op pain and recovery. This prospective study does not support the use of topical anesthetic drop to reduce post-strabismus pain and nausea. Clinical trials registration NCT03672435, Strabismus Recovery With Proparacaine and Oculocardiac Reflex (OCRprop).
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Affiliation(s)
- Robert W Arnold
- Pediatric Ophthalmology and Strabismus, Alaska Children's EYE & Strabismus, Anchorage, AK 99508, USA
| | - Aleah N Bond
- Department of Anesthesiology, Wake Forest Baptist Medical Center, Winston-Salem, NC 27101, USA
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Ducloyer JB, Couret C, Magne C, Lejus-Bourdeau C, Weber M, Le Meur G, Lebranchu P. Prospective evaluation of anesthetic protocols during pediatric ophthalmic surgery. Eur J Ophthalmol 2018; 29:606-614. [PMID: 30280604 DOI: 10.1177/1120672118804798] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PURPOSE To date, no protocol of anesthesia for pediatric ophthalmic surgery is unanimously recognized. The primary anesthetic risks are associated with strabismus surgery, including oculocardiac reflex, postoperative nausea and vomiting, and postoperative pain. METHODS This was a prospective, monocentric, observational study conducted in a tertiary pediatric ophthalmic unit. Our anesthetic protocol for strabismus surgery included postoperative nausea and vomiting prevention using dexamethasone and ondansetron. No drug-based prevention of oculocardiac reflex or local/locoregional anesthesia was employed. RESULTS A total of 106 pediatric ophthalmic surgeries completed between November 2015 and May 2016 were analyzed. The mean patient age was 4.4 (range: 0.2-7.3, standard deviation: 2.4) years. Ambulatory rate was 90%. Oculocardiac reflex incidence was 65% during strabismus surgery (34/52), 50% during congenital cataract surgery (4/8), 33% during intramuscular injection of botulinum toxin (1/3), and 0% during other procedures. No asystole occurred. Postoperative nausea and vomiting incidence was 9.6% after strabismus surgery (5/52) and 0% following the other procedures. One child was hospitalized for one night because of persistent postoperative nausea and vomiting. Postoperative pain generally occurred early on in the recovery room and was quickly controlled. Its incidence was higher in patients who underwent strabismus surgery (27%) than in those who underwent other procedures (9%). CONCLUSION Morbidity associated with ophthalmic pediatric surgery is low and predominantly associated with strabismus surgery. The benefit-risk ratio and cost-effectiveness of oculocardiac reflex prevention should be questioned. Our postoperative nausea and vomiting rate is low, thanks to the use of a well-managed multimodal strategy. Early postoperative pain is usually well-treated but could probably be more effectively prevented.
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Affiliation(s)
| | - Chloé Couret
- Department of Ophthalmology, University Hospital of Nantes, Nantes, France
| | - Cécile Magne
- Department of Anesthesiology and Surgical Intensive Care Médicine, University Hospital of Nantes, Nantes, France
| | - Corinne Lejus-Bourdeau
- Department of Anesthesiology and Surgical Intensive Care Médicine, University Hospital of Nantes, Nantes, France
| | - Michel Weber
- Department of Ophthalmology, University Hospital of Nantes, Nantes, France
| | - Guylène Le Meur
- Department of Ophthalmology, University Hospital of Nantes, Nantes, France
| | - Pierre Lebranchu
- Department of Ophthalmology, University Hospital of Nantes, Nantes, France
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Use of polyetheretherketone (PEEK) in orbital floor fracture reconstruction – A case for concern. JOURNAL OF ORAL AND MAXILLOFACIAL SURGERY MEDICINE AND PATHOLOGY 2015. [DOI: 10.1016/j.ajoms.2014.10.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Steinmetz A, Ellenberger K, März I, Ludewig E, Oechtering G. Oculocardiac Reflex in a Dog Caused by a Choroidal Melanoma with Orbital Extension. J Am Anim Hosp Assoc 2012; 48:66-70. [DOI: 10.5326/jaaha-ms-5685] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
A 7 yr old mixed-breed dog was presented with a choroidal melanoma of the left eye that had penetrated the sclera, producing an orbital mass. Bradycardia was detected on auscultation. The bradycardia resolved after exenteration of the orbit and was therefore presumed to be associated with the oculocardiac reflex.
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Affiliation(s)
- Andrea Steinmetz
- Department of Small Animal Medicine (A.S., E.L., G.O.) and Institute of Veterinary Pathology (K.E.), University of Leipzig, Leipzig, Germany; and Department of Veterinary Clinical Sciences, The Royal (Dick) Veterinary College, University of London, Herts, United Kingdom (I.M.)
| | - Kristin Ellenberger
- Department of Small Animal Medicine (A.S., E.L., G.O.) and Institute of Veterinary Pathology (K.E.), University of Leipzig, Leipzig, Germany; and Department of Veterinary Clinical Sciences, The Royal (Dick) Veterinary College, University of London, Herts, United Kingdom (I.M.)
| | - Imke März
- Department of Small Animal Medicine (A.S., E.L., G.O.) and Institute of Veterinary Pathology (K.E.), University of Leipzig, Leipzig, Germany; and Department of Veterinary Clinical Sciences, The Royal (Dick) Veterinary College, University of London, Herts, United Kingdom (I.M.)
| | - Eberhard Ludewig
- Department of Small Animal Medicine (A.S., E.L., G.O.) and Institute of Veterinary Pathology (K.E.), University of Leipzig, Leipzig, Germany; and Department of Veterinary Clinical Sciences, The Royal (Dick) Veterinary College, University of London, Herts, United Kingdom (I.M.)
| | - Gerhard Oechtering
- Department of Small Animal Medicine (A.S., E.L., G.O.) and Institute of Veterinary Pathology (K.E.), University of Leipzig, Leipzig, Germany; and Department of Veterinary Clinical Sciences, The Royal (Dick) Veterinary College, University of London, Herts, United Kingdom (I.M.)
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Levine JM, Bisker E, Galetta SL, Kumar MA. The oculocardiac reflex may mimic signs of intracranial hypertension in patients with combined cerebral and ocular trauma. Neurocrit Care 2011; 16:151-3. [PMID: 21607785 DOI: 10.1007/s12028-011-9560-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
BACKGROUND In the setting of head trauma, progressive bradycardia may raise suspicion for intracranial hypertension, especially when accompanied by pupillary abnormalities or systemic hypertension. METHODS We describe the case of a patient with concomitant cerebral and ocular trauma who presented with a fixed and dilated pupil and progressive bradycardia due to an oculocardiac reflex. RESULTS The oculocardiac reflex is an unusual cause of bradycardia due to stimulation of the ophthalmic division of the trigeminal nerve and has been described in a variety of clinical settings. CONCLUSIONS Clinicians should be aware that the oculocardiac reflex might mimic signs of intracranial hypertension in patients with combined facial and cerebral trauma.
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Affiliation(s)
- Joshua M Levine
- Department of Neurology, Hospital of the University of Pennsylvania, University of Pennsylvania, Philadelphia, PA 19104, USA.
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Hack KM, Pedersen R. Mental status changes and bradycardia: don't forget the eye! Traumatic hyphema can mimic increased intracranial pressure. Clin Pediatr (Phila) 2009; 48:331-3. [PMID: 18832533 DOI: 10.1177/0009922808324490] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Kara-Marie Hack
- Department of Pediatrics, Tripler Army Medical Center, Honolulu, Hawaii 96859-5000, USA.
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