Influence of Pre- and Intraoperative Local Anaesthetic in Strabismus Surgery under General Anaesthesia in Adults.

BACKGROUND: As studies have shown a reduction in the occurrence of the oculocardiac reflex with the addition of local anaesthesia, we changed our care regime accordingly a few years ago. To promote and establish better patient care, we retrospectively analysed the files of our patients who underwent strabismus surgery from 2013 to 2021 in order to compare strabismus surgery under general anaesthesia with and without local anaesthetics in a routine clinical setting. PATIENTS AND METHODS: Data from 238 adult patients who had undergone strabismus surgery could be extracted from the files: G1: n = 102, only general anaesthesia; G2: n = 136, preoperative application of tetracaine eye drops and intraoperative subtenon lidocaine/levobupivacaine in addition to general anaesthesia. We compared the two groups in regard to the frequency of oculocardiac reflex, the amount of atropine needed to treat, as well as the amount of antiemetic and analgesic medication given, and time spent in the recovery room. RESULTS: Mean age of G1 was 50 years and 52 years in G2. There was no significant difference between the kind of surgeries (recessions/resections), the number of patients who had undergone a reoperation, or the duration of the operations. Adding local anaesthetics resulted in significantly less occurrence of oculocardiac reflex (p = 0.009), a reduction in the need for atropine, analgesic, or antiemetic medication, as well as reduced time in the recovery room. CONCLUSION: As this increases patient safety and comfort and is cost-effective (less time in the recovery room), we recommend adding perioperative local anaesthesia to strabismus surgery performed under general anaesthesia.

Surgical and anesthetic influences of the oculocardiac reflex in adults and children during strabismus surgery.

One of the most common untoward occurrences during strabismus surgery at all ages is the oculocardiac reflex. Although typically easily treated, the sudden bradycardia or cardiac arrest may add a few gray hairs to ophthalmologists and anesthesiologists alike as it can be potentially fatal. This updated review of the literature and novel detailed treatment algorithm may prevent patient morbidity and mortality through proper recognition of at-risk patients and rapid treatment through proper communication between surgical and anesthesia physicians/providers.

Efficacy Of Sub-Tenon's Block In Paediatric Strabismus Surgery In Terms Of Reduction In Oculocardiac Reflex.

Background: Strabismus is a common disease entity in paediatric age group usually requiring surgical intervention under general anaesthesia and Oculocardiac reflex is the most dangerous complications intraoperatively. Various anaesthetic options have been evaluated to mitigate this complication. The objective of this study was to assess the efficacy of sub-tenon's block in paediatric strabismus surgery in terms of reduction in oculocardiac reflex. Methods: This prospective Randomized control trial was conducted at Department of ophthalmology, MTI, Hayatabad Medical complex, Peshawar over a period of six months from 1st July to 31st December 2021. A total of 124, were equally divided in subtenon's group (Group A) and placebo group (Group B). Intraoperatively, patients were assessed for Bradycardia and development of OCR. Data including demographics, intraoperative BP, HR and OCR development were noted and analysed with SPSS version 22. Results: The total number of patients were 124, 62 in each group with a mean age of 9.45±1.61. Sixty-six (53.22%) patients were males and 58 (46.87%) patients were females. At 10-, 20- and 30-minutes interval, the SBP and DBP has no significant difference. At 10, 20, 30 minutes interval, the HR differed significantly (79.33±7.36 vs 66.65±6.83 (p˂0.05), 79.78±7.63 vs 66.57±7.06 (p˂0.05), 79.80±7.78 vs 66.52±7.01 (p˂0.05), respectively. Intraoperative OCR was recorded in 13 (21%) patients in sub-tenon's (Group A) versus 56 (90.30%) patients in placebo (Group B) with statistically significant difference between the two (p<0.05). Conclusion: Sub-tenon's injection of bupivacaine reduces the incidence of Bradycardia and OCR in squint surgery patients after general anaesthesia induction and usage is recommended in routine.

Effect of Ice Slush on Reducing the Oculocardiac Reflex During Strabismus Surgery.

BACKGROUND: The aim of this study was to explore whether ice slush (IS) causing local hypothermia can effectively inhibit the oculocardiac reflex (OCR) during strabismus surgery. METHODS: This prospective, randomized, double-blind study included 58 patients with concomitant strabismus scheduled for lateral rectus (LR) recession under general anesthesia. Patients were randomly allocated to receive IS (IS group) or standard treatment (control group) with sterile saline at room temperature before surgery. OCR was defined as a sudden decrease in heart rate (HR) of >15% from baseline. If one incidence of the OCR was found in 1 patient in any stage (0/I/II/III), the patient was defined as an OCR responder, and the incidence of overall OCR was the incidence of OCR responders. The primary outcome was the incidence of overall OCR during all stages of the surgery, which was analyzed by the Z test and computed based on the absolute risk difference with 2-sided 95% confidence intervals (CIs) using the Newcombe method. RESULTS: The overall OCR occurred in 19 of 29 patients (62.5% [95% CI, 45.7-82.1]) in the IS group and 28 of 29 patients (96.6% [95% CI, 82.2-99.9]) in the control group (absolute risk difference, -31.0% [95% CI, -49.4 to -11.0]; Z test, P < .001), which demonstrated that the incidence of overall OCR in IS group was significantly lower than that in the control group. CONCLUSIONS: IS on the ocular surface causing local hypothermia is a promising and easily accessible method to reduce the overall OCR, which can improve the safety of strabismus surgery.

[Advances in the development of ocular cardiac reflex in extraocular muscle surgery].

Ocular cardiac reflex (OCR) usually occurs in ophthalmic surgery, especially in extraocular muscle(s) surgery. OCR generally can cause sinus bradycardia, arrhythmia, reduced atrial pressure, ventricular tachycardia, ventricular fibrillation, ventricular doublet, dizziness, nausea and other symptoms. Severe cases will appear cardiac arrest, respiratory arrest, etc. Recent studies on the mechanism of OCR and the relationship between surgical operation and anaesthesia in extraocular muscle surgery and the occurrence of OCR are reviewed in this paper in order to reduce the occurrence of OCR and treatment of OCR in extraocular muscle surgery.

White-Eyed Orbital Blowout Fracture With Oculocardiac Reflex Secondary to Extraocular Entrapment in a Pediatric Patient.

White-eyed orbital blowout fractures in the pediatric population can present with acute onset diplopia, ophthalmalgia, and abnormal duction. These findings are attributed to the tendency of younger bone to break and reapproximate owing to greater elasticity. This phenomenon, commonly referred to as the greenstick fracture, increases the risk of entrapment of surrounding soft tissue structures in orbital floor fractures. Further concern arises in the presence of an oculocardiac reflex, which requires urgent intervention to prevent serious bradycardia. Prolonged entrapment can go unnoticed and result in irreversible ischemic damage to entrapped tissues. This case discusses the presentation 16-year-old female who sustained a left sided, white-eyed blowout fracture from a face-first ground level fall. On admission, she displayed restrictive strabismus and mild periorbital edema around the left eye. Vertical gaze was restricted when looking inferiorly on the affected side. With sustained upward gaze, her heart rate decreased from 99 to 81 beats per minute. High-resolution non-contrast computed tomography scans of the head showed entrapment of the inferior rectus muscle and periorbital fat. Liberation of entrapped tissues with reduction of bony segments was performed urgently, utilizing a MEDPOR® Titan 3D orbital floor plate and secured with two screws. The patient had an uneventful postoperative period and showed considerable improvements in periorbital edema, duction, and ophthalmalgia on the affected side. In addition, the oculocardiac reflex could no longer be elicited on prolonged upward gaze. Mild and improving paresthesia was noted in the maxillary distribution of the left trigeminal nerve. Sensory deficits like this are the result of fracture communication with the infraorbital canal, which may cause irritation of the infraorbital nerve responsible for sensation by the maxillary division. By postoperative week 7, she had complete resolution of periorbital edema, indiscernible duction abnormalities, and complete healing of surgical incision sites, and an oculocardiac reflex could not be elicited.

The association between surgical technique and oculocardiac reflex in pediatric strabismus surgery: an observational study.

BACKGROUND AND OBJECTIVES: The most common cause of oculocardiac reflex (OCR) is traction of the extraocular muscles. Therefore, strabismus surgery is highly risk for the development of this complication. This study aimed to investigate whether an association exists between the occurrence of OCR and the type of extraocular muscle manipulated during strabismus in a pediatric population. METHODS: A total of 53 pediatric patients who were operated for strabismus under sevoflurane anesthesia were enrolled in this prospective study. The association between surgical techniques and the occurrence of OCR was investigated. RESULTS: This study included 30 (56.6%) males and 23 (43.4%) females, with a mean age of 8.4 years. Overall, 83 eyes with 93 extraocular muscles were operated. Surgery was performed most frequently on the medial (44.6%) and lateral (36.1%) recti. OCR occurred in 33 (62.3%) patients. OCR was found to be significantly higher in the first operated muscle compared with the second muscle, regardless of muscle type, as identified in the statistical analysis based on the sequence of the operated muscles. CONCLUSIONS: The manipulation of the first extraocular muscle has a higher risk of OCR in the pediatric population undergoing two-muscle surgery for strabismus.

Perioperative dexmedetomidine reduces emergence agitation without increasing the oculocardiac reflex in children: A systematic review and meta-analysis.

BACKGROUND: Intravenous dexmedetomidine (DEX) has been used to prevent emergence agitation (EA) in children. The aim of this meta-analysis was to evaluate whether DEX decreases EA incidence without augmenting oculocardiac reflex (OCR) in pediatric patients undergoing strabismus surgery. METHODS: We searched PubMed, EMBASE, Chinese National Knowledge Infrastructure (CNKI), Wan Fang, and the Cochrane Library to collect the randomized controlled trials (RCTs) investigating the effects of intraoperative DEX in children undergoing strabismus surgery from inception to October 2019. Postoperative Pediatric Agitation and Emergence Delirium (PAED) score, postoperative EA, extubation or laryngeal mask airway (LMA) removal time, postanesthetic care unit (PACU) stay time, OCR, and postoperative vomiting (POV) were evaluated. RESULTS: 11 RCTs including 801 patients were included in this study. Compared with control group, intravenous DEX significantly reduced postoperative PAED score (WMD, 3.05; 95% CI: -3.82 to -2.27, P = .017) and incidences of postoperative EA 69% (RR, 0.31; 95% CI: 0.17 to 0.55, P < .00) and POV (RR, 0.28; 95% CI: 0.13 to 0.61, P = .001). Furthermore, the use of DEX significantly delayed extubation or LMA removal time (WMD, 2.11; 95% CI: 0.25 to 3.97, P < .001). No significant difference was found in the incidence of ORC and PACU stay time. CONCLUSION: Intravenous DEX reduced the incidences of EA without increasing OCR in pediatric patients undergoing strabismus surgery. Meanwhile, DEX infusion decreased the incidence of POV in children.

Oculocardiac reflex in phacoemulsification: Peribulbar vs topical anesthesia.

Purpose: This study compares the vital parameters and pain experienced during phacoemulsification under peribulbar and topical anesthesia to determine the incidence of OCR. Methods: One hundred six patients are enrolled for phacoemulsification in a prospective and randomized study. Fifty-two patients undergo surgery in a peribulbar block (Group PB) and 54 in topical anesthesia (Group TA). Mean arterial pressure (MAP) and pulse rate are recorded during a preoperative check-up and at four other steps of surgery. Pain experienced during surgery and on a postoperative day, 5, is graded with a verbal analogue scale. OCR defined as a decrease in pulse rate by greater than 20% is calculated. Chi-square test, Fisher's exact test, paired t test and the comparison of means give the statistical analysis. A value of P < 0.05 was taken as significant. Results: MAP readings at baseline versus MAP at other steps of surgery show a trend towards rising with a P value of < 0.05 in both groups. Pulse rate measured at all steps of surgery versus baseline pulse rate in Group TA shows P < 0.05. OCR is present in nine patients in peribulbar block verses eleven patients in topical anesthesia with P value of 0.687. The pain scores using verbal analogue scale were higher in Group TA compared with Group PB with a P < 0.0001. Conclusion: Oculocardiac reflex can occur during phacoemulsification under both peribulbar block and topical anesthesia, and the difference is not significant.

Penehyclidine mitigates postoperative nausea and vomiting and intraoperative oculocardiac reflex in patients undergoing strabismus surgery: a prospective, randomized, double-blind comparison.

BACKGROUND: Postoperative nausea and vomiting (PONV) is one of the most frequent complications following strabismus surgery. Penehyclidine, an anticholinergic agent, is widely used as premedication. This study investigated the effect of preoperative penehyclidine on PONV in patients undergoing strabismus surgery. METHODS: In this prospective, randomized, double-blind study, patients scheduled for strabismus surgery under general anesthesia were randomly assigned to either penehyclidine (n = 114) or normal saline (n = 104) group. Penehyclidine was administrated immediately after anesthesia induction, and normal saline was substituted as control. PONV was investigated from 0 to 48 h after surgery. Intraoperative oculocardiac reflex (OCR) was also recorded. RESULTS: Compared with normal saline, penehyclidine significantly reduced PONV incidence (30.7% vs. 54.8%, P < 0.01) and mitigated PONV severity as indicated by severity scoring (P < 0.01). Compared with normal saline, penehyclidine also significantly reduced OCR incidence (57.9% vs. 77.9%, P < 0.01) and mitigated OCR severity, as indicated by the requirement for atropine rescue (77.3% vs. 90.1%, P < 0.05) and the maximum decrease of heart rate during OCR (23.1 ± 9.4 bpm vs. 27.3 ± 12.4 bpm, P < 0.05). The recovery course did not differ between groups. CONCLUSIONS: Penehyclidine administrated after anesthesia induction significantly reduced the incidence of PONV and alleviated intraoperative OCR in patients undergoing strabismus surgery. TRIAL REGISTRATION: ClinicalTrials.gov ( NCT04054479 ). Retrospectively registered August 13, 2019.

Oculocardiac Reflex in A 15-Year-Old With Orbital Fractures and Epidural Hematoma.

ABSTRACT: 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.

Oculocardiac Reflex: An Underrecognized But Important Association With Orbital Trap Door Fractures.

ABSTRACT: Blowout fractures of the floor of the orbit can serve as a "trap door" for extraocular muscles. Presentation of inferior orbital muscle entrapment classically involves an upward gaze restriction. Diplopia and exophthalmos can also be present. Rarely, orbital fractures can result in an oculocardiac reflex, which is a triad of bradycardia, syncope, and nausea. The purpose of this study was to describe a patient who had orbital floor fracture with symptoms highly suggestive for oculocardiac reflex after a traumatic injury. Although entrapment of extraocular muscles does require early intervention to prevent ischemia and tissue necrosis, the presence of oculocardiac reflex warrants emergent evaluation and management by an ophthalmologist due to the risk of developing arrhythmias. Frequently, there may be none or very subtle clinical findings present, and abnormal motility may be the only apparent clinical sign, which can be difficult to assess in very young and uncooperative children; therefore, a high index of suspicion must be maintained for early identification and management as well as a reduction of complications.

The Oculocardiac Reflex: Its Evolution and Management.

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.

Peribulbar anesthesia for strabismus surgery in adult patients.

PURPOSE: To evaluate the efficacy and safety of peribulbar anesthesia during strabismus surgery. METHODS: Medical records of patients undergoing strabismus surgery and peribulbar anesthesia were reviewed. The overall efficacy of peribulbar anesthesia was evaluated as requirement of supplemental peribulbar anesthesia, impossibility to perform eye muscles surgery due to inadequate efficacy of the block and peribulbar block complications that occurred up to 6 weeks postoperatively. Presence of oculocardiac reflex (OCR) and presence of decreased visual acuity and afferent pupillary defect postoperatively were reported. RESULTS: A total of 510 patients comprised our study group. The total amount of peribulbar injections was 717. Four patients (0.7%) required supplemental injection in the superonasal quadrant. Five of 510 (0.9%) required an anesthesiologic intervention with intravenous atropine. Eighty patients of 510 (15.6%) complained about transitory complete ptosis and/or amaurosis postoperatively. No complications were observed up to 6 weeks postoperatively. CONCLUSION: Peribulbar anesthesia was an effective and safe option during strabismus surgery in adult patients.

Dexmedetomidine use in pediatric strabismus surgery: A systematic review and 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.