https://orcid.org/0000-0002-5061-7717
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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.
Graphical abstract
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Abbreviations
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.
Acknowledgments
Alaska OCR study wishes to thank all the members of the institutional review board, the anesthesia teams, the research students and all the strabismus surgery patients who trusted us to protect their hearts and help them see straight.
Disclosure
Financial disclosure: none related to OCR. Dr. Arnold is president and a board member of Glacier Medical Software which markets cloud-based ROP Check. 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. Dr. Arnold coordinates the Alaska Blind Child Discovery which has received discounted vision screening technology from several vendors. Dr. Arnold is an investigator and protocol developer for the NIH-sponsored Pediatric Eye Disease Investigator Group. 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. The author reports no other potential conflicts of interest for this work.