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A case of oculocardiac reflex occurring during general anesthesia for cataract removal is presented. The prevention and treatment of such reflexes is discussed with particular attention to the importance of ECG monitoring at all times in ophthalmic surgery.
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Fifty children in the age-group 1.75-10 years, admitted for cure of strabismus, were anaesthetised with intramuscular ketamine. Half the patients, at random, were given intravenous atropine, while anaesthetised, 5 minutes before operative interference. ECG recording of Lead 2 showed an oculacardiac dysthythmic response to muscle pull in 19 of the 25 unatropinised patients. The atropinised patients failed to show evidence of muscle induced dysrhythmia in any of the subjects (0%) The 25 control traces in the atropinised subjects showed no dysrhythmia after 5 minutes, but the possible immediate transitory dysrhythmic effects of atropine in the presence of ketamine anaesthesia is the subject of further study.
The duration of cardiac asystole induced by ocular compression was measured in 100 consecutive children referred for electroencephalographic examination after one or more febrile convulsions (FC). The children were classified into three groups-namely, those with anoxic FCs, those with epileptic FCs, and "others"-according to the appearances of the FC and the electroencephalogram (EEG). In 14 children the description of the FC suggested non-epileptic anoxic cerebral seizures such as are seen after prolonged syncope or breath-holding. In 35 children the FCs were assumed to be epileptic in mechanism on the basis of unilateral (hemiclonic) twitching, known cerebral disease, a family history of epilepsy, or spikes on the EEG. In the 51 "others" the FCs could not be classified. Definitely abnormal asystole (four seconds or over) was induced by ocular compression in half the anoxic group, in 16% of the "others," but in none of the epileptic group. The differences between the degree of asystole induced in each of the three groups was highly significant (P=0.005).These results support the hypothesis that vagal-mediated cerebral ischaemic anoxia is implicated in the genesis of FCs that resemble anoxic seizures and in a substantial number of those without an obvious epileptic mechanism. The significance, genetics, management, and prognosis of FCs must now be re-examined in this light.
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During operations for squint nodal rhythm and other more serious arrhythmias such as heart block and multifocal ventricular extrasystoles, as well as the oculocardiac reflex, are shown to occur more frequently in patients with brown or hazel eyes than in patients with blue or grey eyes.
In 80 patients undergoing surgery for retinal detachment, cardiac rhythm was observed to improve some means of prevention from consequences of oculocardiac reflex. The injection of a parasympatholytic agent shown its effectiveness; heavy morphinic analgesia prevented from cardiac disturbances induced by scleral cryoapplication; retrobulbar block had no effect.
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The oculocardiac reflex is described as the triad of bradycardia, nausea, and faintness evoked by the stretching of ocular muscles, or by pressure on or within the eyeball. The trigeminal nerve is the afferent limb of this reflex; the efferent limb is the vagus nerve to the heart. This reflex was noted to occur from traction on the levator aponeurosis in five of 36 patients with ptosis, and from traction on the retractors of the lower eyelid in three of 11 patients with entropion. To our knowledge, this is the first documentation of eliciting this reflex by stretching the muscles of the eyelid. Electrocardiogram monitoring for early recognition of these cases, and the availability of an intravenous line with atropine for prompt treatment are strongly recommended. Careful manipulation of the upper and lower eyelid retractors and preoperative atropine therapy may help to reduce the incidence of this reflex.
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The E.E.G., the oculocardiac reflex (OCR), the Valsalva manoeuvre and respiratory capacity, were studied and compared in 183 professional or trainee divers. There was a positive correlation between an alpha rhythm at or below 9 c/sec and a positive OCR. The Valsalva was more often positive in young subjects and trainee divers than in older subjects and professional divers. Also the Valsalva response was more likely to be positive when the subject's respiratory capacity was greater. These observations are used to make conclusions about the significance of a positive response to the Valsalva manoeuvre and about the value that can be attached to these various tests in subject selection.
General anaesthesia is aimed at calming the patient in the praeanaesthetic period, creating good operating conditions and ensuring a quiet post-anaesthetic recovery. A praeanaesthetic examination is necessary and special attention has to be given to the age and condition of the patient. Existant other deseases have to be treated and the anaesthetic technic has to be properly adapted to the kind of surgery. Modern anaesthetic drugs normally provide for these requirements and in particular to prevent the occurrence of the oculocardiac reflex.
From a total number of 822 ophthalmological operations carried out under general anaesthesia two cases of cardiac arrest were observed as a result of oculocardiac reflex. The receptor for this reflex is the eye and the retrobulbal tissue, the effector is the myocardium. Children and adults with certain diseases show a predisposition to this complication. Most frequently the results of the oculocardiac reflex require no treatment, sometimes, however, resuscitation is necessary.
Eight lesser known reflexes were grouped together because of their anatomical and physiological relationship. In all of them a branch of the vagus nerve forms a bridge between a circumscribed area of the skin, mostly the external auditory meatus, and an internal organ, namely the stomach, esophagus, lungs, heart, uterus, and some male and female sex organs. The eight reflexes are: (1) Gastroauricular phenomenon (Gaph) (Engel, 1922) in man; (2) Auricular phenomenon (Malherbe, 1958) in man; (3) Pulmonoauricular phenomenon (Deutsch, 1919) in man; (4) Auriculogenital reflex (Bradford, 1937) in cat; (5) Auriculouterine reflex (Vasiliu, 1932) in women; (6) Oculocardiac reflex (Aschner, 1967) in man; (7) Kalchschmidt's reflex in cattle (1956); and (8) Coughing attack with heartburn (Berlin, 1959) in man. The organs involved are either effector or receptor organs. The six reflexes observed in man are of diagnostic significance. Attention is also drawn to analogous reflexes in which the meningeal branch of the vagus is involved.