Comprehensive Management of Pediatric Orbital Fractures: A Case Series and Review of Literature

Orbital fractures in the pediatric population are rare. A trapdoor fracture is a special anatomic type of orbital fracture associated with herniation of orbital contents and entrapment of extraocular muscles entrapment with no signs of any soft tissue trauma. A delay in diagnosis can lead to a life-threatening condition known as oculocardiac reflex, characterized by nausea, vomiting, bradycardia, and syncope. Many authors recommend early surgical intervention, but some patients may delay for various reasons. We hereby represent three cases of orbital fracture to prevent long-term persistent diplopia. Depending on the case scenario, two cases were operated on in which an autogenous iliac cortical graft was placed in one patient to prevent postoperative herniation of orbital content, and in one patient, only release of entrapped muscles was done. One patient was managed conservatively with a regular follow-up visit.

Comparing Effectiveness and Safety of Intravenous Atropine with Topical Tetracaine in Preventing and Relieving Oculocardiac Reflex in Patients Undergoing Strabismus Surgery: A Randomized Clinical Trial

Background

Oculocardiac reflex (OCR) is one of the serious complications following surgical therapeutic procedures for strabismus. Various medications have been tested to prevent or mitigate this complication. We aimed to compare the effect of intravenous atropine and topical tetracaine on the incidence and severity of OCR in strabismus surgery.

Materials and Methods

In this triple-blind randomized clinical trial study, 120 patients who were candidates for strabismus surgery were randomly assigned to receive intravenous atropine, topical tetracaine, or artificial tears as the control. The incidence of OCR and its severity along with the changes in hemodynamic conditions were compared across the groups.

Results

The incidence rate of OCR in the groups receiving atropine, tetracaine, and the control was found to be 17.5%, 25.0%, and 32.5% in the releasing phase without any difference, respectively (P = 0.303); however, it was 2.5%, 7.5%, and 25.0%, respectively, in the cutting phase, indicating a lower rate in the group receiving tetracaine (P = 0.004). Similarly, there was no difference in the severity of OCR across the three study groups in the releasing phase (P = 0.666); however, in the cutting phase, OCR was revealed to be milder in the group receiving atropine as compared to other groups (P = 0.033). Prescribing atropine led to higher mean systolic blood pressure and mean arterial pressure during surgery.

Conclusion

The injection of atropine can effectively reduce the incidence of OCR during strabismus surgery and reduce its severity if this reflex occurs.

Do Not Fall for This; Diagnostic Challenges in Orbital Floor Fractures With Extraocular Muscle Entrapment

Extraocular muscles that are entrapped in orbital fracture sites require emergent surgical treatment. Muscle entrapment can present with subtle findings or mimic other conditions, contributing to delays in diagnosis. Here, we present two cases of extraocular muscle entrapment that were not immediately identified. By discussing the diagnostic challenge in these cases, we aim to increase the comfort of all physicians in identifying muscle entrapment in the emergency department.

Case report on combined approach for delayed orbital floor repair

"White-eyed blowout" fractures in pediatric patients can be presented with fewer clinical symptoms; therefore, immediate diagnosis and surgery is essential. In cases where early surgery was performed, rapid recovery and better postoperative outcomes were noted regardless of the configuration of fracture. In pediatric patients, due to changes in the orbital volume, autograft is recommended. Although there are different approaches to orbital floor, transantral approach provides enhanced illumination and accessibility to orbital floor. This case report portrays a pediatric case of white-eyed blow out fracture which went unnoticed for about 1 month and was managed at a later date. Combined mid-tarsal and transantral approaches using iliac crest graft was used to repair the orbital blow-out fracture.

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.

Oculocardiac reflex and oculorespiratory reflex during strabismus surgery under general anesthesia using the laryngeal mask airway with maintenance of spontaneous respiration: A retrospective study

Objective

To determine (1) how the specific muscle undergoing surgical treatment affects the occurrence of the oculocardiac reflex (OCR) and oculorespiratory reflex (ORR) and (2) whether the depth of anesthesia influences the occurrence of the OCR and ORR in patients undergoing strabismus surgery with a laryngeal mask airway with maintenance of spontaneous respiration.

Methods

The medical records of patients who underwent strabismus surgery on the lateral rectus (LR) and medial rectus (MR) muscles from January 2017 to December 2017 were retrospectively reviewed.

Results

The incidence of the OCR was not significantly different between LR and MR operations in either pediatric or adult patients. The incidence of the ORR as indexed by the tidal volume (TV) was significantly higher during MR than LR surgery in pediatric patients (29.3% vs. 10.1%, respectively). The change in TV during muscle traction and the bispectral index were significantly correlated in both pediatric and adult patients (r² = 0.034 and 0.058, respectively).

Conclusions

The OCR was not influenced by the specific muscle undergoing surgery or the depth of anesthesia. The incidence of the ORR as indexed by the TV was higher during MR surgery in pediatric patients and was positively correlated with the depth of anesthesia.

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.

Anesthetic Impacts on the Oculocardiac Reflex: Evidence from a Large, Observational Study

Background

The oculocardiac reflex (OCR) is a sudden vagal bradycardia that can be elicited by traction on an extraocular muscle. Bradycardia is highly variable from case to case necessitating a large sample size to observe small to moderate impact on OCR. While the surgeon’s tissue manipulation has immediate impact on OCR and individual patients may have some proclivity to OCR, we sought to characterize the impact on OCR by the anesthesiologist.

Methods

From 1992 to 2019, during routine, community outpatient general anesthetic strabismus surgery, oculocardiac reflex was prospectively observed utilizing a uniform 10-second, 200 gram square wave tension on each extraocular muscle. Anesthetic parameters were recorded and analyzed with double-cohort design and non-parametric statistics and correlations. We define %OCR as the maximally tension-altered heart rate and a percent of stable pre-tension heart rate.

Results

The median (IQR) confidence intervals OCR for 2527 initial cases was 89% (67% to 97%) without anticholinergic, and 99% (95% to 100%) in 165 patients with anticholinergic. OCR was 81% (62% to 96%) in 1034 with opioids and to 75% (60% to 95%) in 59 with dexmedetomidine and in 189 with IV dexamethasone to 72% (56% to 92%) There was a significant (p<0.01 Kruskal–Wallis) impact on OCR by various opioids, muscle relaxants and inhalational agents. Linear regression showed significant inhibitory impact on OCR by increased inhalational agent depth and by lower exhaled CO₂.

Conclusion

The anesthesiologist can block OCR with sufficient anticholinergics, deeper inhalational agents and robust ventilation, and can augment OCR with opioids, dexmedetomidine and apparently also with dexamethasone.

Clinical Trials Registry

NCT04353960.

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Does Topical Proparacaine Improve Postoperative Comfort After Strabismus Surgery?

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).

The 'White-eyed' Orbital Blowout Fracture: An Easily Overlooked Injury in Maxillofacial Trauma

The ‘white-eyed’ blowout fracture (WEBOF) is an injury that is often overlooked in head trauma patients, as it often has few overt clinical and radiographic features. Although benign in appearance, it can lead to significant patient morbidity. Here, we intend to increase the awareness of WEBOF and provide general principles for its diagnosis. WEBOF should be recognized early to ensure timely management and a successful outcome.

Reduction of oculocardiac reflex with Tetracaine eye drop in strabismus surgery

INTRODUCTION

Recently, to reduce the incidence of oculocardiac reflex (OCR) in strabismus surgery, retrobulbar block and anticholinergic drugs or local anesthesia are also used. The present study evaluated the effects of Tetracaine eye drop as a topical nerve blocker on OCR during strabismus surgery.

METHODS AND MATERIALS

In this randomized trial, 70 strabismus surgery candidates were randomly divided into placebo or synthetic teardrop (E) and Tetracaine eye drop (T) groups, so 3 drops of each solution were dropped in four directions of patients' eye immediately after applying anesthesia and before surgery. The incidence and severity of OCR during the stages of muscle release and incision (cutting), hemodynamic changes, the required time for OCR recovery and atropine dose were assessed.

RESULTS

OCR was more seen in release phase compared to cutting phase. There were no significant differences between two group regarding the incidence and severity of OCR in the release phase (p > 0.05), but the incidence and severity of OCR in the cutting phase was more in group E than group T (p = 0.02, for both). The duration of OCR improvement (p-value = 0.74) and Atropine consumption (p-value = 0.92) did not differ between the groups.

CONCLUSION

Tetracaine eye drop only reduces the incidence and severity of OCR during the incision stage of strabismus surgery.

Prospective evaluation of anesthetic protocols during pediatric ophthalmic surgery

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.

Oculocardiac Reflex as a Result of Intraorbital Trauma

BACKGROUND

The oculocardiac reflex is a decrease in heart rate caused by ocular compression or traction upon the extraocular musculature. Multiple instances of this phenomenon have been described in anesthesia, trauma, craniofacial, and ophthalmology literature, but there is a sparsity of documentation in the emergency medicine literature.

CASE REPORT

We describe the observation and management of the oculocardiac reflex in a 26-year-old man with retrobulbar hematoma and intraocular trauma caused by a self-inflicted gunshot wound. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Prompt recognition of the oculocardiac reflex is important for the emergency physician given the common occurrence of craniofacial trauma and the potentially devastating consequences if not recognized and addressed.

Malignant Transformation of Optic Nerve Melanocytoma into Melanoma Associated with Ocular Ischemic Syndrome and Oculocardiac Reflex: Case Report and Review of the Literature

PURPOSE

To describe the clinical and pathological features of malignant transformation of an optic nerve melanocytoma over 25 years, associated with spontaneous extensive tumor necrosis, neovascular glaucoma, ocular ischemic syndrome, and oculocardiac reflex.

PROCEDURES

A 60-year-old Caucasian female presented with acute severe left ocular pain and glaucoma with an intraocular pressure of 80 mmHg and bradycardia (28-40 beats/min).

RESULTS

Histopathological examination of the enucleated eye showed features of malignant transformation of a spontaneously necrotic optic nerve melanocytoma associated with ocular ischemic syndrome and neovascular glaucoma.

CONCLUSIONS

Yearly follow-up and awareness of possible but well-documented malignant transformation, even over several decades, is recommended. This case presents malignant transformation of an optic nerve melanocytoma associated with the common complications described in the literature over the years. Of particular interest was the development of oculocardiac reflex in this patient.

Iatrogenic oculocardiac reflex in a patient with head injury

A 16-year-old girl with a history of a recent fall from the third floor was transferred to the emergency room. On presentation, the patient, who had sustained multiple facial fractures, was in clinical shock with a blood pressure 80/40 mm Hg, heart rate 130/min, tachypnea (>30/min), Po2 50 mm Hg, and So2 82%, and she was intubated for airway protection. Severe nasal hemorrhage was detected (hematocrit: 22%), therefore a bilateral anteroposterior balloon nasal catheter was inserted and inflated with air. Bleeding was controlled. A few minutes later, her heart rate dropped to 40/min. Atropine was administered intravenously and the rate increased to 60/min. Computed tomography of the head revealed brain and subarachnoid hemorrhage, multiple fractures of the facial skeleton, and a round foreign body, full of air, compressing the left eye. The medial wall and the floor of the ipsilateral orbit were also fractured, establishing a naso-orbital communication. The left catheter was immediately removed. Heart rate was restored to normal. Facial fractures were addressed surgically. Patient's vision is intact.

Comparing the preventive effect of 2 percent topical lidocaine and intravenous atropine on oculocardiac reflex in ophthalmological surgeries under general anesthesia

BACKGROUND

The current study aimed to determine preventive effect of 2 percent topical xylocaine on oculocardiac reflex in ophthalmological surgeries except strabismus, including retinal detachment and vitrectomy with scleral buckling under general anesthesia.

METHODS

A randomized controlled clinical trial was carried out on 150 patients aged 18-90 years undergoing ophthalmological surgeries under general anesthesia. Samples randomly divided into the experimental group (received four drops of 2 percent topical xylocaine instilled in desired eye) and control group (received 0.5 mg atropine sulfate injection). Systolic, diastolic and mean arterial blood pressure of patients and baseline heart rate were recorded. They were compared regarding the incidence of bradycardia, heart rate less than 60 beats/minute, hypotension and blood pressure less than 90 mm/Hg. Data were analyzed by Statistical Package for the Social Sciences software version 20 using Chi-square and ANOVA.

RESULTS

The difference between two groups was not statistically significant regarding demographic and basic variables. The incidence of bradycardia in both groups was respectively (90.7 percent vs. 17.3 percent), heart rate less than 60 beats/minute (40 percent vs. 13.3 percent), hypotension (76 percent vs. 32 percent) and blood pressure less than 90 mmHg was (28 percent vs. 8 percent). Accordingly, the differences between both groups were statistically significant (P > 0.001).

CONCLUSIONS

The preventive impact of topical xylocaine upon oculocardiac reflex in ophthalmological surgeries such as retinal detachment and vitrectomy with scleral buckling under general anesthesia was less effective than that of atropine injection. Therefore, to avoid this reflex in high-risk patients, injecting atropine would be safer.

Abnormal oculocardiac reflex in two patients with Marcus Gunn syndrome

Marcus Gunn phenomenon is seen in 4 to 6% of congenital ptosis patients. We report two cases of abnormal oculocardiac reflex during ptosis correction surgery. Marcus Gunn syndrome is an autosomal dominant condition with incomplete penetrance. It is believed to be a neural misdirection syndrome in which fibres of the motor division of the trigeminal nerve are congenitally misdirected into the superior pterygoid and the levator muscles. Anesthetic considerations include taking a detailed history about any previous anaesthetic exposure and any reaction to it as this syndrome has a high probability of being associated with malignant hyperthermia. It is also postulated that an atypical oculocardiac reflex might be initiated in these patients as seen in our patients, so precautions must be taken for its prevention and early detection.

Influence of topical anesthetics on oculocardiac reflex and corneal healing in rabbits

AIM

To investigate the incidence of oculocardiac reflex (OCR) with two anesthetic regimens and its prevention using topical anesthetics in a rabbit model, and to explore the effect of topical anesthetics on corneal healing.

METHODS

Forty-eight clinically healthy adult New Zealand white rabbits of either sex were divided into two groups (Group A and B) and anesthetized with either ketamine (Group A, n =24) or propofol (Group B, n =24). he incidence of OCR was recorded in each group with a variety of ocular manipulation with or without the use of topical anesthetics (40g/L lignocaine, 5g/L proparacain, 5g/L bupivacaine). Corneal toxicity and healing following the use of each topical anesthetic was assessed one day after surgery and up to 7 days postoperatively by clinical examination of the eye, histopathology and collagen staining and transmission electron microscopy.

RESULTS

No incidence of OCR was recorded with ocular manipulation under ketamine anesthesia, whereas significant reduction in heart rate (P<0.01) was recorded under propofol anesthesia. Topical anesthetics could successfully prevent the OCR without affecting the corneal healing.

CONCLUSION

Topical anesthetics may be recommended for prevention of OCR without any local adverse effect.