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Year : 1990  |  Volume : 38  |  Issue : 2  |  Page : 85-87

Prevention of oculocardiac reflex (O.C.R) during extraocular muscle surgery

Dept. of Ophthalmology & Dept. of Pharmacology and Therapeutics M.L.B. Medical College, Jhansi. 284 128, India

Correspondence Address:
V K Misurya
Dept. of Ophthalmology & Dept. of Pharmacology and Therapeutics M.L.B. Medical College, Jhansi. 284 128
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Source of Support: None, Conflict of Interest: None

PMID: 2387608

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In the present study the effectiveness of intravenous atropine sulphate which blocks the peripheral muscarinic receptors at the heart and retrobulbar xylocaine hydrochloride which blocks the conduction at ciliary ganglion on the afferent limb of OCR was studied during strabismus surgery. The study was conducted on fifty three patients of either sex having squint of more than ten years duration. The patients were randomly allocated into four groups. No preanaesthetic medication with atropine or retrobulbar block with xylocaine was given in control group of patients. In the second group, only preanaesthetic medication with atropine was given; while in the third group only retrobulbar injection of xylocaine was given five minutes before operation. In the last group both atropine as preanaesthetic medication and xylocaine as retrobulbar block were given. The electrocardiographic recordings were taken before and throughout the operative procedure. It was interesting to note that in the group where atropine and xylocaine were used none of the patients exhibited activation of OCR. Results have been discussed.

Keywords: Oculocardiac reflex-Atropine Xylocaine

How to cite this article:
Misurya V K, Singh S P, Kulshrestha V K. Prevention of oculocardiac reflex (O.C.R) during extraocular muscle surgery. Indian J Ophthalmol 1990;38:85-7

How to cite this URL:
Misurya V K, Singh S P, Kulshrestha V K. Prevention of oculocardiac reflex (O.C.R) during extraocular muscle surgery. Indian J Ophthalmol [serial online] 1990 [cited 2023 Feb 9];38:85-7. Available from: https://www.ijo.in/text.asp?1990/38/2/85/24530

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  Introduction Top

The oculocardiac reflex (OCR) is of importance to oph­thalmologist and anaesthetist both because it may lead to serious bradycardia during ophthalmic surgery. An exaggerated OCR may even endanger the life of the patient. It was first described by Ashner (1908) [1]. The afferent pathway of the reflex arc is through the ophthal­mic division of the fifth nerve to the vagal centre and efferent pathway is though the vagal nerve to the heart. [Figure - 1]

It's activation leads to bradycardia, slowing of cardiac conduction and decrease in contractility. This reflex sets in due to stretching of the extraocular muscle or increase in the eye ball pressure [2],[3]. Earlier attempts have been made to prevent this clinically significant reflex either with atropine or xylocaine or with both drugs during strabismus surgery. Thus there are many con­troversial reports [4],[5],[6],[7],[8]

Nobody has reported the use and effectiveness of these two drugs with the pharmacological rationale. So in the present study effect of intravenous atropine sulphate which blocks the cardiac muscarinic receptors and of retrobulbar injection of xylocaine hydrochloride which blocks the conduction at the ciliary ganglion on the afferent limb of OCR, were studied during strabismus surgery.

  Material and methods Top

The study was conducted on fifty three otherwise heal­thy cases of both sexes having squint. The duration of squint was ten years or more. The age of patients varied from ten to thirty years. Every patient was subjected to a thorough general and local examination before admis­sion for surgical treatment. The patients were allocated randomly to four groups to minimise error in degree of OCR due to variability of manipulation required during surgery to correct the squint. The electrocardiographic (E.C.G.) monitoring of all the patients was done before and during operation on lead 11 to record any cardiac abnormality during surgery. The patients were operated under general anaesthesia which was induced by in­travenous Sodium thiopentone (150-250 mg) and main­tained by ether inhalation though Boyle's apparatus. Change of ten percent or more in heart rate or dysrrhyth­mia as compared to the control was taken as positive OCR. The patients were randomly allocated to different groups.

Ist Group : This group comprised of ten patients which served as control. In this group atropine was not given as preanaesthetic medication and retrobulbar xylocaine was also not used.

Iind Group : This group comprised of ten patients. Just before the induction of anaesthesia the patients of this group were injected with atropine sulphate (0.6 mg, I.V) as preanaesthetic medication.

Illrd Group : This group also comprised of ten patients in which no preanaesthetic medication with atropine was given. Only retrobulbar block with two percent xylocaine (1 ml) was given five minutes before operation.

IVth Group : Twenty three patients were put into this group who were injected with atropine sulphate (0.6 mg,I.V) for preanaesthetic medication as well as retrobulbar block was given with two percent xylocaine (1 ml) five minutes before operation.

Out of these fifty three squint cases, thirty three were of concomitant convergent type, sixteen were of con­comitant divergent type and four were of vertical type. In a large no. of patients, the angle of deviation of the squinting eye was less than 25°. Binocular vision was not present in any case. In most of the cases combined surgery (on medical and lateral rectus muscle) and in few cases single muscle surgery (on medial/lateral/su­perior/inferior rectus muscle) of recession-resection type was performed. Only in one case of vertical squint, myemectomy of the inferior oblique muscle was done.

Statistical significance was calculated by using the 'Stu­dent 't' test'.

  Observations Top

Ist Group : In the control group of patients in which neither preanaesthetic medication with atropine nor retrobulbar block with xylocaine was used, three cases (30%) showed positive oculocardiac reflex. The E.C.G. recording of one patient having positive oculocardiac reflex is shown in [Figure - 2]. Note that sinus rate decreased from 88 to 68-71 per min during surgery.

IInd Group : The patients of this group were pretreated with intravenous atropine before induction of anaes­thesia. In this group only one out of ten cases (10%) exhibited positive oculocardiac reflex.

Illrd Group: In this group where only xylocaine was used for retrobulbar block five minutes before operation, two cases (20%) showed positive oculocardiac reflex.

IVth Group: Atropine as preanaesthetic medication and xylocaine for retrobulbar block were used in this group of patients. None of the patients exhibited positive OCR. Thus complete prevention occurred with the com­bination of these two drugs.

  Discussion Top

Positive OCR is defined as dysrhythmia or bradycardia of ten percent or more resulting from traction of an extraocular muscle [2]. In the present study the same criteria for positive OCR were chosen.

The average clinical dose (.4 to .6 mg) of atropine sulphate which crosses blood brain barrier often decreases heart rate by central vagal stimulation, occur­ring prior to onset of peripheral muscarinic cholinergic receptors blockade at the heart. Atropine as preanaes­thetic medicant was injected rapidly by I.V. route to minimise it's central vagal stimulatory effect. In atropine premedicated group ten percent patients suffered from positive OCR. Protection provided in comparison to incidence of OCR in control group is not statistically significant (P>.2) [Table - 1]. This is because the vagal blocking action of 0.4 to 0.6 mg of atropine is not sufficient to prevent parasympathetically induced car­diovascular effects such as hypotension and bradycar­dia consequent to activation of oculocardiac reflex [3]. Atropine doses higher than aforementioned are not used by anaesthetists because of intense dryness of mouth and respiratory passage, troublesome tachycar­dia and pupillary dilation which interferes with the correct assessment of depth of anaesthesia. Besides it, dilata­tion of pupil may block the angle of anterior chamber of eye in glaucoma prone patients causing an increase in intraocular tension which may further facilitate OCR [3].

Xylocaine produces more prompt, more intense, longer lasting and more extensive anaesthesia as compared to equal concentration of procaine, that's why, it was preferred in this study. Twenty percent of patients (ex­hibited positive OCR) who were given xylocaine block alone [Table - 1]. The magnitude of protection is less than the atropine pretreated group and is not statistically significant (P>0.60). This may be because the sensa­tion of touch and deep pressure are the last to be abolished by local anaesthetics.

In twenty three patients, where both, atropine as preanaesthetic medicant and xylocaine as retrobulbar block were used, none of the patients exhibited positive OCR[Table - 1], indicating complete protection by drug combination. It is highly significant in comparison to the control group (P<.01). Thus it is concluded that pretreat­ment with both atropine and xylocaine, is better than either of them used alone for prevention of oculocardiac reflex during strabismus surgery. Double check is al­ways better than single.

As the positive OCR. was recorded in only a small number of cases its distribution in different sex and age groups and comparison of sensitivity of different ex­traocular muscle in relation to the reflex was not pos­sible.

  Acknowledgment Top

The authors are thankful to Dr. B.L. Verma, lecturer in medical statistics, for statistical calculations.

Each ml of atropine inj. contain: Atropine sulphate - 0.65 mg

Each ml of xylocaine inj.contain:

Lignocaine hydrochloride I,P- 21.33 mg Sodium chloride I.P - 6.00 mg

Methyl paraben I.P. - 1.00 mg

Water for inj. I.P - To make 1 ml

  References Top

Ashner, B. : Concerning a hitherto not yet described reflex from the eye on circulation & respiration, Wien, Klin, Woschanschr, 1908, 21, 1529-30.  Back to cited text no. 1
2. Apt. L; Isenberg, s. & Gaffney, W.L. : The oculocardiac reflex in strabismus surgery. Amer.J. Ophthalmol, 1973, 76. 533-35.  Back to cited text no. 2
Dauchot, P. and Gravenstein, J.S.: Effects of atropine on the electrocardiogram in different age groups. Clin. Pharmacol. Ther, 1971, 12, 274-80.  Back to cited text no. 3
Kirsch, R.E., Samet. P., Kugel, V. and Axelrod. S.: Electrocar­diographic changes during ocular surgery and their prevention by retrobulbar injection Arch. Ophthalmol, 1957,58. 348-56.  Back to cited text no. 4
Bosomworth, P.P., Ziegler, C.H. & Jacoby. S.: The oculocardiac reflex in eye muscle surgery. Anaesthesiol, 1958.19.7-8.  Back to cited text no. 5
Mendelblatt, F.I., Kirsch, R.E., Lemberg, L.: A study comparing methods of preventing the oculocardiac reflex. Amer. J. Ophthal­mol. 1962,53, 506-8.  Back to cited text no. 6
Berler, D.K.: The oculocardiac reflex. Amer. J. Ophthalmol, 1963,56,954-59.  Back to cited text no. 7
William, R. (Capt)., Welhaf., Donald. C. Johnson, (Capt): The oculocardiac reflex during extraocular muscle surgery. Arch. Ophthalmol, 1965, 73, 43-45.  Back to cited text no. 8


  [Figure - 1], [Figure - 2]

  [Table - 1]

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