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.

When brakes fail you: Oculocardiac reflex elicited by a retained foreign body in a penetrating orbital injury.

Purpose: To report a case of oculocardiac reflex following penetrating orbital injury with entrapment of extraocular muscle secondary to a retained orbital foreign body. Observation: A 19-year-old man with no known comorbidities presented with a foreign object in his right orbit following a motor vehicle accident. Visual acuity was 20/20 bilaterally with positive relative afferent pupillary defect for the right eye. A motorcycle brake lever was embedded in the right inferotemporal conjunctival fornix, missing his globe. He was bradycardic in the emergency department, with a pulse rate ranging between 45 and 48 beats per minute. An urgent computed tomography scan of the orbit confirmed the penetrating injury with a linear hyperdense foreign body extending from the right inferior orbit into the right maxillary sinus. This foreign body was seen abutting the right lateral rectus and the globe inferiorly. Fractures involving the inferior and medial wall of the right orbit were seen with the inferior rectus, and orbital fat herniated into the maxillary sinus.The patient underwent urgent orbit exploration with foreign body removal and orbital floor repair under general anesthesia. Immediately after removing the foreign body, his pulse rate returned to normal, within 72-80 beats per minute. Six months postoperatively, visual acuity was 20/20 for both eyes. Although he had persistent diplopia on upgaze, he refused any other interventions. Conclusion and importance: Prompt detection of the oculocardiac reflex and removal of the inciting stimulus is vital to prevent any life-threatening events.

The role of surgical factors eliciting oculocardiac reflex of patients undergoing orbital tumor surgery: a retrospective study.

PURPOSE: Orbital tumors are an interdisciplinary disease, and surgery is one of the main treatment methods. The oculocardiac reflex (OCR) is a condition of surgery for orbital tumors. The aim of this study was to investigate whether there is an association between many surgical factors and the incidence of OCR in orbital tumor surgery. METHODS: Comparisons were made between patients with and without OCR using the Mann-Whitney test, Fisher's exact test, and Chi-square test. When comparing multiple groups (groups > 2), to explain which two groups had differences, post hoc testing was used for analysis, and the differences between groups were judged according to the adjusted standardized residuals. RESULTS: The results showed that the incidence of intraoperative OCR was different based on the different exposed operative field locations (p = 0.021). The OCR incidence in those with lesions involving the orbital apex and lesions adhering to extraocular muscles was higher than that of others (p < 0.001 and p = 0.003). In addition, multivariate logistic regression analysis revealed that orbital apex involvement and extraocular muscle adhesion were highly associated with a higher incidence of OCR (p < 0.001 and p = 0.013), while the operative field located in the lateral-superior orbit was highly associated with a lower incidence of OCR (p = 0.029). CONCLUSION: In orbital tumor surgery under general anesthesia, lesions involving the orbital apex and lesion adhesion to the extraocular muscles were independent risk factors for OCR, and an operative field located in the lateral-superior orbit was a protective factor for OCR.

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.

Algorithm for pediatric orbital blowout fractures: a 20-year retrospective cohort study

Abstract Objective Pediatric orbital blowout fractures can include pathologies that seem mild but require urgent release; serious sequelae can occur with standby surgery or conservative treatment. We sought to validate an algorithm for the treatment of pediatric orbital blowout fractures. Methods This retrospective cohort study included 61 pediatric patients, aged 18 years or younger, treated for pure orbital blowout fractures according to the algorithm from April 1, 2000, to August 31, 2020, at the Japanese Red Cross Asahikawa Hospital. Results There were 52 males (85%). Median age was 14 years (range, 5-18 years). There were 9 patients categorized as needing urgent release, 16 as needing repair, and 36 as needing conservative treatment. Mean follow-up ocular movement was 98.0 (95% Confidence Interval [95% CI], 96.8-99.2). Postoperative diplopia was not observed in 96% (79.6%-99.9%) of patients, better than in previous studies. A higher proportion of patients aged 0-12 years needed urgent repair than those aged 13-18 years (Odds Ratio [OR] = 14.2; 95% CI 1.6-683.4; p= 0.0046). There were no differences in Hess area ratio by age group. Conclusion Clinical results with the algorithm were satisfactory. The algorithm is suitable for treatment of pediatric orbital blowout fractures. Level of evidence 4.

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.

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.

Algorithm for pediatric orbital blowout fractures: a 20-year retrospective cohort study.

OBJECTIVE: Pediatric orbital blowout fractures can include pathologies that seem mild but require urgent release; serious sequelae can occur with standby surgery or conservative treatment. We sought to validate an algorithm for the treatment of pediatric orbital blowout fractures. METHODS: This retrospective cohort study included 61 pediatric patients, aged 18 years or younger, treated for pure orbital blowout fractures according to the algorithm from April 1, 2000, to August 31, 2020, at the Japanese Red Cross Asahikawa Hospital. RESULTS: There were 52 males (85%). Median age was 14 years (range, 5-18 years). There were 9 patients categorized as needing urgent release, 16 as needing repair, and 36 as needing conservative treatment. Mean follow-up ocular movement was 98.0 (95% Confidence Interval [95% CI], 96.8-99.2). Postoperative diplopia was not observed in 96% (79.6%-99.9%) of patients, better than in previous studies. A higher proportion of patients aged 0-12 years needed urgent repair than those aged 13-18 years (Odds Ratio [OR] = 14.2; 95% CI 1.6-683.4; p = 0.0046). There were no differences in Hess area ratio by age group. CONCLUSION: Clinical results with the algorithm were satisfactory. The algorithm is suitable for treatment of pediatric orbital blowout fractures.

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.

Trigeminocardiac reflex during maxillary third molar extraction: Our experience.

Trigeminocardiac reflex (TCR) is a cascade of physiological response secondary to the stimulation of any of the sensory divisions of the trigeminal nerve, which is the largest cranial nerve and provides sensory supply to the face, scalp, mucosa of the nose, and mouth. This response usually presents as a triad including bradycardia, apnea, and gastric motility changes. On the another side, transient loss of consciousness or vasovagal syncope, a well-known phenomenon in dentomaxillofacial surgery with its pathophysiology fully elucidated, is thought to be mediated by TCR and sometimes termed as dentocardiac reflex. Thus, it is imperative to know about TCR and its association with routine dental and maxillofacial surgery procedures. It can potentially happen during any minor or major oral surgical procedures ranging from simple third molar extractions, soft tissue surgeries, root canal treatments, or management of maxillofacial fractures. This paper presents two case reports demonstrating TCR which presented during maxillary third molar extraction and author(s) own experience in managing the same.

Restrictive strabismus and gaze-evoked oculocardiac reflex following pterygium repair with fibrin glue.

Oculocardiac reflex is a phenomenon caused by traction applied to the extraocular muscles, or pressure on the globes. The afferent stimulus travels via the ophthalmic branch of cranial nerve V, and the efferent stimulus travels via cranial nerve X, which can cause severe bradycardia and potentially hypotension, atrioventricular block, ventricular ectopy, and rarely asystole. Oculocardiac reflex is different from vasovagal syncope which has another pathway, and is triggered by pain or emotional upset, that results in failure of autoregulation of blood pressure. Ophthalmologists often observe oculocardiac reflex intraoperatively upon manipulation of extraocular muscles during strabismus surgeries. We report a case with a previously undescribed complication following pterygium autograft with fibrin glue stimulating oculocardiac reflex resulting in episodes of sudden bradycardia associated with light headedness and nausea.

Prediction of the Occurrence of the Oculocardiac Reflex Based on the Assessment of Heart Rate Variability. An Observational Study.

INTRODUCTION: Ophthalmic surgery is assumed to be safe, but some operations require general anaesthesia which is associated with a number of potential complications. In addition, adverse cardiovascular symptoms, such as severe slowing of the heart rate and, in some cases, cardiac arrest may occur due to the surgical technique. The aim of this study was to determine whether it is possible to predict the occurrence of oculocardiac reflex (OCR) based on heart rate variability (HRV) analysis for autonomic nervous system (ANS) activity assessment measured prior to the induction of anaesthesia and immediately before eyeball traction. METHODS: Fifty-two adults of both sexes (age range 18-65 years) with American Society of Anesthesiologists (ASA) physical status class 1 and 2 were enrolled in this study. All patients had underwent episcleral buckling under general anaesthesia. High-frequency (HF) changes in HRV are thought to reflect parasympathetic impulse transmission, whereas low-frequency (LF) changes reflect both sympathetic and parasympathetic activity. However, in practice, LF changes can be considered to reflect sympathetic changes. Thus, the LF/HF ratio reflects the actual balance between sympathetic and parasympathetic activity. Based on that, frequency domain HRV parameters from 5-min Holter electrocardiogram recordings before anaesthesia induction and before eyeball traction were used for the analysis. The statistical analysis also included patient age, sex, ASA status and preanaesthesia and premanoeuvre heart rate and blood pressure. RESULTS: Data from 42 patients were analysed. Oculocardiac reflex was observed in 32 patients (76.2%). No difference was found in the analysed parameters between patients with and without oculocardiac reflex. There was no relationship between the incidence of the OCR and the analysed parameters. CONCLUSION: The prediction of OCR based on initial ANS tone was not possible, and the initial heart rate, blood pressure, age, sex, and ASA status were not helpful for the identification of patients at risk of this reflex. TRIAL REGISTRATION: ClinicalTrials.gov identifier no.: NCT01714362.

South Texas orbital fracture protocol for emergency department evaluation of orbital fractures.

PURPOSE: Facial trauma and orbital fractures are common reasons for ophthalmology consultation in the emergency department (ED). The purpose of this study is to assess intervention rates and evaluate the acuity of ophthalmology consultation for orbital fractures in the ED. BASIC PROCEDURES: A retrospective chart review of orbital fractures was conducted over a 23-month period. 379 cases of orbital fractures were identified in a single-center study. All patients that received an ophthalmology consultation in the ED were included. Demographics, mechanism and location of orbital fracture, ophthalmic complications, and surgical and non-surgical ophthalmic interventions were recorded. The primary study outcome was the rate of ophthalmic consultation and intervention with and without retrospective application of our proposed South Texas Orbital Fracture Protocol (STOP). RESULTS: Immediate ophthalmic intervention was performed in 18.7% of patients. Statistically significant subjective, radiographic, and physical exam features correlating with ophthalmic intervention were identified and included globe rupture, concern for entrapment, orbital roof fractures, and retrobulbar hematoma. Retrospective application of our proposed South Texas Orbital Fracture Protocol (STOP) would have resulted in 186 of 379 patients requiring ophthalmology consultation, thus reducing consultation rate by 51% with an improved rate of intervention from 18.7% to 37.6%. CONCLUSIONS: Orbital fractures can be associated with severe ocular complications. Most cases, however, do not require emergent evaluation by an ophthalmologist. We propose the South Texas Orbital Fracture Protocol (STOP) for proper assessment and triaging of orbital fractures in the ED. While this clinical decision-making tool requires validation, it may offer improved healthcare efficiency, reduced costs, fewer unnecessary inter-facility transfers, and less burnout for ophthalmology residents.

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.

Oculocardiac reflex: an unusual trigger during dental surgery.

The oculocardiac reflex is a trigeminal-vagal reflex that manifests as cardiac arrythmias, most often bradycardia. The reflex can be triggered by manipulation of periorbital structures and unintended pressure on the bulbus oculi maxillofacial procedures. In this brief communication, we describe an unusual trigger of the oculocardiac reflex during maxillofacial surgery that resulted in severe bradycardia. This case highlights the need for careful securement of medical devices and attention to surgical technique to avoid undue pressure on draped fascial structures.

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.

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.

The trigeminocardiac reflex: Does the activation pathway of its efferent arc affect the intensity of the hemodynamic drop during the management of maxillofacial fractures?

The study aimed to correlate between the stimulated nerve, intensity of trigeminovagal reflex (TVR), and neuropathophysiological pathway by which the efferent arc is activated. Material and methods: A retrospective study included patients who developed TVR during the surgical management of mandibular, midface, and orbital fractures. The reflex was divided into type I, II, III, and IV-TVR according to the following nerves: ophthalmic, maxillary, mandibular, and non-trigeminal nerves, respectively. The magnitude of hemodynamic drops was identified at the intraoperative baseline, during reflex, and postoperatively. The needed time to elicit the reflex, frequency and duration, need for medical intervention, and sequence of the drop were also recorded. P - values < 0.05 was considered significant. Out of 260 patients' files were reviewed, the TVR was observed in only 30 (11.55 %) patients. The ophthalmic nerve activation significantly caused the greatest intensity and magnitude of hemodynamic drop, followed by maxillary nerve, then mandibular division, and the lowest one was non-trigeminal nerves. The highest mean of drops in the mean arterial blood pressure (MABP) was 62.92 ± 2.39 with the type ITVR, whereas those of the type II, III, and IV were 75.5 ±3.98, 81.02±1.31, and 82.22±1.85, respectively. Also, the type I-TVR led to the greatest decrease in the heart rate (HR) with the mean equaled to 52.31± 3.91. The drop percentage in the MABP was -30.5, -17.5, -12, -10.08 for type I, II, III, and IV, whereas those of the HR were - 33.9, -27.13, -26.6, and -25 with type I, II, III, and IV, respectively. All results showed highly significant differences with p-values less than 0.001 when comparing between the baseline and intraoperative values of each TVR type. There is a positive correlation between the activated pathway of the TVR and the intensity of its efferent arc response due to the neural pathway of each division in the brainstem circuitry. Understanding of the pathophysiology and mechanism of the TVR, together with the rapid recognition and treatment could prevent serious negative outcomes, especially when the ophthalmic nerve is stimulated. 1Introduction.