The oculocardiac reflex in strabismus surgery

During strabismus surgery on 81 extraocular muscles in 49 children the cardiac response to calibrated traction on each of the muscles operated on was studied through the use of a microdisplacement transducer and the tachometer of a cardiac monitor. There was no significant difference in the frequency of induction of the oculocardiac reflex between the medial rectus and the other muscles or between the two eyes. However, quick traction provoked a reflex in 87% of instances, whereas progressive traction did so in only 51% of instances, a significant difference (p less than 0.05). Thus, because the oculocardiac reflex is frequent during strabismus surgery, cardiac monitoring during the operation and minimal, gentle manipulation of the extraocular muscles are important.     

Vagal responses to adjustable sutures in strabismus correction.

The oculocardiac reflex is a recognized complication of ocular stimulation, precipitated most commonly by traction on the extraocular muscles. To determine the true incidence of occurrence of the oculocardiac reflex during suture adjustments, 20 patients undergoing suture adjustment were monitored for blood pressure, heart rate, and rhythm abnormalities during the suture adjustment. A control group of ten patients with strabismus were studied postoperatively for comparison. Thirteen study patients and two control patients were noted to have a vagal response (P less than .001). The most common response noted was a decrease in heart rate in 15 patients. Only two patients were symptomatic during vagal response (one patient became light-headed and another had an episode of nausea and vomiting). Suture adjustment was found to be the most common triggering event in precipitating vagal responses. Surgeons performing suture adjustment in strabismus correction should be cognizant of vagal responses so that they may properly inform patients of this possibility and take steps to minimize its occurrence.     

Oculocardiac reflex during manipulation of adjustable sutures after strabismus surgery

We studied 44 patients who underwent strabismus surgery with the use of adjustable sutures to determine the occurrence of the oculocardiac reflex during the postoperative adjustment process. We defined the reflex as at least a 10% decrease in the baseline heart rate. Only two patients (4.5%) displayed an oculocardiac reflex during the adjustment. We did not identify any preadjustment factors that would increase the susceptibility to develop the reflex.     

成人水平斜视手术中局部麻醉监护指标变化的研究

目的：观察局部麻醉监护情况下成人水平斜视手术中心电图、呼吸、血氧饱和度、血压的变化情况。

方法：临床确诊为水平斜视的17例成人患者19眼36条眼外肌纳入研究。其中男10例,女7例。年龄18～71(平均32.65)岁; 外斜视14例(男8例,女6例),内斜视3例(男2例,女1例)。所有患者均进行最佳矫正视力(BCVA)、裂隙灯显微镜、间接检眼镜、角膜荧光及眼科同视机检查。术中由专业麻醉医师采用监护仪对手术采取全程密切监控。对比分析术前与局部麻醉监护术中的心电图、呼吸频率、血氧饱和度及血压的变化情况,对比内外直肌、不同性别及不同年龄组的区别。

结果：局部麻醉监护下17例成人水平斜视手术中牵拉眼外肌共36条,眼心反射发生率86.1%; 牵拉内、外直肌,眼心反射阳性率分别为100%,72.2%。眼心反射在男女性别间无统计学差异。18～30岁眼心反射阳性率明显高于31～71岁。术中呼吸频率的增高与眼心反射同步,与牵拉内外直肌、性别及不同年龄组无关。血氧饱和度无明显变化。血压在手术刚开始时出现一过性增高,首次牵拉眼内外直肌时出现一过性降低,在性别和年龄上无明显差异。

结论：在局部麻醉监护下成人水平斜视手术中,眼心反射发生率高,牵拉内直肌时100%发生; 呼吸增快与眼心反射同步; 手术即将开始时血压增高、牵拉眼内外直肌时血压降低。     

Oculocardiac reflex in sedated patients having laser in situ keratomileusis.

PURPOSE: To eliminate stress as a variable in assessing the frequency of the oculocardiac reflex during laser in situ keratomileusis (LASIK). SETTING: Merida Ophthalmological Hospital and Oftalmedica, Mexico City, Mexico. METHODS: A pulse oximeter registered the heart rate of 30 sedated patients having LASIK. Sedation was accomplished with a combination of midazolam and fentanyl. The heart rate was noted before and during suction. The results in 1 eye of each patient were recorded. Oculocardiac reflex was defined as a decrease of 10% or more of the basal heart rate. RESULTS: Fourteen patients (46.7%) had a 10% or more decrease in heart rate when suction was applied. Ten of the 14 had a decrease in heart rate between 10% and 19%, 3 between 20% and 29%, and 1 of more than 30%. Two patients (6.6%) had an increase in the basal heart rate of more than 10%. CONCLUSIONS: The findings suggest that the oculocardiac reflex occurs more frequently in sedated patients than in nonsedated patients.     

老年性白内障术中的眼心反射

目的探讨老年人在现代白内障摘除术中眼心反射发生情况以及术中哪些操作更易诱发眼心反射。方法由动态心电记录器分别记录术前及术中球后麻醉、软化眼球、上直肌牵引缝线、板层切开角巩膜缘、娩核及人工晶体植入等６项主要操作开始后３０～６０秒钟的心电活动。以每一手术步骤使心率减慢的次数超过其前一步骤心率的１０％为眼心反射阳性。结果３０例中有１０例（３３．３％）发生眼心反射，共发生１４次。除缝上直肌牵引缝线外，其余各项操作均记录到眼心反射。术中５例出现房性或室性早搏。结论现代白内障摘除术可影响老年人的心电活动。或许眼心反射的标准过于保守，有待重新修定。     

The oculocardiac reflex as a surgical aid in identifying a slipped or ''lost'' extraocular muscle.

The oculocardiac reflex during strabismus surgery has generally been regarded as a hazard capable of causing death. Six cases are presented which show a beneficial use of the oculocardiac reflex. Isolation of a previously slipped or 'lost' extraocular muscle can be difficult. In this series identification of the tissue as muscle was substantiated by observing a positive oculocardiac reflex when traction was placed on the suspected tissue. Each of the 6 dislodged extraocular muscles was the medial rectus muscle. Three of the muscles had been resected and 3 either recessed or tenotomised. In one patient, despite 6 previous strabismus operations, including 2 strabotomies on a muscle that slipped, and in another patient, who had a lapse of 6 years since the last strabotomy, when the slipped muscle was isolated, the oculocardiac reflex could still be elicited. To avoid abolishing the oculocardiac reflex during surgery the anaesthetist should be instructed to avoid the use of an intravenous parasympatholytic agent, such as atropine, at the time of induction and during the operation.     

不同麻醉下视网膜脱离手术中的眼心反射观察

目的:观察不同麻醉方法下视网膜脱离外路手术中的眼心反射。方法:选取我科2008-06/2010-03住院患者109例109眼,随机分为对照组和治疗组,分别采用球后阻滞麻醉与静脉复合麻醉进行视网膜脱离外路手术,观察术中血压、心率、眼心反射、血氧饱和度等情况。结果:与球后阻滞麻醉比较,静脉复合麻醉下眼心反射发生率低,收缩压、舒张压及平均血氧饱和度变化较小,经统计学处理,差异有统计学意义(P<0.01)。结论:静脉复合麻醉下行视网膜脱离外路手术相对安全,并发症少,效果满意。     

Combined propofol sedation with sub-Tenon's lidocaine/mercaine infusion for strabismus surgery in adults

AIMS: To evaluate the safety and efficacy of propofol sedation combined with sub-Tenon's anaesthesia for strabismus surgery in adults. METHODS: Thirty-two consecutive patients aged 31-85 years underwent strabismus surgery under general (n=16) or local (n=16) anaesthesia. In the local anaesthesia (study) group, sedation was induced with a loading dose of midazolam, fentanyl, and propofol, followed by continuous infusion of propofol, 3-6 mg/k/h to deep sedation. A nasal tube was inserted to prevent airway obstruction. Sub-Tenon's anaesthesia included infusion of a 3-4 ml mixture (50 : 50) of lidocaine 2%/mercaine 0.5%. General anaesthesia consisted of premedication with midazolam, followed by fentanyl, esmeron-bromate, propofol, and tracheal intubation. Duration of surgery and anaesthesia, intraoperative oculocardiac reflex and arrhythmias, time to discharge, postoperative pain, nausea and vomiting, and patient and surgeon satisfaction were evaluated. RESULTS: The local anaesthesia group had a significantly shorter operative and anaesthesia time, fewer episodes of oculocardiac reflex or arrythmia/bradycardia requiring treatment, fewer early or late episodes of nausea and vomiting, and less pain. The patients and surgeon in this group reported higher satisfaction. CONCLUSION: Propofol sedation with local sub-Tenon's injection of lidocaine/mercaine is recommended for the induction and maintenance of anaesthesia during unilateral or bilateral strabismus surgery in adults. The method is quick and effective, without systemic or ocular side effects.     

Outcome and influencing factors of external levator palpebrae superioris aponeurosis advancement for blepharoptosis

PURPOSE: To evaluate, in patients with acquired good-function blepharoptosis, levator advancement success and surgical failure risk factors. METHODS: This retrospective, case-cohort study was university based. An estimated 828 patients underwent levator advancement for acquired good-function blepharoptosis between January 1, 1990, and December 31, 1999. Seventy-two patients underwent reoperation during the first postoperative year. Of 125 randomly selected patients not undergoing reoperation, 106 met the desired outcome criteria: postoperative margin reflex distance (MRD) >/=2.0 mm and 相似文献   

Quantitative analysis of the oculocardiac reflex by traction on human extraocular muscle

The oculocardiac reflex was quantitatively studied in 15 patients with strabismus. The reflex was observed in all patients when the medial rectus and inferior oblique muscles were stretched; the medial rectus muscle had a lower threshold than the inferior oblique. Bradycardia was evoked in 7 of the 15 patients when the lateral rectus was tractioned with tensions of 50 g and 600 g. The oculocardiac reflex was a graded phenomenon as a function of tension applied to the extraocular muscles. As tension was increased, bradycardia occurred rapidly and became deep. Systemic administration of atropine prevented completely the bradycardia from occurring. The results suggest that the response of the extraocular muscles to stretch are critically mediated through a polysynaptic path to the heart, resulting in suppression of the heart rate.     

七氟醚、氯胺酮静吸复合麻醉与氯胺酮静脉麻醉在小儿斜视手术中的应用

目的:探讨两种麻醉方法在小儿斜视手术中的应用,并比较优缺点。方法:选择ASAI~Ⅱ级,择期接受斜视手术的患儿32例。随机分为七氟醚、氯胺酮静吸复合麻醉组(A组)和氯胺酮静脉麻醉组(B组)各16例,保留自主呼吸,为保证通气安全,均采用喉罩置入技术。记录摇头、肢体活动和血氧饱合度SpO2<95%的发生例数、眼心反射(oculocardiac re-flex,OCR)和术后呕吐(postoperati vevomiting,POV)、燥动的发生例数,睫毛反射消失时间、清醒时间等指标。结果:静吸复合麻醉组患儿接受程度高,血氧饱合度维持好,清醒快,OCR,术后燥动发生率低(P<0.05),但POV无明显差异(P>0.05)。结论:在小儿斜视手术中,七氟醚、氯胺酮静吸复合麻醉优于氯胺酮静脉麻醉。     

Intravitreal Bevacizumab Treatment for Macular Edema due to Branch Retinal Vein Occlusion in a Clinical Setting

Purpose: To report the functional and anatomical outcome of intravitreal bevacizumab (IVB) treatment for macular edema due to branch retinal vein occlusion (BRVO) in a clinical setting. Methods: The files of 45 patients treated with IVB for BRVO-induced macular edema at a tertiary medical center in 2007-2010 were reviewed. All received three loading doses (1.25 mg) and were followed every 6 weeks. Treatment was repeated for persistent or recurrent edema. If the edema did not resolve after 4-6 injections, grid laser photocoagulation was performed. Results: Mean patient age was 70.7 years (SD 8.5); mean follow-up time, 18.8 months (SD 8.3); mean number of injections, 8.8 (SD 3.8). Fourteen patients (33%) received grid laser treatment before bevacizumab and 23 (51%) after. Mean logMAR visual acuity (VA) was 0.63 (SD 0.43) before treatment (Snellen, 20/140) and 0.4 (SD 0.43) (Snellen, 20/70) after (p < 0.0005). Corresponding central macular thickness (CMT) values were 382.2 microns (SD 155.6) and 320.5 microns (SD 172.8) (p= 0.028). Positive correlations were found between initial VA and initial and final CMT (p = 0.004) and between gain in VA and reduction in CMT (p = 0.03). There was no statistically significant difference in mean initial or final VA and CMT between patients who received grid laser treatment before or during the study and those who did not. Conclusions: IVB treatment improves visual function and reduces CMT in patients with BRVO-induced macular edema.     

Intraocular pressure changes after repeated intravitreal antivascular endothelial growth factor injections in patients with neovascular age-related macular degeneration with or without glaucoma

PurposeTo investigate the long-term effects of multiple intravitreal injections on intraocular pressure (IOP) in patients with exudative age-related macular degeneration, and to determine whether this is related to a pre-existing diagnosis of glaucoma.MethodsA retrospective study was carried out on 209 eyes in 173 patients with neovascular age-related macular degeneration who received at least three intravitreal injections of bevacizumab or ranibizumab, or both, from January 2006 to December 2012 at Shin Kong Wu Ho-Su Memorial Hospital. Sequential changes in IOP following the intravitreal injections were documented and the incidence and characteristics of the patients diagnosed with glaucoma were recorded and analyzed.ResultsTwo hundred and nine eyes in 173 patients were included in this study. The mean number of injections was 10.1 (range 3–23). No significant change was found in IOP (p = 0.41, paired t test) and none of the patients experienced delayed ocular hypertension during the treatment course. No correlation was found between differences in IOP and the number of injections (correlation coefficient −0.086) and no significant change in IOP was found in patients with or without glaucoma (p = 0.42 and 0.37, respectively, paired t test). In addition, the use of drugs to lower IOP did not increase with repeated intravitreal injections in patients with glaucoma [single drug, 24 (63.2%) patients; two drugs 14 (36.8%) patients].ConclusionRepeated intravitreal antivascular endothelial growth factor injections of bevacizumab or ranibizumab, or both, did not increase the risk of increasing IOP in patients with exudative age-related macular degeneration, with or without glaucoma.     

眼外伤与眼心反射

目的　了解眼外伤对心脏的间接影响 ,评估创伤性眼心反射的临床意义。方法　回顾性分析 65 7例眼外伤住院患者的血压、脉博及部分心电图变化。结果　伤后 1小时内首次平均动脉压低于 70mmHg者 7例 ( 2 2 7% ) ( 1mmHg =0 13 3kPa) ;首次脉搏较基础频率减慢者 14例 ( 4 5 4% ) ,二者同步 1例。异常心电图 2 17例 ( 5 6 66% ) ,眼挫伤比眼烧伤发生异位心律失常明显增多 (P <0 0 5 ) ;窦性心动过缓 ,异位心律失常与ST -T异常心电图以 40岁以上年龄段多见 (P <0 0 5 )。结论　眼外伤导致血压下降甚微且与脉搏减慢无同步关系 ;心脏植物神经功能的稳定性受到伤情影响 ;窦性心动过缓、异位心律失常及ST -T异常发生与年龄段密切相关。应加强创伤性眼心反射的防治 ,注重 40岁以上年龄段     

球后麻醉在斜视手术中的应用

目的探讨在斜视手术中应用球后麻醉的可行性及其临床意义。方法将84例斜视随机分为传统麻醉组及传统麻醉联合球后麻醉组,记录钩取眼外肌前后心率变化,比较两组眼心反射发生的阳性率并对其术后正位率进行统计学分析。结果联合球后麻醉组眼心反射发生的阳性率明显低于传统麻醉组,两组术后正位率在统计上无差异。结论在传统麻醉的基础上联合球后麻醉可以减少眼心反射的发生,在提高斜视手术安全性的同时并不影响手术效果。     

Impact of patient face mask use on endophthalmitis after intravitreal anti-VEGF injections

ObjectiveTo compare the incidence of endophthalmitis after intravitreal anti-vascular endothelial growth factor (anti-VEGF) injections with and without patient face masking.DesignTwo-centre retrospective cohort studyParticipantsPatients receiving a total of 28 501 injections (period 1 before masking: n = 13 863; period 2 after masking: n = 14 638)MethodsPeriods before and after implementation of patient masking were compared: period 1 (July–December 2019) and period 2 (July–December 2020). All patients requiring treatment for endophthalmitis following intravitreal anti-VEGF injections were reviewed. Endophthalmitis risks were compared. Statistical simulations were run to determine the number of injections or endophthalmitis cases required to detect a statistically significant difference between both periods.ResultsFive patients (0.036%) had endophthalmitis in period 1 compared with 7 patients (0.048%) in period 2. Odds ratio, 95% confidence interval, for risk of patient masking was 1.326, 0.421–4.179 (p = 0.63). Three patients (0.022%) in period 1 had culture-positive endophthalmitis compared with 2 patients (0.014%) in period 2. Risk of patient masking for culture-positive endophthalmitis was 0.631, 0.105–3.779 (p = 0.61). Assuming similar rates of endophthalmitis, 476,806 injections in both groups would be required to detect a significant difference. Alternatively, assuming that masking would increase endophthalmitis risk in period 2, a significant difference would require twice as many cases (n = 15, 0.102%) for a risk of 2.843, 1.033–7.825 (p = 0.043).ConclusionsThe implementation of patient masking in clinical practice did not significantly alter the rate of endophthalmitis following intravitreal anti-VEGF injections.     

Outcome of trabeculectomy with intraoperative mitomycin C for uveitic glaucoma

BACKGROUND: The purpose of this study was to compare the outcomes of mitomycin C (MMC)-augmented trabeculectomy in glaucoma patients with uveitis to those without uveitis but with other high-risk characteristics. METHODS: A retrospective comparative cohort analysis consisting of 51 eyes of 51 patients (21 uveitic patients and 30 nonuveitic patients) was performed. Two outcome classifications were analyzed: absolute success (intraocular pressure [IOP]相似文献   

The photic sneeze reflex and ocular anesthesia

BACKGROUND AND PURPOSE: Intravenous sedation to minimize discomfort from local anesthetic injection has many potential complications including severe involuntary sneezing (i.s.). This prospective study evaluates the occurrence of i.s. and a history of photic sneezing (p.s.). METHODS AND MATERIALS: All patients receiving local anesthesia (retrobulbar or periocular injections) after intravenous thiopentone for eye surgery during eight months were asked about p.s. and observed for i.s. RESULTS: The 557 patients (40% males) had a mean age of 69.9 years and 14% recalled p.s. (29.5% males). I.s. developed in 5.2% of the 557. Only 7.6% of those with p.s. developed i.s. After periocular injections 23.8% developed as compared to 4.5% after retrobulbar injections. (P < 0.001). There was no relationship between p.s. and i.s. (p = 0.43). CONCLUSION: I.s. is not linked to p.s., with males and females at equal risk for either. I.s. is more common after periocular injections.