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Year : 2017  |  Volume : 4  |  Issue : 3  |  Page : 205-206

Oculocardiac reflex: An incident reporting during metopic craniosynostosis repair

1 Department of Anaesthesia and Critical Care, Institute of Naval Medicine, INHS Asvini, Mumbai, Maharashtra, India
2 Department of Neurosurgery, Institute of Naval Medicine, INHS Asvini, Mumbai, Maharashtra, India

Date of Web Publication21-Nov-2017

Correspondence Address:
Deepak Dwivedi
Departments of Anaesthesia and Critical Care, Institute of Naval Medicine, INHS Asvini, Colaba, Mumbai - 400 005, Maharashtra
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jclpca.jclpca_58_17

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How to cite this article:
Dwivedi D, Chauhan A, Ray A, Datta SG. Oculocardiac reflex: An incident reporting during metopic craniosynostosis repair. J Cleft Lip Palate Craniofac Anomal 2017;4, Suppl S1:205-6

How to cite this URL:
Dwivedi D, Chauhan A, Ray A, Datta SG. Oculocardiac reflex: An incident reporting during metopic craniosynostosis repair. J Cleft Lip Palate Craniofac Anomal [serial online] 2017 [cited 2022 Jan 27];4, Suppl S1:205-6. Available from: https://www.jclpca.org/text.asp?2017/4/3/205/218877


Aschner reflex or oculocardiac reflex (OCR) is a vagal response noted with strabismus surgery and manipulation of the orbital muscles trapped in the medial orbital wall fractures.[1] Afferents from the ophthalmic division of the fifth cranial nerve and efferents from the vagus nerve complete the reflex. The reflex has been known to cause junctional rhythm, bradycardia, or asystole.

We report an incidence of OCR during the metopic craniosynostosis repair in a 9-month-old male infant weighing 6 kg. The infant was born prematurely at 32-week period of gestation with low birth weight and neonatal jaundice which prolonged its stay at neonatal Intensive Care Unit (ICU). Parents noticed the abnormal growth and shape of the forehead with crowding of the eyes. On evaluation, the infant was diagnosed as a case of nonsyndromic craniosynostosis involving metopic suture, resulting in trigonocephaly [Figure 1]a. The infant was planned for the repair with anterior cranial vault removal and orbital temporal advancement. General anesthesia with controlled ventilation was planned. Adequate arrangements for the blood and fresh frozen plasma (FFP) were made. Operation theater was prepared and apt measures were taken to prevent hypothermia with the use of warming blanket and inline warming system. Standard monitoring (electrocardiography, pulse oximetry, capnography, noninvasive blood pressure, and nasopharyngeal temperature) was done along with the invasive blood pressure monitoring (right radial). Right internal jugular access was taken along with two peripheral 22-G intravenous (IV) cannulas. The infant was co-induced with IV fentanyl and IV propofol. Intubation was done with IV atracurium and 3.5 mm ID flexometallic endotracheal tube secured with transparent film dressing. The infant was maintained on oxygen, air, and sevoflurane.
Figure 1: (a) X-ray of the skull with fused metopic suture and hypotelorism (b) intraoperative image showing opening up of the metopic suture and reshaped fronto-orbital bandeau attached with absorbable vicryl plates and screws

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Postbifrontal craniotomy, the fronto-orbital bar was separated, and broadening of the bandeau was done with absorbable vicryl screws and plates [Figure 1]b. Orbital bandeau was reposited and scalp was pulled back for suturing when bilateral compression happened and sudden bradycardia occurred with heart rate (HR) plummeted to as low as 54 beats/min from the basal HR of 136 beats/min. The surgeon was notified and the pressure was released and the HR normalized. The rest of the intraoperative period was uneventful with monitoring within normal limits. The second episode of bradycardia occurred during the dressing of the scalp with external pressure on the forehead lowering HR transiently from 140 to 62 beats/min. Total blood loss was 240 ml which was replaced with packed red cells (220 ml) and 70 ml FFP. Postsurgery, the infant was shifted to pediatric ICU for further monitoring.

Isolated nonsyndromic craniosynostosis involving a single suture constitutes about 80% of the cases and the remaining 20% are associated with syndromes.[2] Unlocking the brain is warranted to prevent the cranial nerve palsies, increased intracranial pressure, and avoiding neurocognitive developmental delay.[3] Early surgery is fraught with the challenges due to smaller blood volume of the infants. There is an increased incidence of blood loss from the relatively larger head.[4] Estimation of the blood loss is difficult due to the blood collected under the drapes.

Direct orbital compression can present acutely with OCR during surgery for fronto-orbital advancement.[2] Our case also witnessed the same during the repositioning of orbital bandeau. However, it is imperative to rule out bradycardia with hemodynamic compromise secondary to venous air embolism (VAE) at this juncture. The incidence of VAE consequent to the ongoing blood loss is very high (82.6%) due to the creation of pressure gradient between the operative site and right atrium.[2] The second episode of OCR in our index case occurred while applying the dressing to the scalp when the inadvertent pressure on the forehead had led to compression of the fronto-orbital bar. The OCR is normally a transient phenomenon and reverts back within seconds. However, one should not hesitate longer to administer injection atropine to revert bradycardia, thereby preventing the cardiovascular collapse.

Vagal response has also been reported during repair of syndromic craniosynostoses where prone positioning for surgery can lead to direct compression of the orbit.[2] Kosaka et al. have demonstrated OCR in pediatric patients due to medial wall blowout fractures with entrapment of the extraocular muscles or herniation of the orbital contents.[5] Swamy et al. described delayed OCR in the pediatric patients post, medial orbital wall trauma with normal extraocular mobility.[1]

Therefore, vigilant invasive monitoring and keeping track of the ongoing blood loss with two-way communication with the surgeon can prevent the morbidity and mortality in such high-risk surgeries.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Swamy L, Phan LT, Sadah ZM, McCulley TJ, Warwar RE. Oculocardiac reflex in a medial orbital wall fracture without clinically evident entrapment. Middle East Afr J Ophthalmol 2013;20:268-70.  Back to cited text no. 1
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Thomas K, Hughes C, Johnson D, Das S. Anesthesia for surgery related to craniosynostosis: A review. Part 1. Paediatr Anaesth 2012;22:1033-41.  Back to cited text no. 2
Garza RM, Khosla RK. Nonsyndromic craniosynostosis. Semin Plast Surg 2012;26:53-63.  Back to cited text no. 3
Hughes C, Thomas K, Johnson D, Das S. Anesthesia for surgery related to craniosynostosis: A review. Part 2. Paediatr Anaesth 2013;23:22-7.  Back to cited text no. 4
Kosaka M, Sakamoto T, Yamamichi K, Yamashiro Y. Different onset pattern of oculocardiac reflex in pediatric medial wall blowout fractures. J Craniofac Surg 2014;25:247-52.  Back to cited text no. 5


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