Orbit, 2014; 33(4): 286–288 ! Informa Healthcare USA, Inc. ISSN: 0167-6830 print / 1744-5108 online DOI: 10.3109/01676830.2014.881890
C ASE REPORT
The Oculocardiac Reflex in an Adult with a Non-Displaced Orbital Floor Fracture Sundeep K. Kasi, Ian R. Gorovoy, M. Reza Vagefi, and Robert C. Kersten Department of Ophthalmology, University of California, San Francisco, San Francisco, California, USA
ABSTRACT The current dogma is that the oculocardiac reflex from orbital trapdoor fractures occurs only in children and young adults. We present the occurrence of the oculocardiac reflex in an adult with a non-displaced orbital floor fracture. CT demonstrated the adventitia surrounding the inferior rectus trapped in and below the orbital floor fracture. The patient’s oculocardiac reflex resolved by early next morning, presumably from the tissue escaping from the orbital floor defect. Keywords: Oculocardiac reflex, trapdoor fracture
INTRODUCTION
riding intoxicated. The patient was wearing a helmet but sustained unilateral lacerations and a zygomaticomaxillary complex fracture with an orbital floor fracture. Examination of extraocular motility revealed a -2 restriction in upgaze in the affected eye, and a continuous cardiac monitor revealed a reproducible decrease in heart rate from a baseline pulse of 65–70 to a pulse as low as 42–45 with attempted upgaze. The bradycardia would promptly resolve after return to primary gaze, and the degree of bradycardia would also diminish with sustained upgaze to around 50 beats per minute after approximately 20 seconds. The patient did not endorse syncopal symptoms during the bradycardia, but he did have 3 witnessed episodes of vomiting, while in the emergency department. The rest of the eye exam was unremarkable. It was felt initially that the bradycardia was related to inferior rectus muscle entrapment. However, a CT of the head/orbits demonstrated no prolapse of the inferior rectus but instead evidence of a small amount of soft tissue, which likely represented adventitia surrounding the inferior rectus trapped in and below the orbital floor fracture (Figure 1a, b, and c). The orbital floor bones were also non-displaced with only a linear fracture, consistent with a trapdoor fracture.
The oculocardiac reflex consists of bradycardia, nausea, and syncope and is attributed to traction on the extraocular muscles and/or compression of the eyeball. Other symptoms include gastric hypermotility and orbital pain. It is most commonly described in pediatric patients undergoing strabismus surgery.1 The reflex is mediated by connections between the ophthalmic branch of the trigeminal nerve via the ciliary ganglion and the parasympathetic nervous system through the vagus nerve.2 The association with orbital fractures is rare but repair is urgent to prevent functional damage of the extraocular muscles and adjacent soft tissue and reduce the risk of fatal cardiac arrhythmias.3 Incarceration of either the inferior rectus or soft tissue has been reported.4 We present the occurrence of the oculocardiac reflex in an adult with a non-displaced orbital floor fracture.
CASE REPORT A 33-year-old healthy male presented to the emergency department after falling from a bicycle while
Received 6 July 2013; Revised 6 October 2013; Accepted 6 January 2014; Published online 14 May 2014 Correspondence: Robert C. Kersten, MD, Department of Ophthalmology, University of California, San Francisco, 10 Koret Way, K301, San Francisco, CA 94143-0730, USA, E-mail: [email protected]
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FIGURE 1. Coronal (a), sagittal (b), and axial (c) CT sections through the right orbit demonstrating a small, non-displaced orbital floor fracture with a small prolapse of tissue of the inferior rectus sheath into the maxillary sinus without herniation of the inferior rectus itself. The ZMC fracture with displacement of the anterior maxillary wall with blood in the sinus is best seen in (c).
With repeated testing over the next 8 hours, his motility had improved and he no longer exhibited the oculocardiac reflex. Emergent fracture repair was canceled and the patient was transferred to another hospital for further management. HIPAA regulations were met in the treatment of this patient.
DISCUSSION The current dogma is that the oculocardiac reflex from orbital trapdoor fractures occurs only in children and young adults. Trapdoor fractures in adults are exceedingly rare because the elasticity required for the fractured bone to snap back into its native position and incarcerate the tissue that has prolapsed into the maxillary sinus through the defect is lacking in older populations. A parallel can be drawn with greenstick fractures that are also only seen also in pediatric patients. Compared to adult bones, pediatric bones are more flexible and less brittle because they are less !
2014 Informa Healthcare USA, Inc.
calcified secondary to a greater proportion of osteocytes than osteoblasts.5 A 2009 case report described a 37-year-old man with blunt trauma resulting in only diplopia and dysmotility with no obvious fracture or prolapsed muscle on CT, which resolved after orbital exploration and release of entrapped muscle sheath and adventitia.6 In the same issue, a case report described a 40-year-old man with blunt trauma resulting in a very large orbital floor fracture who demonstrated only pain, intermittent nausea and bradycardia, which also promptly resolved after surgical repair of the fracture.7 Our case represents a minimally displaced floor fracture resulting in a reproducible oculocardiac reflex. With repeated excursions on examination the patient’s motility improved and the oculocardiac reflex had resolved suggesting that adventitial tissue trapped in the linear fracture may have released with time. To the best of our knowledge, occurrence of the oculocardiac reflex in an adult with a non-displaced
288 S. K. Kasi et al. orbital floor fracture has not been described. Recognition of this possibility, especially in light of the fact that oftentimes the urgency of evaluation of orbital floor fractures is triaged through emergency medicines physicians who are also faced with other injuries that can cause bradycardia, will lead to better patient outcomes.
ACKNOWLEDGMENTS Financial support was received from: That Man May See, Inc. and Research to Prevent Blindness.
DECLARATION OF INTEREST The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.
REFERENCES 1. Milot JA, Jacob JL, Blanc VF, Hardy JF. The oculocardiac reflex in strabismus surgery. Can J Ophthalmol 1983; 18(7):314–317. 2. Lang S, Lanigan D, van der Wal M. Trigeminocardiac reflexes: maxillary and mandibular variants of the oculocardiac reflex. Can J Anaesth 1991;38(6):757–760. 3. Mendelblatt FI, Kirsch, RE, Lemberg L. Study comparing methods of preventing oculocardiac reflex. Am J Ophthalmol 1962;53:506–512. 4. Sires BS, Stanley RB, Levine LM. Oculocardiac reflex caused by orbital floor trapdoor fracture: an indication for urgent repair. Arch Ophthalmol 1998;116(7):955–956. 5. Glorieux FH, Pettifor JM, Juppner H. Pediatric Bone: Biology and Diseases, 2nd edition, Amsterdam, Netherlands: Elvesier. 2012; 143. 6. Kum C, McCulley TH, Yoon MK, Hwang TN. Adult orbital trapdoor fracture. Ophthal Plast Reconstr Surg 2009;25(6): 486–487. 7. Joseph J, Rosenberg C, Zoumalan C, et al. Oculocardiac reflex associated with a large orbital fracture. Ophthal Plast Reconstr Surg 2009;25(6):496–497.
Orbit
Copyright of Orbit is the property of Taylor & Francis Ltd and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
C ASE REPORT
The Oculocardiac Reflex in an Adult with a Non-Displaced Orbital Floor Fracture Sundeep K. Kasi, Ian R. Gorovoy, M. Reza Vagefi, and Robert C. Kersten Department of Ophthalmology, University of California, San Francisco, San Francisco, California, USA
ABSTRACT The current dogma is that the oculocardiac reflex from orbital trapdoor fractures occurs only in children and young adults. We present the occurrence of the oculocardiac reflex in an adult with a non-displaced orbital floor fracture. CT demonstrated the adventitia surrounding the inferior rectus trapped in and below the orbital floor fracture. The patient’s oculocardiac reflex resolved by early next morning, presumably from the tissue escaping from the orbital floor defect. Keywords: Oculocardiac reflex, trapdoor fracture
INTRODUCTION
riding intoxicated. The patient was wearing a helmet but sustained unilateral lacerations and a zygomaticomaxillary complex fracture with an orbital floor fracture. Examination of extraocular motility revealed a -2 restriction in upgaze in the affected eye, and a continuous cardiac monitor revealed a reproducible decrease in heart rate from a baseline pulse of 65–70 to a pulse as low as 42–45 with attempted upgaze. The bradycardia would promptly resolve after return to primary gaze, and the degree of bradycardia would also diminish with sustained upgaze to around 50 beats per minute after approximately 20 seconds. The patient did not endorse syncopal symptoms during the bradycardia, but he did have 3 witnessed episodes of vomiting, while in the emergency department. The rest of the eye exam was unremarkable. It was felt initially that the bradycardia was related to inferior rectus muscle entrapment. However, a CT of the head/orbits demonstrated no prolapse of the inferior rectus but instead evidence of a small amount of soft tissue, which likely represented adventitia surrounding the inferior rectus trapped in and below the orbital floor fracture (Figure 1a, b, and c). The orbital floor bones were also non-displaced with only a linear fracture, consistent with a trapdoor fracture.
The oculocardiac reflex consists of bradycardia, nausea, and syncope and is attributed to traction on the extraocular muscles and/or compression of the eyeball. Other symptoms include gastric hypermotility and orbital pain. It is most commonly described in pediatric patients undergoing strabismus surgery.1 The reflex is mediated by connections between the ophthalmic branch of the trigeminal nerve via the ciliary ganglion and the parasympathetic nervous system through the vagus nerve.2 The association with orbital fractures is rare but repair is urgent to prevent functional damage of the extraocular muscles and adjacent soft tissue and reduce the risk of fatal cardiac arrhythmias.3 Incarceration of either the inferior rectus or soft tissue has been reported.4 We present the occurrence of the oculocardiac reflex in an adult with a non-displaced orbital floor fracture.
CASE REPORT A 33-year-old healthy male presented to the emergency department after falling from a bicycle while
Received 6 July 2013; Revised 6 October 2013; Accepted 6 January 2014; Published online 14 May 2014 Correspondence: Robert C. Kersten, MD, Department of Ophthalmology, University of California, San Francisco, 10 Koret Way, K301, San Francisco, CA 94143-0730, USA, E-mail: [email protected]
286
Oculocardiac Reflex in Adult with Floor Fracture
287
FIGURE 1. Coronal (a), sagittal (b), and axial (c) CT sections through the right orbit demonstrating a small, non-displaced orbital floor fracture with a small prolapse of tissue of the inferior rectus sheath into the maxillary sinus without herniation of the inferior rectus itself. The ZMC fracture with displacement of the anterior maxillary wall with blood in the sinus is best seen in (c).
With repeated testing over the next 8 hours, his motility had improved and he no longer exhibited the oculocardiac reflex. Emergent fracture repair was canceled and the patient was transferred to another hospital for further management. HIPAA regulations were met in the treatment of this patient.
DISCUSSION The current dogma is that the oculocardiac reflex from orbital trapdoor fractures occurs only in children and young adults. Trapdoor fractures in adults are exceedingly rare because the elasticity required for the fractured bone to snap back into its native position and incarcerate the tissue that has prolapsed into the maxillary sinus through the defect is lacking in older populations. A parallel can be drawn with greenstick fractures that are also only seen also in pediatric patients. Compared to adult bones, pediatric bones are more flexible and less brittle because they are less !
2014 Informa Healthcare USA, Inc.
calcified secondary to a greater proportion of osteocytes than osteoblasts.5 A 2009 case report described a 37-year-old man with blunt trauma resulting in only diplopia and dysmotility with no obvious fracture or prolapsed muscle on CT, which resolved after orbital exploration and release of entrapped muscle sheath and adventitia.6 In the same issue, a case report described a 40-year-old man with blunt trauma resulting in a very large orbital floor fracture who demonstrated only pain, intermittent nausea and bradycardia, which also promptly resolved after surgical repair of the fracture.7 Our case represents a minimally displaced floor fracture resulting in a reproducible oculocardiac reflex. With repeated excursions on examination the patient’s motility improved and the oculocardiac reflex had resolved suggesting that adventitial tissue trapped in the linear fracture may have released with time. To the best of our knowledge, occurrence of the oculocardiac reflex in an adult with a non-displaced
288 S. K. Kasi et al. orbital floor fracture has not been described. Recognition of this possibility, especially in light of the fact that oftentimes the urgency of evaluation of orbital floor fractures is triaged through emergency medicines physicians who are also faced with other injuries that can cause bradycardia, will lead to better patient outcomes.
ACKNOWLEDGMENTS Financial support was received from: That Man May See, Inc. and Research to Prevent Blindness.
DECLARATION OF INTEREST The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.
REFERENCES 1. Milot JA, Jacob JL, Blanc VF, Hardy JF. The oculocardiac reflex in strabismus surgery. Can J Ophthalmol 1983; 18(7):314–317. 2. Lang S, Lanigan D, van der Wal M. Trigeminocardiac reflexes: maxillary and mandibular variants of the oculocardiac reflex. Can J Anaesth 1991;38(6):757–760. 3. Mendelblatt FI, Kirsch, RE, Lemberg L. Study comparing methods of preventing oculocardiac reflex. Am J Ophthalmol 1962;53:506–512. 4. Sires BS, Stanley RB, Levine LM. Oculocardiac reflex caused by orbital floor trapdoor fracture: an indication for urgent repair. Arch Ophthalmol 1998;116(7):955–956. 5. Glorieux FH, Pettifor JM, Juppner H. Pediatric Bone: Biology and Diseases, 2nd edition, Amsterdam, Netherlands: Elvesier. 2012; 143. 6. Kum C, McCulley TH, Yoon MK, Hwang TN. Adult orbital trapdoor fracture. Ophthal Plast Reconstr Surg 2009;25(6): 486–487. 7. Joseph J, Rosenberg C, Zoumalan C, et al. Oculocardiac reflex associated with a large orbital fracture. Ophthal Plast Reconstr Surg 2009;25(6):496–497.
Orbit
Copyright of Orbit is the property of Taylor & Francis Ltd and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
