J Plast Surg Hand Surg, 2014; 48: 170–174 © 2014 Informa Healthcare ISSN: 2000-656X print / 2000-6764 online DOI: 10.3109/2000656X.2013.836529
ORIGINAL ARTICLE
The oculocardiac reflex in aponeurotic blepharoptosis surgery Hirokazu Uda, Yasusih Sugawara, Syunji Sarukawa & Ataru Sunaga Department of Plastic Surgery, Jichi Medical University, Tochigi, Japan Abstract The purpose of this study was to investigate the correlation between the oculocardiac reflex (OCR) and blepharoptosis surgery for safe eyelid surgery. Fifty-four consecutive patients with bilateral aponeurotic blepharoptosis were enrolled in this study. Changes in electrocardiography (ECG) monitoring were recorded during surgery. Preoperative pressing on the globe and intraoperative stretching of the levator aponeurosis were also carried out and the occurrence rate of the OCR was recorded. A positive OCR was observed in 12 patients (22.2%) in the preoperative globepressing test, whereas a positive OCR was observed in 22 patients (40.7%) in the levator-stretching test. The levator-stretching test did not indicate a significant difference in the rate of heart rate decrease with respect to laterality. No correlation was observed between age and the occurrence of OCR. On the other hand, there was a significant difference in the percentage of heart rate decrease between patients with positive OCR and negative OCR as determined in the globe-pressing test (mean = 13.1% vs. 5.4%). During the practical operative manoeuvre, no bradycardia was observed in any case. This study confirmed that a rapid and strong traction of levator aponeurosis induces the OCR regardless of laterality and age. Atraumatic and gentle handling are essential to prevent OCR. The preoperative globe-pressing test may be an index of the OCR in reflex-prone patients. Intraoperative ECG monitoring will be useful for early onset detection, although positive OCR was not observed in any patient during the practical surgical manoeuvre. Key Words: Oculocardiac reflex, trigeminal-vagal arc, aponeurotic blepharoptosis, aponeurotic advancement, orbital septum, levator muscle
Introduction The oculocardiac reflex (OCR) is caused by pressing on the globe or traction of the extraocular muscle and is defined as a triad of bradycardia, nausea, and faintness. Aschner [1] and Dagnini [2] first described the reflex in 1908. The main phenomenon of the reflex is bradycardia, with a decrease in heart rate ‡10% being defined as OCR positivity [3,4]. The OCR mechanism is related to a trigeminal-vagal arc (Figure 1 and, for ophthalmologists, the OCR is a well-known and serious problem because it could cause fatal complications such as cardiac arrest and death [5]. However, in eyelid plastic surgery, few reports advocating the risk of OCR are available in the literature [6–9]. In the present study, we examined the correlation between OCR occurrence and eyelid surgery by examining aponeurotic blepharoptosis cases and determining the prevention and control measures for intraoperative OCR onset to ensure safe eyelid surgery. Materials and methods Fifty-four consecutive aponeurotic blepharoptosis patients (10 men, 44 women) participated in this study. The mean age was 54.9 years (range = 19–87 years). All patients were investigated and operated on by one surgeon (H.U.). Patients with a history of severe cardiac disease such as acute myocardial infarction were excluded. First, electrocardiography monitoring was performed in each case, and the bilateral globes were gently pressed on before surgery (globe-pressing test). The maximum heart rate changes before and after the test were recorded. In all
patients, both eyelids were operated on simultaneously. The operation was carried out with the aponeurotic advancement using the orbital septum, which had been reported by Matsuo [10]. After the administration of local anaesthesia using 1.0% lidocaine with adrenaline, the upper eyelid skin was incised and the lower portion of the orbital septum, which is continuous with the superficial expansion of the levator aponeurosis, was opened and turned downward. The orbital fat was then reflected cephaladly and the levator aponeurosis was exposed. The levatorstretching test was then carried out (Figure 2). First, the right levator aponeurosis was pulled to the most caudal sliding position. This position was held for 10 seconds and the maximum heart rate change was recorded. Second, to eliminate the influence of the fatigue phenomenon, the subject was allowed sufficient rest to permit restoration and stabilization of the heart rate; the heart rate change on the left side was then investigated. After measurement, the operation was resumed. The orbital septum was gently pulled caudally and the levator aponeurosis was properly fixed to the upper border of the tarsal plate. Any procedure of dissection around the levator aponeurosis was not performed in this surgical method so that Mueller’s muscle could be kept intact [10]. The excess skin of the eyelid was excised and the volume of the preaponeurotic fat was reduced when necessary. Finally, the skin was closed using a double eyelid crease. During surgery, electrocardiography monitoring was continuously applied and any abnormal findings were recorded, especially any decrease in heart rate that was caused by the practical operating manoeuvres. Great care was taken to avoid acute and strong traction of the tissue except in the
Correspondence: Hirokazu Uda, Jichi Medical University, Department of Plastic Surgery, 3311-1 Yakushiji, Shimotuke, Tochigi, 329-0498, Japan. Tel: +81 285 58 7371. Fax: +81 285 44 3234. E-mail: [email protected] (Received 26 April 2013; accepted 16 August 2013)
Oculocardiac reflex in blepharoptosis surgery
171
Long ciliary nerve Ciliary ganglion
Short ciliary nerve Afferent pathway
Main sensory nucleus of the trigeminal nerve
V1 V
Gasserian ganglion
Cardiac restraint branch of vagus nerve
X
Motor nucleus of vagus nerve
Efferent pathway
Figure 1. Trigeminal-vagal arc. Afferent pass way: short ciliary nerve to ciliary ganglion and long ciliary nerve ! V1 ! Gasserian ganglion ! main sensory nucleus of V. Efferent pass way: vagus nerve ! heart (V, trigeminal nerve; V1, ophthalmic division of the trigeminal nerve; X, vagus nerve).
levator-stretching test during the surgery. All of the 54 patients consented to participate in the study, and the study was approved by our institutional review board for human subjects. Based on the acquired data of heart rate change in the globe pressing and levator-stretching tests, we statistically investigated the correlation between the occurrence of OCR and age, the existence of laterality, and the correlation between the preoperative globe-pressing and intraoperative levator-stretching tests. Student’s t-test was used for statistical analysis. A difference between two values was considered statistically significant for values of p < 0.05. Results Globe-pressing test (54 patients) In this preoperative test, a positive OCR was observed in 12 patients (22.2%; three men, nine women). Patients with positive OCR in this test were classified into Group A, while those with negative OCR were classified into Group B
(Figure 3). The mean percentage decrease in heart rate was 16.0% (range = 10.3–26.9%) in Group A and 2.8% (range = 4.4–8.8%) in Group B. Levator-stretching test (54 patients, 108 levators) In this intraoperative test, a positive OCR was observed in 22 cases (40.7%; only on the right side, nine patients; only on the left side, four patients; on both sides, nine patients). Patients with positive OCR in this test were classified in Group I, while those with negative OCR were classified in Group II (Figure 4). The mean percentage decrease in heart rate was 13.9% (64 levators; range = 10.3–26.9%) in Group I and 3.4% (64 levators; range = 6.4–9.26%) in Group II. In all patients, bradycardia was immediately relieved when the levator stretching ended. The mean age in Group I was 55.3 years, whereas that in Group II was 54.7 years. There was no significant difference between the ages of the two groups and no correlation between age and the occurrence of the OCR 45
77.8%
40 35 30 F
25
35 M
20 15
22.2%
10 9 5 0
Figure 2. Levator-stretching test. The levator aponeurosis was pulled to the most caudal sliding position.
7 3 Group A
Group B
Figure 3. Globe-pressing test. Group A, patients with positive oculocardiac reflex (OCR) (12 patients; 22.2%); Group B, patients with negative OCR (42 patients; 77.8%) (F, female; M, male).
172 H. Uda et al. Table II. Comparison of percentage decrease of heart rate in levatorstretching test (54 cases, 108 levators).
35 59.3%
Number of levators
30 25
5 0
None
Group A, OCR positive in globe-pressing test; Group B, OCR negative in globepressing test.*Student t-test.
Lt. 32
15 10
Bil.
Rt. 9
4
9
Group I
Group II
Figure 4. Levator-stretching test. Group I, patients with positive oculocardiac reflex (OCR) (22 patients, 40.7%: right side only, nine patients; left side only, four patients; both sides, nine patients); Group II, patients with negative OCR (32 patients, 59.3%).
(Table I). Regarding laterality, the mean percentage decrease in heart rate was 8.5% (range = 1.3–30.5%) on the right side and 6.9% (range = 6.4–24.4%) on the left side. No significant difference was observed in the rate of decrease in heart rate with respect to laterality (Table II). Correlation between the preoperative globe-pressing and intraoperative levator-stretching tests In Group A (OCR positive in the globe-pressing test, 12 patients and 24 levators), eight patients were detected with (66.6%) positive OCR in the levator-stretching test. That rate was clearly higher than the overall rate of positive OCR in the levatorstretching test (40.7%). In addition, in Group A, the mean percentage decrease of heart rate in the levator-stretching test was 13.1%, whereas it was 6.1% in Group B (OCR negative in the glove-pressing test, 42 cases and 84 levators). The percentage decrease in heart rate in Group A was significantly larger than that in Group B in the levator-stretching test (Table II). Intraoperative electrocardiogram findings No abnormal findings such as a decrease in heart rate were seen in any of the 54 patients during the procedure, and surgery was conducted safely without any trouble in all patients. Discussion In 1978, Anderson [6] first described the occurrence of the OCR caused by manipulation of the eyelid muscles, the levator aponeurosis of the upper eyelid, and the capsuloparpebral fascia of the lower eyelid. He referred to the OCR induced by eyelid Table I. Relation of age and oculocardiac reflex in levatorstreching test (54 cases). Levator-stretching test Group I Group II
Number of cases 22 32
p*
Laterality Right side Left side Globe-pressing test Group A Group B
40.7%
20
Mean % decrease (SD)
Mean age (SD) 55.3 (16,8) 54.7 (19.7)
p* 0.91
Group I, OCR positive in levator-streching test; Group II, OCR negative in levator-streching test.*Student t-test.
54 54
8.5 (7.7) 6.9 (6.8)
0.25
24 84
13.1 (9.0) 6.1 (5.9)
< 0.001
surgery as the “blepharocardiac reflex”. Matarasso [7] reported that the OCR could also be elicited by cosmetic blepharoplasty with an incidence rate of 25% (25 of 100 patients). However, these two reports did not mention the details of the situations in which the OCR occurred. In our study, we focused only on bilateral aponeurotic blepharoptosis cases, and the examinations were also performed under the same conditions and using the same strategy to ensure confidentiality of the objective data. Therefore, compared with the data of initial reports, we believe that our data are both confidential and valuable. The influence of levator stretching Anderson [6] found that OCR occurred in five of 36 (13.8%) patients among blepharoptosis cases. Our levator-stretching test results clearly reconfirmed the occurrence of the blepharocardiac reflex caused by the stretching of the levator aponeurosis. It is well known that the OCR is often observed when extraocular muscles are pulled strongly, as in strabismus surgery [11]. The levator muscle and the superior rectus muscle are strongly related considering that these two muscles receive the same motor nerve supply, namely the upper division of the oculomotor nerve, and run together and adhere at the origin so that strong pulling of the levator muscle induces rectus muscle traction. Moreover, the nerve fibres of the afferent pathway of the OCR reach both muscles (Figure 1). Therefore, it is theoretically plausible that OCR occurs because of traction on the levator aponeurosis. In this test, the OCR was observed in 22 of 54 cases (Group I, 40.7%). The rate was much higher than that found in the report by Anderson [6]. It was thought that OCR was strongly induced by intentional rapid and strong stretching of the levator aponeurosis in our levator-stretching test [12]. Regarding the laterality in the occurrence of the OCR, there was no statistically significant difference even though some reports insist on laterality in the occurrence rate of the OCR [7,13]. The fatigue phenomenon is considered the first cause that influences laterality [4]. The OCR often occurs on the first stimulated side, followed by the vagal escape. Therefore, OCR occurrence tends to be restricted on the other side. In our study, we excluded the influence of the fatigue phenomenon by allowing participants to rest until their heart rates were restored and stabilized. Therefore, our results, which showed no laterality-based difference in the occurrence rate of the OCR, should be considered reliable. Regarding the correlation between the OCR and age, it has been generally said that younger patients are more sensitive to the reflex and that the sensitivity drops in elderly patients because of ageing [14,15].
Oculocardiac reflex in blepharoptosis surgery
173
*** * #
**
a
b
Figure 5. Aponeurotic advancement using the orbital septum. (a) The orbital septum is opened (red line) and reflected caudally. (*orbital septum, **thinned levator aponeurosis, ***levator muscle, #Mueller’s muscle). (b) Levator aponeurosis is advanced and fixed properly to the tarsus.
However, contrary to our expectation, our results did not show a significant difference in age between Group I (OCR positive) and Group II (OCR negative) (Table I). Age may not be a major influencing factor of OCR occurrence. Correlation between pressing on the globe and stretching the levator aponeurosis The correlation between the preoperative globe-pressing test and the intraoperative levator-stretching test is of interest. As mentioned above, a significant correlation in the incidence of decrease of heart rate could be seen between the two actions of pressing on the globe and stretching the levator aponeurosis. This can be considered an understandable result because the outbreak processes of the reflex are essentially the same in the two actions. This fact may suggest that the preoperative globepressing test can be used as an index of the risk of an OCR outbreak in blepharoptosis surgery and other forms of blepharoplasty surgery, which may lead to serious complications. The incidence of the OCR in practical operations for blepharoptosis In our study, there were no cases of positive OCR during the practical manoeuvre of the operation. This result was not consistent with initial reports [6–9]. Two reasons for this finding are suspected. First, maximum attention was paid to performing the operation from the beginning. Excluding the levatorstretching test, the application of rapid and strong traction to the levator aponeurosis was strictly avoided. Also, when the orbital fat was removed, sufficient local anaesthesia was injected into the fat pad and atraumatic resection was conducted. Second, the results vary depending on the operative method. In conventional aponeurotic surgery for blepharoptosis, the levator aponeurosis is generally separated from the upper border of the tarsus and dissected from Mueller’s muscle with direct traction, then the aponeurotic dehiscence or disinsertion is fixed [16]. Therefore, the risk of an OCR breakout would be high. In contrast, in the operation procedure of aponeurotic advancement using the orbital septum, which is based on the anatomical relation of which orbital septum reflects at lower border and continues to the superficial expansion of the levator aponeurosis [10], the aponeurotic dehiscence or disinsertion can
be repaired properly without any dissection around the aponeurosis (Figure 5). Therefore, we believe the risk of inducing the OCR in this procedure is small. Prevention of OCR for safe surgery In our study, we found that the OCR can be caused during both strabismus surgery and eyelid surgery. In particular, a rapid and strong traction of the levator muscle significantly induced the OCR, and our investigation showed clearly that atraumatic procedures are very useful; this should be considered by plastic surgeons and special care should be taken to avoid rapid and strong traction to the levator muscle, hard pressure on the globes, and disorderly handling. In aponeurotic blepharoptosis surgery, in particular, the choice of an atraumatic procedure may prevent the OCR. The operative procedure must be stopped until normalization of heart rate with thorough follow-up care in case of the occurrence of a reflex despite precautions. In this respect, intraoperative ECG monitoring could be useful, as noted in past reports [6–9], although positive OCR was not observed during the practical surgical manoeuvre in our study. In addition, the preoperative gentle globe-pressing test may be useful in the identification of the group at risk of OCR. 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] Aschner B. Veber einen bischen noch nicht beschrieben reflex von auge auf kreislauf und atmung. Verschwinden des radialispulses bei druck auf das auge. Wien Klin Wochenschr 1908;21:1529–30. [2] Dagnini G. Intero ad un reflesso provocato in alcuni emplegica collo stimolo della corne e colla pressione sulbulbo oculare. Bull Sci Med (Bologna) 1908;8:380–2. [3] Bosomworth PP, Ziegler CH, Jacoby J. The oculo-cardiac reflex in eye muscle surgery. Anesthesiology 1958;19:7–10. [4] Moonie GT, Rees DL, Elton D. The oculocardiac reflex during strabismus surgery. Can Anesth Soc J 1964;11:621–32. [5] Kirsch RE, Samet P, Kugel V, Axelrod S. Electrocardiographic changes during ocular surgery and their prevention by retrobulbar injection. Arch Ophthalmol 1957;58:348–56. [6] Anderson RL. The blepharocardiac reflex. Arch Ophthalmol 1978;96:1418–20.
174 H. Uda et al. [7] Matarasso A. The oculocardiac reflex in blepharoplasty surgery. Plast Reconstr Surg 1989;83:243–50. [8] Cui W. Blepharoplasty and oculocardiac reflex. Zhonghua Zheng Xing Shao Shang Wai Ke Za Zhi 1993;9:355–6, 397. [9] Rippmann V, Scholz T, Hellmann S, et al. The oculocardiac reflex in blepharoplasties. Handchir Mikrochir Plast Chir 2008; 40:267–71. [10] Matsuo K. Restration of involuntary tonic contraction of the levator muscle in patients with aponeurotic blepharoptosis or horner syndrome by aponeurotic advancement using the orbital septum. Scand J Plast Reconstr Surg Hand Surg 2003;37:81–9. [11] Dewar KM. The oculocardiac reflex. Proc R Soc Med 1976;69: 373–4.
[12] Blanc VF, Hardy JF, Milot J, Jacob JL. Oculocardiac reflex: a graphic and statistical analysis in infants and children. Can Anaesth Soc J 1983;30:360–9. [13] Alexander JP. Reflex disturbances of cardiac rhythm during ophthalmic surgery. Br J Ophthalmol 1975;59:518–24. [14] Tulppo MP, Mäkikallio TH, Seppänen T, et al. Vagal modulation of heart rate during exercise: effects of age and physical fitness. Am J Physiol 1998;274:424–9. [15] Jones PP, Shapiro LF, Keisling GA, et al. Altered autonomic support of arterial blood pressure with age in healthy men. Circulation 2001;104:2424–9. [16] Anderson RL, Dixon RS. Aponeurotic ptosis surgery. Arch Opthalmol 1979;97:1123–8.Can Anesth Soc J 1964;11:621–32.
Copyright of Journal of Plastic Surgery & Hand Surgery 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.
ORIGINAL ARTICLE
The oculocardiac reflex in aponeurotic blepharoptosis surgery Hirokazu Uda, Yasusih Sugawara, Syunji Sarukawa & Ataru Sunaga Department of Plastic Surgery, Jichi Medical University, Tochigi, Japan Abstract The purpose of this study was to investigate the correlation between the oculocardiac reflex (OCR) and blepharoptosis surgery for safe eyelid surgery. Fifty-four consecutive patients with bilateral aponeurotic blepharoptosis were enrolled in this study. Changes in electrocardiography (ECG) monitoring were recorded during surgery. Preoperative pressing on the globe and intraoperative stretching of the levator aponeurosis were also carried out and the occurrence rate of the OCR was recorded. A positive OCR was observed in 12 patients (22.2%) in the preoperative globepressing test, whereas a positive OCR was observed in 22 patients (40.7%) in the levator-stretching test. The levator-stretching test did not indicate a significant difference in the rate of heart rate decrease with respect to laterality. No correlation was observed between age and the occurrence of OCR. On the other hand, there was a significant difference in the percentage of heart rate decrease between patients with positive OCR and negative OCR as determined in the globe-pressing test (mean = 13.1% vs. 5.4%). During the practical operative manoeuvre, no bradycardia was observed in any case. This study confirmed that a rapid and strong traction of levator aponeurosis induces the OCR regardless of laterality and age. Atraumatic and gentle handling are essential to prevent OCR. The preoperative globe-pressing test may be an index of the OCR in reflex-prone patients. Intraoperative ECG monitoring will be useful for early onset detection, although positive OCR was not observed in any patient during the practical surgical manoeuvre. Key Words: Oculocardiac reflex, trigeminal-vagal arc, aponeurotic blepharoptosis, aponeurotic advancement, orbital septum, levator muscle
Introduction The oculocardiac reflex (OCR) is caused by pressing on the globe or traction of the extraocular muscle and is defined as a triad of bradycardia, nausea, and faintness. Aschner [1] and Dagnini [2] first described the reflex in 1908. The main phenomenon of the reflex is bradycardia, with a decrease in heart rate ‡10% being defined as OCR positivity [3,4]. The OCR mechanism is related to a trigeminal-vagal arc (Figure 1 and, for ophthalmologists, the OCR is a well-known and serious problem because it could cause fatal complications such as cardiac arrest and death [5]. However, in eyelid plastic surgery, few reports advocating the risk of OCR are available in the literature [6–9]. In the present study, we examined the correlation between OCR occurrence and eyelid surgery by examining aponeurotic blepharoptosis cases and determining the prevention and control measures for intraoperative OCR onset to ensure safe eyelid surgery. Materials and methods Fifty-four consecutive aponeurotic blepharoptosis patients (10 men, 44 women) participated in this study. The mean age was 54.9 years (range = 19–87 years). All patients were investigated and operated on by one surgeon (H.U.). Patients with a history of severe cardiac disease such as acute myocardial infarction were excluded. First, electrocardiography monitoring was performed in each case, and the bilateral globes were gently pressed on before surgery (globe-pressing test). The maximum heart rate changes before and after the test were recorded. In all
patients, both eyelids were operated on simultaneously. The operation was carried out with the aponeurotic advancement using the orbital septum, which had been reported by Matsuo [10]. After the administration of local anaesthesia using 1.0% lidocaine with adrenaline, the upper eyelid skin was incised and the lower portion of the orbital septum, which is continuous with the superficial expansion of the levator aponeurosis, was opened and turned downward. The orbital fat was then reflected cephaladly and the levator aponeurosis was exposed. The levatorstretching test was then carried out (Figure 2). First, the right levator aponeurosis was pulled to the most caudal sliding position. This position was held for 10 seconds and the maximum heart rate change was recorded. Second, to eliminate the influence of the fatigue phenomenon, the subject was allowed sufficient rest to permit restoration and stabilization of the heart rate; the heart rate change on the left side was then investigated. After measurement, the operation was resumed. The orbital septum was gently pulled caudally and the levator aponeurosis was properly fixed to the upper border of the tarsal plate. Any procedure of dissection around the levator aponeurosis was not performed in this surgical method so that Mueller’s muscle could be kept intact [10]. The excess skin of the eyelid was excised and the volume of the preaponeurotic fat was reduced when necessary. Finally, the skin was closed using a double eyelid crease. During surgery, electrocardiography monitoring was continuously applied and any abnormal findings were recorded, especially any decrease in heart rate that was caused by the practical operating manoeuvres. Great care was taken to avoid acute and strong traction of the tissue except in the
Correspondence: Hirokazu Uda, Jichi Medical University, Department of Plastic Surgery, 3311-1 Yakushiji, Shimotuke, Tochigi, 329-0498, Japan. Tel: +81 285 58 7371. Fax: +81 285 44 3234. E-mail: [email protected] (Received 26 April 2013; accepted 16 August 2013)
Oculocardiac reflex in blepharoptosis surgery
171
Long ciliary nerve Ciliary ganglion
Short ciliary nerve Afferent pathway
Main sensory nucleus of the trigeminal nerve
V1 V
Gasserian ganglion
Cardiac restraint branch of vagus nerve
X
Motor nucleus of vagus nerve
Efferent pathway
Figure 1. Trigeminal-vagal arc. Afferent pass way: short ciliary nerve to ciliary ganglion and long ciliary nerve ! V1 ! Gasserian ganglion ! main sensory nucleus of V. Efferent pass way: vagus nerve ! heart (V, trigeminal nerve; V1, ophthalmic division of the trigeminal nerve; X, vagus nerve).
levator-stretching test during the surgery. All of the 54 patients consented to participate in the study, and the study was approved by our institutional review board for human subjects. Based on the acquired data of heart rate change in the globe pressing and levator-stretching tests, we statistically investigated the correlation between the occurrence of OCR and age, the existence of laterality, and the correlation between the preoperative globe-pressing and intraoperative levator-stretching tests. Student’s t-test was used for statistical analysis. A difference between two values was considered statistically significant for values of p < 0.05. Results Globe-pressing test (54 patients) In this preoperative test, a positive OCR was observed in 12 patients (22.2%; three men, nine women). Patients with positive OCR in this test were classified into Group A, while those with negative OCR were classified into Group B
(Figure 3). The mean percentage decrease in heart rate was 16.0% (range = 10.3–26.9%) in Group A and 2.8% (range = 4.4–8.8%) in Group B. Levator-stretching test (54 patients, 108 levators) In this intraoperative test, a positive OCR was observed in 22 cases (40.7%; only on the right side, nine patients; only on the left side, four patients; on both sides, nine patients). Patients with positive OCR in this test were classified in Group I, while those with negative OCR were classified in Group II (Figure 4). The mean percentage decrease in heart rate was 13.9% (64 levators; range = 10.3–26.9%) in Group I and 3.4% (64 levators; range = 6.4–9.26%) in Group II. In all patients, bradycardia was immediately relieved when the levator stretching ended. The mean age in Group I was 55.3 years, whereas that in Group II was 54.7 years. There was no significant difference between the ages of the two groups and no correlation between age and the occurrence of the OCR 45
77.8%
40 35 30 F
25
35 M
20 15
22.2%
10 9 5 0
Figure 2. Levator-stretching test. The levator aponeurosis was pulled to the most caudal sliding position.
7 3 Group A
Group B
Figure 3. Globe-pressing test. Group A, patients with positive oculocardiac reflex (OCR) (12 patients; 22.2%); Group B, patients with negative OCR (42 patients; 77.8%) (F, female; M, male).
172 H. Uda et al. Table II. Comparison of percentage decrease of heart rate in levatorstretching test (54 cases, 108 levators).
35 59.3%
Number of levators
30 25
5 0
None
Group A, OCR positive in globe-pressing test; Group B, OCR negative in globepressing test.*Student t-test.
Lt. 32
15 10
Bil.
Rt. 9
4
9
Group I
Group II
Figure 4. Levator-stretching test. Group I, patients with positive oculocardiac reflex (OCR) (22 patients, 40.7%: right side only, nine patients; left side only, four patients; both sides, nine patients); Group II, patients with negative OCR (32 patients, 59.3%).
(Table I). Regarding laterality, the mean percentage decrease in heart rate was 8.5% (range = 1.3–30.5%) on the right side and 6.9% (range = 6.4–24.4%) on the left side. No significant difference was observed in the rate of decrease in heart rate with respect to laterality (Table II). Correlation between the preoperative globe-pressing and intraoperative levator-stretching tests In Group A (OCR positive in the globe-pressing test, 12 patients and 24 levators), eight patients were detected with (66.6%) positive OCR in the levator-stretching test. That rate was clearly higher than the overall rate of positive OCR in the levatorstretching test (40.7%). In addition, in Group A, the mean percentage decrease of heart rate in the levator-stretching test was 13.1%, whereas it was 6.1% in Group B (OCR negative in the glove-pressing test, 42 cases and 84 levators). The percentage decrease in heart rate in Group A was significantly larger than that in Group B in the levator-stretching test (Table II). Intraoperative electrocardiogram findings No abnormal findings such as a decrease in heart rate were seen in any of the 54 patients during the procedure, and surgery was conducted safely without any trouble in all patients. Discussion In 1978, Anderson [6] first described the occurrence of the OCR caused by manipulation of the eyelid muscles, the levator aponeurosis of the upper eyelid, and the capsuloparpebral fascia of the lower eyelid. He referred to the OCR induced by eyelid Table I. Relation of age and oculocardiac reflex in levatorstreching test (54 cases). Levator-stretching test Group I Group II
Number of cases 22 32
p*
Laterality Right side Left side Globe-pressing test Group A Group B
40.7%
20
Mean % decrease (SD)
Mean age (SD) 55.3 (16,8) 54.7 (19.7)
p* 0.91
Group I, OCR positive in levator-streching test; Group II, OCR negative in levator-streching test.*Student t-test.
54 54
8.5 (7.7) 6.9 (6.8)
0.25
24 84
13.1 (9.0) 6.1 (5.9)
< 0.001
surgery as the “blepharocardiac reflex”. Matarasso [7] reported that the OCR could also be elicited by cosmetic blepharoplasty with an incidence rate of 25% (25 of 100 patients). However, these two reports did not mention the details of the situations in which the OCR occurred. In our study, we focused only on bilateral aponeurotic blepharoptosis cases, and the examinations were also performed under the same conditions and using the same strategy to ensure confidentiality of the objective data. Therefore, compared with the data of initial reports, we believe that our data are both confidential and valuable. The influence of levator stretching Anderson [6] found that OCR occurred in five of 36 (13.8%) patients among blepharoptosis cases. Our levator-stretching test results clearly reconfirmed the occurrence of the blepharocardiac reflex caused by the stretching of the levator aponeurosis. It is well known that the OCR is often observed when extraocular muscles are pulled strongly, as in strabismus surgery [11]. The levator muscle and the superior rectus muscle are strongly related considering that these two muscles receive the same motor nerve supply, namely the upper division of the oculomotor nerve, and run together and adhere at the origin so that strong pulling of the levator muscle induces rectus muscle traction. Moreover, the nerve fibres of the afferent pathway of the OCR reach both muscles (Figure 1). Therefore, it is theoretically plausible that OCR occurs because of traction on the levator aponeurosis. In this test, the OCR was observed in 22 of 54 cases (Group I, 40.7%). The rate was much higher than that found in the report by Anderson [6]. It was thought that OCR was strongly induced by intentional rapid and strong stretching of the levator aponeurosis in our levator-stretching test [12]. Regarding the laterality in the occurrence of the OCR, there was no statistically significant difference even though some reports insist on laterality in the occurrence rate of the OCR [7,13]. The fatigue phenomenon is considered the first cause that influences laterality [4]. The OCR often occurs on the first stimulated side, followed by the vagal escape. Therefore, OCR occurrence tends to be restricted on the other side. In our study, we excluded the influence of the fatigue phenomenon by allowing participants to rest until their heart rates were restored and stabilized. Therefore, our results, which showed no laterality-based difference in the occurrence rate of the OCR, should be considered reliable. Regarding the correlation between the OCR and age, it has been generally said that younger patients are more sensitive to the reflex and that the sensitivity drops in elderly patients because of ageing [14,15].
Oculocardiac reflex in blepharoptosis surgery
173
*** * #
**
a
b
Figure 5. Aponeurotic advancement using the orbital septum. (a) The orbital septum is opened (red line) and reflected caudally. (*orbital septum, **thinned levator aponeurosis, ***levator muscle, #Mueller’s muscle). (b) Levator aponeurosis is advanced and fixed properly to the tarsus.
However, contrary to our expectation, our results did not show a significant difference in age between Group I (OCR positive) and Group II (OCR negative) (Table I). Age may not be a major influencing factor of OCR occurrence. Correlation between pressing on the globe and stretching the levator aponeurosis The correlation between the preoperative globe-pressing test and the intraoperative levator-stretching test is of interest. As mentioned above, a significant correlation in the incidence of decrease of heart rate could be seen between the two actions of pressing on the globe and stretching the levator aponeurosis. This can be considered an understandable result because the outbreak processes of the reflex are essentially the same in the two actions. This fact may suggest that the preoperative globepressing test can be used as an index of the risk of an OCR outbreak in blepharoptosis surgery and other forms of blepharoplasty surgery, which may lead to serious complications. The incidence of the OCR in practical operations for blepharoptosis In our study, there were no cases of positive OCR during the practical manoeuvre of the operation. This result was not consistent with initial reports [6–9]. Two reasons for this finding are suspected. First, maximum attention was paid to performing the operation from the beginning. Excluding the levatorstretching test, the application of rapid and strong traction to the levator aponeurosis was strictly avoided. Also, when the orbital fat was removed, sufficient local anaesthesia was injected into the fat pad and atraumatic resection was conducted. Second, the results vary depending on the operative method. In conventional aponeurotic surgery for blepharoptosis, the levator aponeurosis is generally separated from the upper border of the tarsus and dissected from Mueller’s muscle with direct traction, then the aponeurotic dehiscence or disinsertion is fixed [16]. Therefore, the risk of an OCR breakout would be high. In contrast, in the operation procedure of aponeurotic advancement using the orbital septum, which is based on the anatomical relation of which orbital septum reflects at lower border and continues to the superficial expansion of the levator aponeurosis [10], the aponeurotic dehiscence or disinsertion can
be repaired properly without any dissection around the aponeurosis (Figure 5). Therefore, we believe the risk of inducing the OCR in this procedure is small. Prevention of OCR for safe surgery In our study, we found that the OCR can be caused during both strabismus surgery and eyelid surgery. In particular, a rapid and strong traction of the levator muscle significantly induced the OCR, and our investigation showed clearly that atraumatic procedures are very useful; this should be considered by plastic surgeons and special care should be taken to avoid rapid and strong traction to the levator muscle, hard pressure on the globes, and disorderly handling. In aponeurotic blepharoptosis surgery, in particular, the choice of an atraumatic procedure may prevent the OCR. The operative procedure must be stopped until normalization of heart rate with thorough follow-up care in case of the occurrence of a reflex despite precautions. In this respect, intraoperative ECG monitoring could be useful, as noted in past reports [6–9], although positive OCR was not observed during the practical surgical manoeuvre in our study. In addition, the preoperative gentle globe-pressing test may be useful in the identification of the group at risk of OCR. 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] Aschner B. Veber einen bischen noch nicht beschrieben reflex von auge auf kreislauf und atmung. Verschwinden des radialispulses bei druck auf das auge. Wien Klin Wochenschr 1908;21:1529–30. [2] Dagnini G. Intero ad un reflesso provocato in alcuni emplegica collo stimolo della corne e colla pressione sulbulbo oculare. Bull Sci Med (Bologna) 1908;8:380–2. [3] Bosomworth PP, Ziegler CH, Jacoby J. The oculo-cardiac reflex in eye muscle surgery. Anesthesiology 1958;19:7–10. [4] Moonie GT, Rees DL, Elton D. The oculocardiac reflex during strabismus surgery. Can Anesth Soc J 1964;11:621–32. [5] Kirsch RE, Samet P, Kugel V, Axelrod S. Electrocardiographic changes during ocular surgery and their prevention by retrobulbar injection. Arch Ophthalmol 1957;58:348–56. [6] Anderson RL. The blepharocardiac reflex. Arch Ophthalmol 1978;96:1418–20.
174 H. Uda et al. [7] Matarasso A. The oculocardiac reflex in blepharoplasty surgery. Plast Reconstr Surg 1989;83:243–50. [8] Cui W. Blepharoplasty and oculocardiac reflex. Zhonghua Zheng Xing Shao Shang Wai Ke Za Zhi 1993;9:355–6, 397. [9] Rippmann V, Scholz T, Hellmann S, et al. The oculocardiac reflex in blepharoplasties. Handchir Mikrochir Plast Chir 2008; 40:267–71. [10] Matsuo K. Restration of involuntary tonic contraction of the levator muscle in patients with aponeurotic blepharoptosis or horner syndrome by aponeurotic advancement using the orbital septum. Scand J Plast Reconstr Surg Hand Surg 2003;37:81–9. [11] Dewar KM. The oculocardiac reflex. Proc R Soc Med 1976;69: 373–4.
[12] Blanc VF, Hardy JF, Milot J, Jacob JL. Oculocardiac reflex: a graphic and statistical analysis in infants and children. Can Anaesth Soc J 1983;30:360–9. [13] Alexander JP. Reflex disturbances of cardiac rhythm during ophthalmic surgery. Br J Ophthalmol 1975;59:518–24. [14] Tulppo MP, Mäkikallio TH, Seppänen T, et al. Vagal modulation of heart rate during exercise: effects of age and physical fitness. Am J Physiol 1998;274:424–9. [15] Jones PP, Shapiro LF, Keisling GA, et al. Altered autonomic support of arterial blood pressure with age in healthy men. Circulation 2001;104:2424–9. [16] Anderson RL, Dixon RS. Aponeurotic ptosis surgery. Arch Opthalmol 1979;97:1123–8.Can Anesth Soc J 1964;11:621–32.
Copyright of Journal of Plastic Surgery & Hand Surgery 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.
