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  • Neuro-Ophthalmology/Orbit, Pediatric Ophth/Strabismus

    Review of: Surgical and anesthetic influences of the oculocardiac reflex in adults and children during strabismus surgery

    Juan I, Lin M, Greenberg M, et al. Survey of Ophthalmology, in press 2023

    The oculocardiac reflex (OCR) is a common occurrence during strabismus surgery. Identifying at-risk patients and instituting an intraoperative anesthesia protocol may reduce morbidity and mortality associated with OCR.

    Study design

    The authors first present the case of a 4-year-old girl who experienced asystole during routine strabismus surgery. They then review published data on the relevant anatomy and physiology of OCR and its prevalence and risk factors, and finally propose an algorithm for prevention and management of OCR.


    In the published studies, the incidence of OCR during strabismus surgery was found to range from 14% to as high as 90%, and was more common in younger children, male patients, those taking opioids, and those with hypoxia or hypercarbia. The risk of OCR occurrence appeared to increase during medial rectus surgery and in the first muscle undergoing surgery, but appeared to decrease when inhaled anesthetics were administered (vs propofol or intravenous [IV] anesthetics). The OCR management algorithm proposed by the authors involves, among other measures, continuous EKG monitoring during and after surgery, administration of IV atropine if the patient experiences asystole, and administration of atropine or glycopyrrolate if the patient has sustained bradycardia without hemodynamic compromise.


    While this was a detailed review and summary of the available literature, additional studies are needed to determine which patients are at greatest risk of developing OCR and how it can safely be prevented.

    Clinical significance

    This is the first published review of and treatment algorithm for OCR during strabismus surgery. Due to the risk of arrhythmia, routine preoperative administration of anticholinergics is not recommended. Inhaled volatile anesthetics are preferred and total IV sedation should be used with caution. Surgeons and anesthesiologists should be aware of these risk factors to determine how best to both prevent and treat OCR.

    Financial Disclosures: Dr. Allison Umfress discloses no financial relationships.