Oculocardiac Reflex During Facial Surgery


Hsin-Shun Tseng1, Duen hern Shiau


Oculocardiac reflex (OCR) is not very well known among plastic surgeons, and it¡¦s an uncommon complication

in facial surgery. It can result in severe morbidity and mortality if OCR occurs. It is a vagally mediated bradyarrhythmia

after orbital manipulation. OCR is usually followed by stretching the muscles on the eyelids ¡V it¡¦s associated with

tension on the extraocular muscles. In 1908, Aschner first described the trigeminal afferent pathway [1], And, in 1970,

Katz and Bigger described the pathway of reflex with more detail and clarity [2].


The reflex stimulates the trigeminal nerve at the sensory nucleus, and brain stem processing, resulting in stimulation

of the dorsal efferent nucleus of vagus nerve. We present a patient who showed bradycardia when elevating a

fractured zygoma buttress. The history and mechanism of OCR is also reviewed. (Changhua J Med 2005;10:



Key words: oculocardiac reflex, trigeminal nerve, bradycardia




Periorbital surgery is a routine operation in the

plastic field under local anesthesia. If vital sign monitors

like EKG¡¦s etc are not available, so profound bradycardia

during ocular manipulation may be easily overlooked.

The fact that some individuals demonstrate profound

bradycardia with tension on several different

muscles during the course of the surgical procedure had

been proposed by Aschner in 1908 [1]. But it was only

until 1970 that Katz and Bigger described the pathway

of reflex more clearly [2]. In 1988, Arnold RW et al

have observed profound bradycardia during similar surgery

on identical twins [3]. We herein present a patient

who showed bradycardia during facial surgery.


Case Report


A healthy 25-year-old man survived a vehicle accident

and got a right zygomatic fracture with an asymmetric

outward appearance. He accepted Gillies¡¦ procedure

and the subciliary approach to reducing bone fracture

under general anesthesia. While we were elevating

the zygoma with a Dingman elevator, the young man¡¦s

pulse rate suddenly fell to 30 beats per minute and the

operation was stopped. The anesthesiologist administered

0.2 mg of Glycopyrrolate intravenously immedi



ately. We tried to proceed with the operation but the

pulse rate fell drastically when elevating the zygoma.

Finally the operation was aborted.




A wide variety of causes have been associated with

profound bradycardia via vagotonic maneuvers including

the diving response, the Valsalva maneuver, the carotid

sinus massage and the oculocardiac reflex. The

common efferent pathway for these maneuvers originates

in the dorsal efferent nucleus of the vagus nerve,

resulting in an increase in cardiac parasympathetic impulses.



The Oculocardiac Reflex (OCR) mechanism has

been shown to be trigemino-vagal, and the pathway was

described by Katz and Bigger in 1970 [1]. The reflex

was elicited by proprioceptive and pain receptors whose

neurons terminate in the rostral mesencephalic trigeminal

nucleus [4]. The efferent pathway from the eyeball

winds through the long and short ciliary nerves to ciliary

ganglion, the Gasserian gangion and then runs to

trigeminal nucleus in the floor of the fourth ventricle.

Some short internuncial fibers in the reticular formation

connect the trigeminal nucleus to the motor nucleus of

the vagus nerve [5]. The depression impulse from the

vagus nerve end in the heart and involved its rhythm


1Division of General Surgery, 2Division of Plastic and Reconstructive Surgery, Department of Surgery, Changhua

Christian Hospital, Changhua, Taiwan

Received: May 4, 2005 Revised: June 10, 2005 Accepted: September 23, 2005

Reprint requests and correspondence to: Dr. Hsin-Shun Tseng, Division of General Surgery, Department of Surgery,

Changhua Christian Hospital, 135 Nanhsiao Street, Changhua 500, Taiwan.

E-mail: 91694@cch.org.tw.




Changhua J Med 2005£»Vol 10£»No 3



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