Vagal manoeuvres are traditionally used in certain types of tachycardia, either to decrease their frequency and make the ECG easier to interpret or to convert them to sinus rhythm. Rare cases of eyeball rupture during the compression manoeuvre have been reported. We present an original observation on this topic. The patient provided informed consent for this case report.
Mr X, aged 73 years, retired, 180 cm tall and weighing 83 kg underwent surgery under general anaesthesia for a left colon neoplasia in a private health institution. His medical record noted an atherosclerotic aneurysm with hypercholesterolaemia. He had undergone only one prior operation, an intervention on his left eye for perforating trauma, 5 years earlier. Apart from a cholesterol-lowering drug and low-dose aspirin, no long-term drug prescriptions were reported.
The patient was brought into the operating room after receiving premedication in the form of alprazolam 1 mg. Spinal anaesthesia was performed at 11.20 h at L3-L4 with a 25-gauge needle. Bupivacaine 0.5% was injected in a volume of 3.5 ml together with morphine 0.1 mg. General anaesthesia was administered at 11.50 h using propofol 150 mg, sufentanil 10 μg, cisatracurium besylate 10 mg and ketamine 10 mg.
Anaesthesia was maintained using 80% nitrous oxide in oxygen and desflurane. At the same time, an infusion of isotonic saline 1 l was started. The patient received amoxicillin 2 g and clavulanic acid as antibiotic prophylaxis at 12.05 h. In addition, a central venous line was inserted for postoperative parenteral nutrition at 12.20 h and then checked.
At 12.35 h, prior to any surgical stimulation, the patient experienced tachycardia at 120 bpm even though his blood pressure (BP) had not changed (SBP between 110 and 100 mmHg). The anaesthetist increased the depth of anaesthesia with an injection of propofol 100 mg and sufentanil 5 μg, and increased the desflurane concentration. No electrocardiogram was performed in the operating room.
At 12.40 h, the anaesthetist decided to intervene by compressing the eyeballs. This compression almost immediately induced rupture of the right eyeball.
The patient's pulse rate gradually slowed to 100 bpm at 12.50 h, then to 95 bpm at 13.00 h. It stayed between 70 and 90 bpm thereafter. The operation was concluded without further incident.
Regarding the ophthalmological issue, after topical care was given, a scan was performed on postoperative day 3. It showed a perforation of the eyeball with rupture of the lens. Mr X underwent surgery under general anaesthesia to suture the scleral wound and perform a vitrectomy. Lens residue was found in the anterior part of the eye, under the conjunctiva and in the posterior part of the eye at the retina. He was discharged home on day 13. At postoperative review, it was found that he had experienced a permanent decrease in visual acuity to 6/10 with lower nasal visual field loss.
Vagal manoeuvres are widely used by various medical disciplines for diagnostic and/or therapeutic purposes; for example in neurology (for a potentially vagal syncope), in paediatrics (vagal hyperactivity of premature babies) and in cardiology (interpretation of electrical patterns, sinus conversion, Bouveret tachycardia).1,2 Among the manoeuvres for vagal stimulation, the oculocardiac reflex (OCR), which produces vagal bradycardia by stimulating the ocular sphere, was described in 1908 by Bernard Ashner.3 There is no targeted literature on the use of the OCR in anaesthesia.
During general anaesthesia, it is not unusual to have episodes of tachycardia that reveal various events, most often a lack of analgesia or hypovolaemia but sometimes cardiac decompensation as well. According to the anaesthetist questioned for the expert medical report, the OCR in this patient was performed for diagnostic purposes.
In this case, which we assume involves sinus tachycardia in the absence of any documented electrical patterns, the first two hypotheses were possible. The patient did undergo spinal anaesthesia, which may have led to low BP and hypovolaemia via the vasoplegic mechanism that is induced, and the fact that the patient's BP gradually dropped after the spinal puncture is an argument in favour of this.
Similarly, the episode occurred after the central venous line was inserted and 45 min after induction. This may correspond to a minor painful stimulation, but one that is sufficient to trigger tachycardia without high SBP as the effects of the analgesic are wearing off. Even if this were a common practice, no consensus exists as to its use.4,5
Obviously, other treatments of first intention are possible depending upon the origin of the tachycardia. For example, if the patient is suffering from paroxysmal supraventricular tachycardia, adenosine is recommended in the first place, or a calcium inhibitor or β-blocker (if left ventricular function is preserved), or digoxin or amiodarone.6 In our case, there was no indication for treating the tachycardia immediately because the patient's haemodynamic status was normal and analgesia was taking effect. There is no ECG in the patient's file.
The most prevalent response of this reflex is sinus bradycardia. It is not an insignificant act because an undesired abnormality in intracardiac conduction may occur involving ventricular extrasystoles, atrioventricular dissociation, bundle branch block3 and even sinus arrest (occasionally protracted) and sudden death.4 Along with the haemodynamic complications shared by vagal manoeuvres, OCR with eyeball compression presents specific complications. The traditional contraindications are contact lens use and glaucoma, which do not apply in this case, but the existence of a history of eyeball surgery presented by the patient should have prompted greater caution.
Ophthalmic involvement is often mentioned but rarely referenced in the literature and this eyeball rupture accident remains exceptional, both in terms of its frequency and of the severity of the injuries.5 Lens rupture is typically reported during closed-globe contusions in accidents caused by a major force exerted on the eyeball.7
However, this complication appears to occur more often in patients suffering from arteriopathy and this may have been an underlying vulnerability in our patient. Owing to its associated risks, the oculocardiac reflex is no longer used in clinical practice.
Acknowledgements relating to this article
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