The Journal of Emergency Medicine, Vol. -, No. -, pp.

1–2, 2016
Ó 2016 Elsevier Inc. All rights reserved.
0736-4679/$ - see front matter

http://dx.doi.org/10.1016/j.jemermed.2016.08.022

Clinical
Communications: Adult

OCULOCARDIAC REFLEX AS A RESULT OF INTRAORBITAL TRAUMA

Joel M. Fahling, MS and L. Kendall McKenzie, MD

Department of Emergency Medicine, University of Mississippi Medical Center, Jackson, Mississippi
Corresponding Address: Joel M. Fahling, MS, Department of Emergency Medicine, University of Mississippi Medical Center, 2500 North State
Street, Jackson, MS 39216.

, Abstract—Background: The oculocardiac reflex is a
decrease in heart rate caused by ocular compression or trac-
tion upon the extraocular musculature. Multiple instances
of this phenomenon have been described in anesthesia,
trauma, craniofacial, and ophthalmology literature, but
there is a sparsity of documentation in the emergency med-
icine literature. Case Report: We describe the observation
and management of the oculocardiac reflex in a 26-year-
old man with retrobulbar hematoma and intraocular
trauma caused by a self-inflicted gunshot wound. Why
Should an Emergency Physician Be Aware of This?: Prompt
recognition of the oculocardiac reflex is important for the
emergency physician given the common occurrence of
craniofacial trauma and the potentially devastating conse-
quences if not recognized and addressed. Ó 2016 Elsevier
Inc. All rights reserved.
, Keywords—Aschner phenomenon; cantholysis; facial
trauma; lateral canthotomy; oculocardiac reflex
INTRODUCTION
The oculocardiac reflex, also known as the Aschner phe-
nomenon, is classically described as a decrease in heart
rate caused by ocular compression or traction upon the
extraocular musculature. The ophthalmic division of the
trigeminal nerve serves as the afferent loop to the visceral
motor nucleus of the vagus nerve in the brain stem. The
oculocardiac reflex has been observed perhaps most
notably during ophthalmologic procedures, especially
Reprints are not available from the authors.
strabismus repair in children. The oculocardiac reflex is
felt to be part of a wider phenomenon involving all tri-
geminal afferent terminations. Dysrhythmias have been
documented during surgical manipulation of periorbital
structures after facial trauma. Ample documentation of
this phenomenon exists in ophthalmology, anesthesia,
trauma, and craniofacial surgical literature. However,
there is a paucity of oculocardiac reflex documentation
in the emergency medicine literature.
CASE REPORT
A 26-year-old white man was transferred to our emer-
gency department (ED) after reportedly sustaining a
self-inflicted gunshot wound under his right mandible
from a .22-caliber rifle. He arrived via ambulance approx-
imately 2 hours postinjury. Radiographs of the patient’s
head and neck from the outside hospital revealed multiple
radio-opaque fragments involving the right mandible, the
maxillary region, and the right orbit with associated
mandible fracture.
Upon arrival, the patient complained of having no
vision in his right eye, feeling lightheaded, and was noted
to be frequently spitting blood. He had no medical or sur-
gical history, took no medications, and had no allergies.
His initial vital signs included blood pressure of 140/
82 mm Hg, a temperature of 36.9 C, a heart rate of 72
beats/min, a respiratory rate of 16 breaths/min, and
oxygen saturation of 100% on room air.

RECEIVED: 13 April 2016; FINAL SUBMISSION RECEIVED: 29 July 2016;

ACCEPTED: 22 August 2016

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2 J. M. Fahling and L. K. McKenzie
The physical examination revealed that the patient was
alert and oriented with moderate periorbital ecchymosis,
swelling, and proptosis. Right extraocular movement was
diminished. His right pupil was fixed at 6 mm, and diffuse
subconjunctival hemorrhage was present. He had no light
perception in his right eye. There was significant right
facial swelling. Inside his mouth, an open wound was
identified between his right lower teeth and buccal mu-
cosa. He also had an open wound between the right upper
teeth and buccal mucosa. No cervical bruits or hema-
tomas were present. His chest was clear to auscultation
with equal breath sounds, and examination of his heart re-
vealed a regular rate and rhythm.
The patient was intubated for airway protection
because of the oral edema/hematoma formation and
bleeding. A computed tomography scan of the face and
head revealed a comminuted fracture of the right side
of the mandible with dislocated teeth and a fracture
involving the right orbital floor with fracture of the right
lamina papyracea. Multiple metallic densities were seen
in the soft tissues on the right side of the face, vitreous
hemorrhage was seen in the right globe, and there was
opacification of the right maxillary sinus and ethmoid
air cells. The computed tomography scan also revealed
obliteration of the optic nerve. Intravenous cefazolin
and gentamicin were given along with an intramuscular
dose of adult tetanus toxoid. While in the ED, his prop-
tosis was noted to increase and his heart rated decreased
to 43 beats/min. Of note, no changes in blood pressure
occurred during this episode of bradycardia. Emergent
lateral canthotomy and cantholysis (LCC) was performed
to offset the negative chronotropic effect of the oculocar-
diac reflex. After the procedure, the patient’s heart rate
stabilized in the 60s and no further episodes of brady-
cardia were noted during the subsequent few hours he re-
mained in the ED while awaiting disposition from the
ophthalmology and trauma services. Of note, no atropine
was given to the patient. A review of recorded inpatient
progress notes from the surgical intensive care unit and
the floor yielded no recurrence of bradycardia.
DISCUSSION
The oculocardiac reflex is a well-known phenomenon
mediated via the trigeminal nerve (afferent limb) and
the vagus nerve (efferent limb). Initiation of the afferent
limb is triggered by activation of stretch receptors in
the ocular and periorbital tissues, with impulses being
carried along the long and short ciliary nerves to the
ciliary ganglion and then to the gasserian ganglion via
the ophthalmic branch of the trigeminal nerve. This
afferent pathway terminates in the floor of the fourth
ventricle in the trigeminal sensory nucleus. Internuclear
communication occurs between the trigeminal sensory
nucleus and the visceral motor nucleus of the vagus nerve
located in the brainstem. Efferent pathways emanating
from this nucleus synapse at the sinoatrial node and cause
a negative chronotropic effect to complete the reflex arc.
The maxillary and mandibular branches of the trigeminal
nerve have been noted to mediate a similar reflex with re-
sulting bradychardia when stimulated during facial sur-
geries.
The occurrence of the oculocardiac reflex and strate-
gies for prevention and treatment have been described
in anesthesia, trauma, ophthalmology, and craniofacial
literature (1–3). Asystole and sudden death caused by
dysrhythmias have been reported in zygomatic
fractures, maxillary and mandibular trauma, and
periorbital lacerations (1–3). In our patient, stretch of
the extraocular musculature and increased intraocular
pressure initiated the afferent limb of the oculocardiac
reflex. This is demonstrated by resolution of
bradycardia after performing LCC. LCC is performed
by anesthetizing the lateral canthus and then crushing it
with hemostats to control bleeding. An approximately
1-cm cut is subsequently made laterally through the
lateral canthus. At this point, both the superior and
inferior crus of the lateral canthal ligament are exposed.
Cutting just the inferior crus (as in our patient) relieves
elevated intraocular pressure in most cases because it
releases the inferior lid from the orbital rim, allowing
the globe to move forward (4). The resulting release of
ocular pressure decreases the activation of receptors in
the oculocardiac reflex arc and offsets the negative chro-
notropic effect of the reflex.
WHY SHOULD AN EMERGENCY PHYSICIAN BE
AWARE OF THIS?
Given the common occurrence of craniofacial trauma
initially evaluated in the ED, it is important for the emer-
gency physician to be aware of and promptly recognize
the oculocardiac reflex. In patients with elevated intraoc-
ular pressure caused by retrobulbar hematoma, LCC is
often the treatment of choice.
REFERENCES
1. Kosaka M, Asamura S, Kamiishi H. Oculocardiac reflex induced by
zygomatic fracture; a case report. J Craniomaxillofac Surg 2000;28:
106–9.
2. Lang S, Lanigan DT, van der Wal M. Trigeminocardiac reflexes:
maxillary and mandibular variants of the oculocardiac reflex. Can J
Anaesth 1991;38:757–60.
3. Osborn T, Ueeck B, Ham L, et al. A case of asystole from periorbital
laceration manipulation and oculocardiac reflex in an acute trauma
setting. J Trauma 2008;65:228–30.
4. Kaiser PK, Friedman NJ, Pineda R. The Massachusetts Eye and Ear
Infirmary illustrated manual of ophthalmology. 4th edn. London: Sa-
unders; 2014:2–3.