PREVENTION OF OCULOCARDIAC REFLEXES DURING ANESTHESIA IN PEDIATRIC OPHTHALMIC SURGERY

ОБРАЗОВАНИЕ НАУКА И ИННОВАЦИОННЫЕ

ИДЕИ В МИРЕ

https://scientific-jl.org/obr

Выпуск журнала №

-70

Часть–

9_

июня

–

2025

19

2181-3187

PREVENTION OF OCULOCARDIAC REFLEXES DURING

ANESTHESIA IN PEDIATRIC OPHTHALMIC SURGERY

S.Sh. Joniev,

Yuldashev M.I., Shodmonov I. B.

Samarkand State Medical University, Samarkand, Uzbekistan

Abstract:

The use of general anesthesia is unquestionable in the surgical

correction of congenital ophthalmic pathologies occurring in children. Anesthetic

approaches employed in these cases are typically aimed at enhancing the quality of

surgical interventions. Unlike other branches of ophthalmic surgery, the impact of the

anesthetics used on the functional state of the visual organs is of significant importance.

Certain anesthetics (ketamine) and agents (muscle relaxants) can increase intraocular

pressure during surgery, potentially inducing unexpected adverse effects. Therefore, a

tailored approach is essential in selecting anesthetic agents and techniques for surgeries

for congenital ophthalmic pathologies in children, aiming to prevent potential

complications that may arise during and after surgery.

Components of General Anesthesia in Pediatric Ophthalmic Surgery

The active development of ophthalmic microsurgery in the last decade has

introduced new demands for improving anesthetic management in these procedures.

Anesthesia in pediatric ophthalmic surgery necessitates a specialized approach,

encompassing the provision of adequate sedation, effective preoperative and

postoperative analgesia, prevention of undesirable reflex reactions (oculocardiac,

swallowing), reduction of postoperative nausea and vomiting, and prevention of post-

anesthetic agitation [1, 2, 3]. Numerous researchers suggest that low-dose ketamine

improves the surgical process and reduces the risk of oculocardiac reflex during

surgery, while also eliminating the need for atropine administration for OCR

prophylaxis. The oculocardiac reflex was first described by Aschner and Dagnini in

1908. It is considered a peripheral type of the trigeminal cardiac reflex (TCR), similar

ОБРАЗОВАНИЕ НАУКА И ИННОВАЦИОННЫЕ

ИДЕИ В МИРЕ

https://scientific-jl.org/obr

Выпуск журнала №

-70

Часть–

9_

июня

–

2025

20

2181-3187

to the maxillomandibular cardiac reflex (MMCR). According to Shevchenko Y.L.,

stimulation of any branch of the trigeminal nerve causes the afferent signal flow to pass

from the Gasserian ganglion to the sensory nucleus of the trigeminal nerve, while

efferent pathways from the motor nucleus of the vagus nerve are interrupted [3, 4].

Some researchers believe that not only traction of the extraocular muscles or

pressure on the eyeball, but also stimulation of the periosteum can lead to cardiac

rhythm disturbances, such as bradycardia, AV block, ventricular ectopy, or asystole [9,

10]. The authors also report the risk of temporary cardiac arrest during strabismus

surgery as 1 in 2200 cases. It has been shown that even prophylactic atropine

administration does not reduce the risk of developing complications [11]. In the field

of pediatric ophthalmic anesthesia, it was long considered necessary to premedicate

with atropine and seduxen when performing anesthesia with ketamine [1, 2]. However,

this option did not fully meet all the requirements set by surgeons, as they aimed to

prevent postoperative agitation, excitement, nausea, and vomiting, as these conditions

can increase intraocular pressure and, consequently, reduce the effectiveness of the

surgical intervention [5]. This combination also creates vagotonic and bronchodilator

effects [8, 10], reduces the risk of hypoventilation when used in precise doses [9], and

initiates a rapid awakening process with single administration. Joniev S.Sh. and

colleagues (2015) discuss propofol, describing it as a drug that fully meets all the

requirements for anesthetic management in eye surgery. The authors emphasize that

propofol does not increase intraocular pressure, general anesthesia begins at a

predictable rate, is stable, and then quickly and smoothly restores consciousness and

somatic functions, while strain or vomiting are not observed. Anesthesia combined

with propofol creates the most suitable conditions for surgical correction, minimizes

the negative effects of its individual components, and maximally ensures the specific

tasks of anesthetic management for ophthalmic operations [4]. While ketamine has the

most pronounced psychotropic adverse effects, according to, anesthesia combined with

propofol affects the psyche through a sedation mechanism, making the ketamine-

propofol combination more favorable [5]. In his study on ophthalmic surgery using

ОБРАЗОВАНИЕ НАУКА И ИННОВАЦИОННЫЕ

ИДЕИ В МИРЕ

https://scientific-jl.org/obr

Выпуск журнала №

-70

Часть–

9_

июня

–

2025

21

2181-3187

ketamine, sevoflurane, propofol, midazolam, and halothane, found that hemodynamic

changes were minimal with ketamine, and the risk of developing oculocardiac reflex

was minimal [11]. Autors (2021) recommends conducting anesthesia induction using

ketamine and midazolam, and also notes that propofol and remifentanil increase the

risk of oculocardiac reflex development [10]. However, in a study by of a combination

of propofol, sufentanil, and remifentanil, no adverse complications such as

oculocardiac, oculopulmonary, and oculogastric reflexes were observed during and

after surgery [3]. The authors emphasize the negative aspects of using fentanyl, which

are manifested in respiratory depression and prolongation of postoperative recovery

time. Faster recovery of consciousness and spontaneous breathing has also been noted

in patients where regional anesthesia was used [2,3]. The author explains his

conclusions as follows: the use of general anesthesia and retrobulbar blockade in

strabismus surgery eliminates oculogastric and oculocardiac reflexes, provides

effective pain relief during and after surgery, which creates a positive psychological

environment for children and their parents [3].

Use of Inhalation Anesthesia in Pediatric Ophthalmic Surgery

Inhalation anesthetics are among the most common anesthetic agents used in

ophthalmic surgical interventions and are actively employed in pediatric practice.

These drugs are characterized by their ability to depress respiration in a dose-dependent

manner, with minimal impact on the cardiovascular system, enabling highly

controllable inhalation anesthesia. They reduce cerebral metabolism, adapting it to

ischemic conditions [3], although a characteristic is a dose-dependent increase in

intracranial pressure and a slight increase in cerebral blood flow under normal capnia

conditions [5]. One of the positive qualities of inhalation anesthesia, particularly with

sevoflurane, includes the possibility of conducting anesthesia using low and minimal

flow techniques. This provides more comfortable conditions in the breathing circuit

and offers economic benefits [4]. Emergence from anesthesia is often accompanied by

motor hyperactivity (crying, negativism towards parents and medical staff). The author

ОБРАЗОВАНИЕ НАУКА И ИННОВАЦИОННЫЕ

ИДЕИ В МИРЕ

https://scientific-jl.org/obr

Выпуск журнала №

-70

Часть–

9_

июня

–

2025

22

2181-3187

indicates that premedication with midazolam and the use of conduction anesthesia

before surgery can ensure a smoother emergence from anesthesia, reducing the

incidence of emergence agitation syndrome to 5% of cases [5]. Scientists emphasize

that using propofol after sevoflurane inhalation effectively prevents the development

of post-anesthetic agitation syndrome in 82.8% of cases; however, this prolongs the

drug-induced sedation phase. As a prophylactic measure, they recommend using

intranasal dexmedetomidine 30 minutes before the start of anesthesia, which reduces

the risk of agitation development by 90% [9]. Joniev S.Sh. (2022) in their work, note

that sevoflurane provides the best preservation of mental functions, similar to

droperidol and propofol [10]. Currently, in pediatric ophthalmic anesthesia, preference

is given to inhalation anesthetics that ensure rapid anesthesia induction and rapid

recovery, do not exhibit significant negative hemodynamic effects, and have minimal

impact on intracranial and intraocular pressure.

Pain Management Components in Pediatric Ophthalmic Surgery Anesthesia

Numerous works dedicated to anesthesia in ophthalmic interventions raise the

issue of the combined use of non-opioid analgesics. Paracetamol is the most commonly

used in pediatric practice. It possesses a significant analgesic effect, prevents the

development of central sensitization, which provides grounds to consider it a central

analgesic, and is applicable in all age groups [11]. The analgesic effect of the drug

begins within 5-10 minutes after the start of infusion and reaches its maximum within

1 hour, with the peak analgesic effect lasting for 4-6 hours. Paracetamol is actively

used as a non-opioid analgesic for postoperative pain management [11]. Intravenous

administration of paracetamol (15 mg/kg) during surgery does not cause postoperative

nausea and vomiting for 24 hours, and its effectiveness increases if the drug is used

prophylactically before or during surgical intervention compared to its administration

when pain occurs [7]. Undoubtedly, the positive role of paracetamol as an effective

analgesic in intravenous anesthesia and postoperative pain relief in ophthalmic

interventions can be emphasized [8]. Furthermore, the drug is often used as a co-

ОБРАЗОВАНИЕ НАУКА И ИННОВАЦИОННЫЕ

ИДЕИ В МИРЕ

https://scientific-jl.org/obr

Выпуск журнала №

-70

Часть–

9_

июня

–

2025

23

2181-3187

anesthetic under general anesthesia conditions, often by reducing the doses of opioid

analgesics.

Use of Combined Anesthesia in Pediatric Ophthalmic Surgery

To ensure the necessary conditions for performing ophthalmic surgeries, success

is often achieved through regional blocks, which include: retrobulbar, parabulbar,

perilimbal, epibulbar, sub-Tenon's, epibulbar-intracameral anesthesia, pterygopalatine

fossa block (PPFB), and topical (instillation) anesthesia [6,7]. For example, sub-

Tenon's anesthesia, when used in combination with NSAIDs (non-steroidal anti-

inflammatory drugs) and serotonin receptor antagonists, significantly reduces pain, and

also prevents postoperative joint pain and vomiting in the surgical treatment of eyelid

diseases in children, as it contributes to a more complete interruption of afferent

impulses associated with the ophthalmic intervention zone [7]. Although the use of

retrobulbar anesthesia has decreased, abroad this block is still used in at least 5% of

cases [8]. Researchers, based on this data, have concluded that retrobulbar hematoma

is not a fatal complication leading to loss of function. They also cited foreign

publications indicating the incidence of retrobulbar hematomas is 0.14

–

1.7% [10].

Stretching of extraocular muscles, injury to epibulbar structures, and traction on the

eyeball during surgical procedures can lead to an increase in intraocular pressure (IOP).

Therefore, the authors recommend using a combined anesthesia technique via

pterygopalatine fossa (PPF) access [7]. Given that vegetative innervation of the eye is

carried out from the ciliary and pterygopalatine ganglia, simultaneous targeting of both

ganglia is advisable [10]. Through this block, simultaneous influence on the ciliary and

pterygopalatine autonomic ganglia can be achieved. In such a block, a depot of the

drug substance is created, its action begins more gently, and the effect lasts longer.

They also indicate that this technique (access to the pterygopalatine ganglion via

zygomatic approach) is beneficial in a number of operations, including vitreous

surgeries and dacryocystorhinostomy, as well as in relieving glaucoma attacks [9].

ОБРАЗОВАНИЕ НАУКА И ИННОВАЦИОННЫЕ

ИДЕИ В МИРЕ

https://scientific-jl.org/obr

Выпуск журнала №

-70

Часть–

9_

июня

–

2025

24

2181-3187

Experimentally, they determined the accuracy of the canal's location in the sagittal

plane, determined the percentage of successful procedures, and defined the optimal

angle for needle insertion. The angle size varies greatly from 20 to 70 degrees,

averaging 45.88 degrees and is considered optimal in 75% of cases.

Performing regional blocks during ophthalmic operations always requires

determining the amount of local anesthetic (LA), as there is a constant risk that LA

may enter the orbit through the inferior orbital fissure, leading to the development of

transient diplopia (double vision) [9,10]. Factors of significant importance in ensuring

effectiveness and safety when performing regional blocks are related to the properties

of the local anesthetics used, among which are: analgesic potential, duration of the

latent period, duration of action, and toxicity [9]. The authors also note that this drug

induces deep and long-lasting anesthesia and analgesia. They emphasize that the

effectiveness of anesthesia is ensured by rapid sensory blockade due to the effect of

lidocaine and long-lasting postoperative pain relief due to the effect of ropivacaine

[13].

Conclusion:

The prevalence and structure of eye diseases are of significant

importance in providing ophthalmic care to the population. Unilateral blindness,

enucleation, and loss of the eye are major complications of eye damage. Among eye

diseases, congenital pathologies, particularly congenital strabismus, are frequently

observed and are mostly surgically corrected at an early age. However, the anatomical

and physiological condition of children, and the age-related stages of organism

development, influence the pathogenesis and clinical presentation of diseases they

experience. Therefore, all treatment methods, including anesthetic management, must

take these factors into account.

bibliography

1.

Joniev, S.Sh. (2020). Hemodynamic aspects in multicomponent

general anesthesia in endocrine surgery [Text].

MEDICUS International

Medical Scientific Journal (MEDICUS Mezhdunarodnyy Meditsinskiy

Nauchnyy Zhurnal)

,

№ 5 (35)

, 8-13. [In Russian]

ОБРАЗОВАНИЕ НАУКА И ИННОВАЦИОННЫЕ

ИДЕИ В МИРЕ

https://scientific-jl.org/obr

Выпуск журнала №

-70

Часть–

9_

июня

–

2025

25

2181-3187

2.

Joniev, S.Sh., Pardayev, Sh.K., Goyibov, S.S., & Akramov, B.R.

(2019). The use of a modified method of preoperative preparation and anesthesia

in thyroid surgery [Text]. In

Collection of Scientific Articles XIV International

Correspondence Scientific Specialized Conference

. Boston: PROBLEMS OF

SCIENCE, pp. 175-186. [In Russian]

3.

Joniev, S.Sh., & Khushvaktov, U.O. (2020). Rational hemodynamic

monitoring in anesthetic management in endocrine surgery. In

Actual Issues of

Diagnosis and Treatment of New Coronavirus Infection

, pp. 6-11. [In Russian]

4.

Joniev, S.Sh. (2013). Influence of complex preoperative preparation

on biochemical parameters of blood in patients with nodular goiter

[Text].

Doctor's News (Doktor Axborotnomasi)

,

№ 1(3)

, 71-73. [In Russian]

5.

Joniev, S.Sh., Rakhimov, A.U., & Babajanov, A.S. (2013).

Significance of biochemical parameters in preoperative preparation of patients

with nodular goiter [Text].

Science and World

,

№ 9(136)

, 136-138. [In Russian]

6.

Joniev, S.Sh., Babajanov, A.S., Khushnayev, S., & Sultanova, S.

(2018). Improving methods of preoperative preparation and anesthesia in the

perioperative period of thyroid diseases [Text].

European Research

,

№ 5

, 135-

138. [In Russian]

7.

Joniev, S.Sh., Babajanov, A.S., & Rakhimov, A.U. (2017).

Analysis of the effectiveness of preoperative preparation and anesthesia options

in the treatment of thyroid diseases [Text].

Problems of Biology and Medicine

(Problem

ы

Biologii i Meditsin

ы

)

,

№ 1

, 93-95. [In Russian]

8.

Joniev, S.Sh. (2014). Determination of the effectiveness of

preoperative preparation of patients with nodular goiter based on biochemical

parameters [Text].

Problems of Biology and Medicine (Problem

ы

Biologii i

Meditsin

ы

)

,

№ 1 (77)

, 14-18. [In Russian]

9.

Joniev, S.Sh. (2019). Modified method of preoperative preparation

and anesthesia in the surgical treatment of thyroid pathology. In

Materials of the

ОБРАЗОВАНИЕ НАУКА И ИННОВАЦИОННЫЕ

ИДЕИ В МИРЕ

https://scientific-jl.org/obr

Выпуск журнала №

-70

Часть–

9_

июня

–

2025

26

2181-3187

Interregional Scientific-Practical Forum with International Participation

"Healthy Family - Future of Russia" (Material

ы

mezhregionalnogo nauchno-

prakticheskogo foruma s mezhdunarodn

ыm uchastiyem «Zdorovye semi —

budu

щyeye Rossii»)

. Izhevsk: MedExpoForum LLC, pp. 37-40. [In Russian]

10.

Joniev, S.Sh. (2015). Preoperative preparation and anesthesia in

thyroid surgery. In

Collection of Lecture Cycles "Anesthesia in Patients with

Comorbidities and in Various Types of Surgical Interventions" (Sbornik sikla

leksii "Anesteziya u pasiyentov s soputstvuyu

щ

imi zabolevaniyami i pri

razlichn

ыx tipax xirurgicheskix vmeshatelstv»)

. Samarkand: SamGMI, pp. 72-

81. [In Russian]