PURPOSE: To report the clinical manifestations and computed tomography (CT) findings of patients with a trapdoor type medial orbital wall blowout fracture.METHODS: From March 2009 to October 2016, the clinical records and computed tomography findings of patients who underwent surgical treatment for a trapdoor type medial orbital wall blowout fracture were retrospectively analyzed.RESULTS: A total of eight patients (six males and two females) were enrolled with a combined mean age of 14.4 years. Clinical manifestations were eyeball movement limitation (abduction and adduction) and ocular motility pain (eight patients, 100%), diplopia (seven patients, 87.5%), and nausea and vomiting (four patients, 50%). On CT, the distance from the orbital apex to the fracture site was an average of 22.0 mm and occurred in the middle position of the entire wall. Two patients had missed rectus completely dislocated into the ethmoid sinus through the fracture gap and six patients had definite involvement in the fracture gap and edema of the medial rectus muscle. The medial rectus muscle cross-sectional area was 47.7 mm² which was edematous compared to the contralateral eye (40.1 mm²). Orbital wall reconstruction was performed an average of 4.1 days after the injury. In all patients with oculocardiac reflex-like nausea and vomiting immediately improved after surgery. Six out of eight patients who had eyeball movement limitations (abduction and adduction) preoperatively showed adduction limitation after surgery. The eyeball movement limitation and diplopia disappeared 11.7 days and 46.7 days after surgery, respectively.CONCLUSIONS: Patients with trapdoor type medial wall blowout fracture showed characteristic computed tomographic findings and clinical manifestations such as eyeball movement limitation, ocular motility pain, diplopia, and oculocardiac reflex. An understanding of clinical findings and quick surgical treatment are therefore required. The type of eyeball movement limitation was abduction and adduction limitation preoperatively and adduction limitation postoperatively.
Diplopia ; Edema ; Ethmoid Sinus ; Humans ; Male ; Nausea ; Orbit ; Reflex, Oculocardiac ; Retrospective Studies ; Vomiting

BACKGROUND: Among the various signs and symptoms of orbital fractures, certain clinical findings warrant immediate surgical exploration, including gaze restriction, computed tomographic (CT) evidence of entrapment, and prolonged oculocardiac reflex. Despite proper surgical reconstruction, prolonged complications such as diplopia and gaze restriction can occur. This article evaluated the prognostic factors associated with prolonged complications of orbital fractures with muscle incarceration. METHODS: The medical records of 37 patients (37 orbits) with an orbital fracture with muscle incarceration from January 2001 to January 2015 were reviewed. The presence of Incarcerated muscle was confirmed via CT, as well as by intraoperative findings. Various factors potentially contributing to complications lasting for over 1 year after the injury were categorized and analyzed, including age, cause of injury, injury-to-operation time, operative time, fracture type, nausea, vomiting and other concomitant symptoms and injuries. RESULTS: All patients who presented with extraocular muscle limitations, positive CT findings, and/or a positive forced duction test underwent surgery. Of the 37 patients, 9 (24%) exhibited lasting complications, such as diplopia and gaze restriction. The mean follow-up period was 18.4 months (range, 1–108 months), while that of patients who experienced prolonged complications was 30.1 months (range, 13–36 months). Two factors were significantly associated with prolonged complications: injury-to-operation time and nausea/vomiting. Loss of vision, worsening of motility, and implant complication did not occur. CONCLUSIONS: Patients who present with gaze limitations, with or without other signs of a blow-out fracture, require a thorough evaluation and emergent surgery. A better prognosis is expected with a shorter injury-to-operation time and lack of nausea and vomiting at the initial presentation.
Diplopia ; Follow-Up Studies ; Humans ; Medical Records ; Nausea ; Operative Time ; Orbit* ; Orbital Fractures* ; Prognosis ; Reflex, Oculocardiac ; Vomiting

BACKGROUND: Among the various signs and symptoms of orbital fractures, certain clinical findings warrant immediate surgical exploration, including gaze restriction, computed tomographic (CT) evidence of entrapment, and prolonged oculocardiac reflex. Despite proper surgical reconstruction, prolonged complications such as diplopia and gaze restriction can occur. This article evaluated the prognostic factors associated with prolonged complications of orbital fractures with muscle incarceration. METHODS: The medical records of 37 patients (37 orbits) with an orbital fracture with muscle incarceration from January 2001 to January 2015 were reviewed. The presence of Incarcerated muscle was confirmed via CT, as well as by intraoperative findings. Various factors potentially contributing to complications lasting for over 1 year after the injury were categorized and analyzed, including age, cause of injury, injury-to-operation time, operative time, fracture type, nausea, vomiting and other concomitant symptoms and injuries. RESULTS: All patients who presented with extraocular muscle limitations, positive CT findings, and/or a positive forced duction test underwent surgery. Of the 37 patients, 9 (24%) exhibited lasting complications, such as diplopia and gaze restriction. The mean follow-up period was 18.4 months (range, 1–108 months), while that of patients who experienced prolonged complications was 30.1 months (range, 13–36 months). Two factors were significantly associated with prolonged complications: injury-to-operation time and nausea/vomiting. Loss of vision, worsening of motility, and implant complication did not occur. CONCLUSIONS: Patients who present with gaze limitations, with or without other signs of a blow-out fracture, require a thorough evaluation and emergent surgery. A better prognosis is expected with a shorter injury-to-operation time and lack of nausea and vomiting at the initial presentation.
Diplopia ; Follow-Up Studies ; Humans ; Medical Records ; Nausea ; Operative Time ; Orbit* ; Orbital Fractures* ; Prognosis ; Reflex, Oculocardiac ; Vomiting

BACKGROUND: The oculocardiac reflex (OCR) can be elicited during manipulation of the orbital structures in the strabismus correction surgery. A sinus bradycardia is the most common manifestation of OCR; and cardiac dysrhythmia and asystole may also occur. Various efforts to reduce OCR have been attempted, but without coherent outcome results. METHODS: Sixty one children, undergoing elective strabismus surgery, were randomly allocated into 2 groups: Group K received ketamine 1.0 mg/kg; and Group M received midazolam 0.15 mg/kg for induction of anesthesia. Anesthesia was maintained with 1-1.3 MAC of sevoflurane with 50% N2O in O2. Heart rate and blood pressure were measured 30 seconds before extraocular muscle (EOM) traction and immediately after traction. The OCR was defined as a decrease in heart rate more than 20% of the baseline heart rate, following manipulating EOM. Postoperative nausea and vomiting (PONV) and emergence agitation (EA) were assessed in postanesthetic care unit (PACU). RESULTS: Blood pressure before tightening EOM in Group K was higher than that in Group M (P < 0.05). However Delta HR (2.7 +/- 15% vs. - 0.9 +/- 16%) and incidence of OCR (10.0% vs. 19.4%) after traction an EOM were not different between the two groups. The occurrence of PONV (6.7 vs. 9.7%) and EA (30.0% vs. 22.6%) were similar. CONCLUSIONS: Ketamine does not reduce the incidence of OCR compared with midazolam in pediatric strabismus surgery. In addition, ketamine does not increase the incidence of PONV and EA. In conclusion, it is reliable to use ketamine in pediatric strabismus surgery.
Anesthesia ; Anesthesia, General ; Arrhythmias, Cardiac ; Blood Pressure ; Bradycardia ; Child ; Dihydroergotamine ; Heart Arrest ; Heart Rate ; Humans ; Incidence ; Ketamine ; Methyl Ethers ; Midazolam ; Muscles ; Orbit ; Postoperative Nausea and Vomiting ; Reflex, Oculocardiac ; Strabismus ; Traction

PURPOSE: 'White-eye blowout' fracture is often occur in young patients and defined as blow out fracture with little or no clinical sign of soft tissue trauma such as edema, ecchymosis, but with marked motility restrictions in vertical gaze. In this conditions, immediate operation is essential. We reported the clinical investigation study of these cases about clinical symptoms and radiologic findings and introduce our experiences about immediate operations in 'white-eye blowout' fractures. METHODS: From January 2008 to December 2009, nine pediatric patients who were diagnosed as pure white-eye blowout fractures were involved this study. Patients with other facial bone fractures or with poor general medical condition were excluded. In all cases, we performed immediate operation within 48 hours. RESULTS: All patients had diplopia, vertical gaze restriction or systemic symptoms. Six patients had nausea, vomiting and syncope caused by oculocardiac reflex. In all patients, preoperative symptoms were improved after immediate operation. There were no postoperative complications such as infection, hematoma or wound dehiscence. CONCLUSION: When we meet the young patients with history of periocular trauma, with little or no soft tissue trauma signs, but with marked vertical gaze restriction or general symptoms caused by oculocardiac reflex, we should immediately examine by facial bone computed tomography and refer the patient to ophthalmologist for ophthalmic evaluations. If patient is diagnosed as orbital floor fracture with entrapped muscle or soft tissue, the earlier surgical reduction get better clinical outcomes.
Diplopia ; Ecchymosis ; Edema ; Facial Bones ; Floors and Floorcoverings ; Hematoma ; Humans ; Muscles ; Nausea ; Orbit ; Postoperative Complications ; Reflex, Oculocardiac ; Syncope ; Vomiting

Ophthalmic surgery presents challenges for the anesthesiologists, including control of intraocular pressure, prevention and management of the oculocardiac reflex. In addition to understanding ocular anatomy and physiology, the anesthesiologists must have possess technical expertise and knowledge of ophthalmic drug's systemic effects. Patients undergoing ophthalmic surgery have extremes of age and several medical diseases, like as hypertension, diabetes mellitus, coronary heart disease, chronic renal failure, and chronic obstructive lung disease. Anesthesiologist should be knowledgeable about the content as stated above to perform safe and desirable anesthesia for ophthalmic surgery.
Anesthesia ; Coronary Disease ; Diabetes Mellitus ; Humans ; Hypertension ; Intraocular Pressure ; Kidney Failure, Chronic ; Professional Competence ; Pulmonary Disease, Chronic Obstructive ; Reflex, Oculocardiac

PURPOSE: To evaluate the incidence and examine the development of oculocardiac reflex during ptosis operation under local anesthesia. METHODS: Twenty-eight patients (52 eyes) who underwent ptosis operation under local anesthesia participated in this prospective study. We examined the change of heart rate. We also investigated the incidence of oculocardiac reflex and analyzed factors associated with it. RESULTS: The mean preoperative heart rate was 76.06+/-11.24 beats/min. During local anesthetic injection, skin incision, traction of the central fat pad, traction of the medial fat pad, traction of the levator palpebrae muscle, the mean heart rates were 74.81+/-12.64 beats/min, 74.73+/-12.20 beats/min, 73.63+/-11.73 beats/min, 73.35+/-12.24 beats/min, 71.44+/-11.93 beats/min respectively. Hence, the mean heart rate decreased during each successive part of the operation. The oculocardiac reflex was positive in 24 (46.2%) of 52 eyes. There was no significant difference between the incidence of oculocardiac reflex in males and females. The incidence of oculocardiac reflex was highest during traction of the levator palpebrae muscle. CONCLUSIONS: During ptosis operation under local anesthesia, oculocardiac reflex can occur. Gentle manipulation of surgical tissues and cardiac monitoring is needed to prevent side effects from oculocardiac reflex.
Adipose Tissue ; Anesthesia, Local ; Blepharoplasty ; Eye ; Female ; Heart Rate ; Humans ; Incidence ; Male ; Muscles ; Prospective Studies ; Reflex, Oculocardiac ; Skin ; Traction

The oculocardiac reflex is provoked by pressure applied to the globe of the eye or traction on the surrounding structures. It has been known that children and adults undergo eye muscle surgery under general anesthesia are most susceptible. When it occurs the most common manifestation is sinus bradycardia and other arrhythmia including atrioventricular block, ventricular premature beat and cardiac arrest. Endoscopic sinus surgery has been used popularly for treatment of chronic paranasal sinusitis. However endoscopic sinus surgery can be difficult for narrow visual field and anatomical variations. Oculocardiac reflex during endoscopic sinus surgery is rare case but potentially it can be life threatening event. The authors report the case of oculocardiac reflex during endoscopic sinus surgery with a review of literature.
Adult ; Anesthesia ; Anesthesia, General ; Arrhythmias, Cardiac ; Atrioventricular Block ; Bradycardia ; Cardiac Complexes, Premature ; Child ; Eye ; Heart Arrest ; Humans ; Muscles ; Reflex ; Reflex, Oculocardiac ; Sinusitis ; Traction ; Visual Fields

Endoscopic sinus surgery has been used popularly for treatment of chronic paranasal sinusitis. Sometimes endoscopic sinus surgery is complicated by narrow visual field and anatomical variations. Oculocardiac reflex is developed by surgical or nonsurgical procedures to the eyeball. It occurs because of decreasing of heart rate and other arrhythmia including atrioventricular block, ventricular premature beat and cardiac arrest. Oculocardiac reflex during endoscopic sinus surgery is unusual and it is potentially a life threatening complication. The authors report the first case of oculocardiac reflex experienced during endoscopic sinus surgery in Korea with a review of the literature.
Arrhythmias, Cardiac ; Atrioventricular Block ; Cardiac Complexes, Premature ; Heart Arrest ; Heart Rate ; Korea ; Reflex, Oculocardiac ; Sinusitis ; Visual Fields

BACKGROUND: This study evaluated the hemodynamic response and recovery profile of remifentanil-N2O anesthesia, compared with sevoflurane-N2O anesthesia in pediatric strabismus surgery. METHODS: Fifty-seven healthy children aged 1-9 years undergoing strabismus surgery were randomly assigned to two groups, group R or group S. None of the children was premedicated with an anticholinergic agent. Anesthesia was induced with intravenous ketamine 1.0 mg/kg. A laryngeal mask airway (LMA) was placed with rocuronium 0.4 mg/kg. Anesthesia was maintained with sevoflurane 2.0-3.0 vol% and N2O 66% in group S, and with remifentanil 0.75 microgram/kg over 1 min followed by remifentanil 0.5 microgram/kg/min and N2O 66% in group R. At the end of surgery, the anesthetic agents were discontinued, and the early emergence, recovery, and side effects were assessed. RESULTS: During anesthesia, the heart rate and blood pressure were lower in group R (P < 0.05). The incidence of an oculocardiac reflex was similar in both groups. The times to spontaneous ventilation and the removal of LMA were similar in the two groups. The times from eye opening to command, orientation and full recovery were faster in group R (P < 0.05). The incidence of postoperative nausea and vomiting was similar in both groups. The incidence of coughing was lower in group R (P < 0.05). Mild pruritus developed in 17.2% of patients in group R. CONCLUSIONS: In pediatric strabismus surgery, remifentanil provided similar hemodynamic stability, and an earlier and smoother recovery, compared with sevoflurane anesthesia.
Anesthesia* ; Anesthetics ; Blood Pressure ; Child ; Cough ; Heart Rate ; Hemodynamics* ; Humans ; Incidence ; Ketamine ; Laryngeal Masks ; Postoperative Nausea and Vomiting ; Pruritus ; Reflex, Oculocardiac ; Strabismus* ; Ventilation