The oculocardiac reflex in blepharoplasty surgery

The oculocardiac reflex (OCR), a previously undescribed phenomenon in aesthetic blepharoplasty surgery, involves intraoperative bradycardia exceeding 10 percent of the preoperative heart rate or any dysrhythmia during ocular manipulation. It is a trigeminal-vagal-mediated reflex arc. The oculocardiac reflex was noted to occur in 25 of 100 patients (25 percent) undergoing blepharoplasty. A data sheet designed and distributed for use in the operating room identified a reflex-prone patient (RPP) as a young, anxious female, with a cardiac history, operated on under light anesthesia with aggressive fat pad resection. The oculocardiac reflex was more likely to occur in a reflex-prone patient during traction on the medial fat pads and in the left eye. Despite anticipating the fatigue phenomenon in those patients who exhibited a profound bradycardia (35 to 40 beats per minute), it was necessary to release traction in order to permit the heart rate to return to normal. Awareness and treatment of this potentially life-threatening oculocardiac reflex are necessary. Careful patient surveillance and monitoring are mandatory.     

Ocular motility in craniofacial reconstruction

Of 140 children undergoing major craniofacial reconstruction at The Children's Hospital of Philadelphia and examined preoperatively and postoperatively by the Ophthalmology Division, only 10 had surgically induced alteration in primary position horizontal alignment, 4 greater than 10 prism diopters. Only 2 patients had a new strabismus in primary position created by craniofacial surgery, both cranial nerve palsies. We believe early strabismus surgery is advantageous for attainment of binocularity and ease of tissue manipulation. Of 44 patients with craniofacial dysostosis (Crouzon), 20 had preoperative strabismus, and 12 required extraocular muscle surgery. Five of 12 had anomalies of extraocular muscle number and structure, usually involving the superior rectus muscle.     

Muscle Union Procedure in Patients with Paralytic Strabismus

To present the surgical outcomes of a muscle union procedure in patients with paralytic strabismus, this retrospective study included 27 patients with paralytic strabismus who underwent a muscle union procedure. In this procedure, the two vertical rectus muscles are united with the paralytic horizontal muscle without splitting the muscles. Postoperative ocular deviations, complications, surgical success rates, and reoperation rates were obtained by examining the medical records of the patients. Seventeen patients had a sixth cranial nerve palsy, seven patients had a third cranial nerve palsy, and three patients had a medial rectus muscle palsy after endoscopic sinus surgery. The mean preoperative angle of horizontal deviation in the primary position was 56 ± 21 prism diopters. The mean follow-up period was 12 ± 9 months. The mean final postoperative ocular deviation was 8 ± 13 prism diopters. The success rate was 74%, and the reoperation rate was 0%. No significant complications, including anterior ischemia, occurred in any of the patients. One patient exhibited an increase in intraocular pressure in the immediate postoperative period, but this resolved spontaneously within 1 week. Our muscle union procedure was effective in patients with paralytic strabismus, especially in patients with a large angle of deviation. This muscle union procedure is potentially a suitable option for muscle transposition in patients with paralytic strabismus who have large-angle deviation or a significant residual angle after conventional surgery.     

Change in plasma amino acid concentrations during breath-hold diving at high altitude

We studied the plasma concentration of various amino acids in 6 Italian sport divers in Italy and at approximately 4,500 m altitude in Peru; 6 Peruvian inhabitants were examined for comparison. We attempted to create a situation of pronounced hypoxia in muscles by breath-hold diving at altitude. The diving reflex diverts blood away from muscles while diving increases central oxygen tension and prevents loss of consciousness. Differences in certain amino acids, probably related to diet, were noted between Italy and Peru. Increases in concentration of plasma alanine and some branched-chain amino acids occurred after breath-hold diving. These changes were similar to those seen after prolonged hard exercise, even though physical work was low. Hypoxia in muscles, common during hard work and during breath-hold diving at altitude, might thus be the stimulus for amino acid release from working muscles.     

Acquired strabismus following cosmetic blepharoplasty

The purpose of this study was to report on 12 patients with acquired strabismus following cosmetic blepharoplasty and to identify patterns of strabismus related to the surgical procedure. Clinical ophthalmologic examinations were performed to specifically clarify the type of strabismus. Operative reports of the blepharoplasty procedures were reviewed. Patients were followed for a minimum of 3 months after the blepharoplasty procedure before surgical intervention was considered. Operative findings at corrective strabismus surgery were noted and an attempt was made to correlate these findings with the clinical ophthalmologic examination and the blepharoplasty surgical procedure. Twelve cases of persistent vertical strabismus occurred following blepharoplasty procedures. Five patients had clinical findings consistent with the diagnosis of acquired superior oblique palsy; one of these five patients also showed signs of an acquired Brown syndrome. Seven patients developed an incomitant vertical deviation consistent with an inferior rectus paresis. Strabismus occurred after conventional lower lid, upper lid, and four-lid blepharoplasty with or without laser blepharoplasty. Acquired strabismus accompanied by persistent diplopia may occur as a complication of cosmetic blepharoplasty. Extraocular muscle damage resulting in either superior oblique muscle palsy or inferior rectus paresis was noted in these patients. In some cases, patients with inferior rectus paresis also showed mechanical restriction to upward rotation of the globe.     

Maxillomandibulocardiac reflex in a dog

Background

The trigeminocardiac reflex (TCR) is a brainstem reflex that may be observed in anaesthesia during surgical procedures stimulating the intracranial or peripheral portion of the trigeminal nerve. The peripheral TCR is divided into the oculocardiac reflex and the maxillomandibulocardiac reflex based on the affected sensory branches of the trigeminal nerve. In veterinary medicine the oculocardiac reflex has been described, however the maxillomandibulocardiac reflex has never been reported.

Case presentation

A 5-year-old male Epagneul Breton was presented for surgical management of an upper lip mass. During surgery, a sudden severe bradycardia and a decrease in systemic arterial blood pressure developed. The occurrence of a maxillomandibulocardiac reflex was suspected on the basis of the temporary link between surgical stimulation and haemodynamic changes. Three doses of atropine were given before starting a dopamine infusion due to lack of response. The dopamine infusion normalized heart rhythm and blood pressure. The dog recovered uneventfully and he was discharged 24 h later with a sinus rhythm and no sign of recurrence of arrhythmias.

Conclusion

The TCR is a rare but potentially life-threatening complication of procedures involving the sensory areas innervated by the three branches of the trigeminal nerve and it may cause bradycardia with hypotension. The use of a β1-adrenergic receptor agonist such as dopamine may be indicated in cases of a refractory response to the conventional treatment with atropine.

     

Morphology of the mammalian vestibulo-ocular reflex: the spatial arrangement of the human fetal semicircular canals and extraocular muscles

The vestibulo-ocular reflex is the system of compensatory ocular movements in response to stimulation of the kinetic labyrinth seen in all vertebrates. It allows maintenance of a stable gaze even when the head is moving. Perhaps the simplest influence on the VOR is the spatial orientation of the planes of the semicircular canals relative to the extraocular muscles. It is hypothesized that the extraocular muscles are in parallel alignment with their corresponding semicircular canals in order to reduce the amount of neural processing needed and hence keep reflex times to a minimum. However, despite its obvious importance, little is known of this spatial arrangement. Moreover, nothing is known about any ontogenetic changes in the relative orientations of the extraocular muscles and semicircular canals. The morphologies of fetal and adult specimens of Homo sapiens were examined using magnetic resonance (MR) images. Three-dimensional co-ordinate data were taken from the images and used to calculate vector equations of the extraocular muscles and planes of best fit for the semicircular canals. The relative orientations of the muscles and canals were then calculated from the vectors and planes. It was shown that there are significant correlations between both the anterior and lateral semicircular canals and their corresponding extraocular muscles during ontogeny. In the case of the lateral canal with the medial rectus, the lateral canal with the lateral rectus, and the anterior canal with the inferior oblique, the trend is towards, though never reaching, alignment, whereas the anterior canal and the superior rectus muscle move out of alignment as age increases. Furthermore, it was noted that none of the six muscle-canal pairs is in perfect alignment, either during ontogeny or in adulthood. It was also shown that the three semicircular canals are not precisely orthogonal, but that the anterior and posterior canals form an angle of about 85 degrees , while the anterior and lateral canals diverge by approximately 100 degrees . Overall, it was shown that there is significant reorientation of the extraocular muscles and semicircular canals during ontogeny, but that, in most cases, there is little realignment beyond the fetal period.     

The properties of the extraocular muscles of the frog. I. Mechanical properties of the isolated superior oblique and superior rectus muscles.

The mechanical properties of two extraocular muscles (superior oblique and superior rectus muscles) of the frog were studied and compared with those of a frog's skeletal muscle (iliofibularis muscle) which contains the same types of muscle fibres as the oculorotatory muscles. The extraocular muscles are very fast twitching muscles. They exhibit a smaller contraction time, a smaller half-relaxation time, a higher fusion frequency, and a lower twitch-tetanus ratio than the skeletal muscles. The maximum isometric tetanic tension produced per unit cross-sectional area is lower in the extraocular muscles than in skeletal muscles. However, the extraocular muscles show a higher fatigue resistance than the skeletal muscles. With respect to the dynamic properties there are some differences between the various oculorotatory muscles of the frog. The superior rectus muscle exhibits a faster time-course of the contraction, a higher fusion frequency, and a higher fatigability than the superior oblique muscle. An increase of the extracellular K+-concentration evokes sustained contractures not only in the extraocular muscles but also in the iliofibularis muscle; between these muscles there are no striking differences in the mechanical threshold of the whole muscle preparation. The mechanical threshold depends on the Ca++-concentration of the bathing solution and it is found in a range between 12.5 and 17.5 mM K+ in a normal Ringer solution containing 1.8 mM Ca++. The static-mechanical properties of the extraocular muscles of the frog and the dependence of the active developed tension on the muscle extension are very similar to those which are known to exist in the extraocular muscles of other vertebrates. In tetanic activated frog's oculorotatory muscles a linear relationship exists between length and tension. A variation of the stimulation frequency does not change the slope of this curve but causes parallel shifts of the curve. The peculiar properties of the extraocular muscles of the frog are discussed with respect to the muscle fibre types in these muscles and to the diameter of the muscle fibres.     

斜视矫正手术对双眼视觉功能影响的临床研究

目的:探讨斜视矫正手术对双眼视觉功能的影响。方法:将收集的85例斜视患者根据斜视类型分组,共同性外斜视组51例,占60.00%;共同性内斜视组16例,占18.82%。麻痹性斜视组13例,占15.30%,特殊类型斜视组5例,占5.88%。同视机检查并记录患者术前及术后双眼视功能情况。结果:外斜视手术方式多选用单眼外直肌后徙+内直肌缩短术,内斜视手术主要选用双眼内直肌后徙术,上斜肌麻痹多行患眼下斜肌适量后徙或转位术,麻痹性内斜和外斜手术方式为患眼水平肌后徙联合缩短术,外斜V征手术方式为双眼外直肌后徙联合上移半个肌腱,伴有斜肌亢进者需同时行斜肌减弱术,固定性内斜1例手术方式为患眼内直肌断键+直肌联结术。85例患者术后正位73例(85.89%),双眼视觉功能手术前后比较有显著性差异(P0.05),术后较术前可见明显改善。结论:斜视矫正手术可促进双眼视觉功能的恢复,尤其是对于学龄前儿童效果更明显。     

Acute Spinal-Cord Lesions from Diving—Epidemiological and Clinical Features

The aquatic activity that produces the greatest number of spinal-cord lesions is diving. Persons in the general population at greatest risk are males aged 15 to 19 years. Of the cases identified, 45 percent resulted from diving into a river or stream, 27 percent into swimming pools and 28 percent into lakes, reservoirs or the ocean. Distribution by age differed for the major groups of bodies of water. The incidence of spinal-cord injuries was related to season (spring-summer) and day of the week (weekends). The incidence of injuries was highest in those county areas with the least opportunity for exposure to swimming pools or rivers. Of the injured persons, 60 percent were tetraplegic at hospital admission. The most frequent radiologic finding was wedge fracture. This finding, in the absence of objective evidence that most divers struck the bottom of the water reservoir or a hard object, suggests that hyperventroflexion was the mechanism responsible for injury in most of the cases. Physicians and others should be aware of strategy options for preventing or reducing such injuries.     

Injection of methylprednisolone directly into the extraocular muscles of eyes with disturbed motility secondary to Graves' ophthalmopathy. Preliminary report

Aim of the study was to estimate the efficacy of 6-alpha-methylprednisolone injection into involved extraocular muscles in eyes with motility disturbances caused by endocrine ophthalmopathy. MATERIAL AND METHODS: For further evaluation we qualified 4 patients, 1 female and 3 males, aged: 60, 43, 42 and 64 years, with clinical activity score equal 4, with duration of Graves' ophthalmopathy of mean 2.1 years (0.16 - 5.5). Included were patients with movement restrictions in vertical plane and echographic findings of isolated extraocular muscle involvement (inferior rectus). Each of the patients received 20 mg 6-alpha-methylprednisolone into the muscle belly of inferior rectus, in one case injection was done in both eyes. RESULTS: In all cases we were able to archive lessening of the intraocular pressure in secondary position, with slight improvement in ocular motility and bigger range of duction free of diplopia. CONCLUSIONS: Visual function improvement found by the patients is the best evidence for application of 6-alpha-methylprednisolone into the extraocular muscles of patients with motility disturbances secondary to endocrine ophthalmopathy.     

Balancing conflicting metabolic demands of exercise and diving

During enforced diving, aquatic animals activate a set of physiological reflexes (apnea, bradycardia, peripheral vasoconstriction), which are termed the diving response and are in effect the first line of defense against hypoxia. At least in the Weddell seal, this strategy is now known also to be used in voluntary diving at sea, but the response is necessarily modified to accommodate potentially conflicting demands of diving and swimming exercise. The main modification appears to involve skeletal muscles used in swimming, which, because of their high energy requirements, must be powered by aerobic metabolism. Thus they must remain perfused at rates porportional to swimming velocity (which is why heart rates are adjusted to swimming velocity). The required regulation of O2 delivery is achieved at least in part by a well-paced release of oxygenated red blood cells, stored at the beginning of the dive apparently in the spleen. The main metabolic difference between laboratory and voluntary diving is that, in the latter, working muscles serve as a sink for lactate and thus the entry rates of lactate into the plasma can be balanced by exit rates from the plasma; the maintenance of this balance means that no excess lactate remains for a lactate washout in postdiving exercise except under long, exploratory diving. Even in the latter long dives, however, the amount of lactate formed is far less than would be expected if the energetic shortfall caused by hypoperfusion and O2 lack were made up by anaerobic glycolysis (Pasteur effect). Consequently, during diving, hypoperfused tissues necessarily sustain a metabolic arrest of variable degrees as a mechanism of defense against hypoxia.     

Distribution of motoneurones innervating extraocular muscles in the brain of the marmoset (Callithrix jacchus)

Extraocular muscle motoneurones were localised in the oculomotor nucleus (ON), trochlear nucleus (TN) and abducens nucleus (AN) in the marmoset brain using the horseradish peroxidase (HRP) retrograde labelling technique. HRP pellets injected into individual extraocular muscles revealed one or more groups of labelled neurones occupying discrete loci within these nuclei. Relatively little overlap of motoneurone pools was observed, except in the case of the inferior oblique and superior rectus muscles. Injections of HRP into the medial rectus muscle revealed three separate populations of labelled cells in the ipsilateral ON. Motoneurones innervating the inferior rectus muscle were mainly localised in the lateral somatic cell column of the ipsilateral ON. A second smaller grouping was observed in the medial longitudinal fasciculus. The inferior oblique muscle motoneurones were localised in the ipsilateral medial somatic cell column intermingled with motoneurones supplying the superior rectus muscle of the opposite eye. The superior oblique muscle motoneurones occupied the entire TN and the lateral rectus muscle motoneurones the AN. It was concluded that the organisation of nuclei and subnuclei responsible for controlling the extraocular muscles in the marmoset is broadly similar to that of other primates.     

Experimental free-muscle transplantation with microneurovascular anastomoses

In 13 rabbits the rectus femoris muscle was freely transplanted from the left to the right side using microneurovascular anastomoses. About 7 months after surgery the muscle transplants were assessed functionally by force measurements. On the average, the transplanted muscles regained 55 percent of the maximal tetanic tension of unoperated, normal rectus femoris muscles, expressed as force per gram of muscle weight even 68 percent. After functional assessment, the muscles were weighed and then used for histologic, histochemical, planimetric, and biochemical evaluation. H&E-stained cross sections showed a high content of healthy muscle fibers; only some small atrophic and single fat cells were scattered over the cross sections. Good reinnervation over the sutured muscle nerve was confirmed by the type-grouping of muscle fibers in the NADH and myofibrillar ATPase staining. There was an excellent correlation between the functional results and the histologic picture as well as the content of choline acetyltransferase (CAT). A certain parallelism was found between the function of the transplants and the content of hexokinase, but none for the other estimated muscle enzymes, such as malate dehydrogenase (MDH), creatine kinase (CK), and lactic dehydrogenase (LDH). All enzyme levels were lower than in normal muscles. The results of this experimental series underline the utility of muscle transplantation with microneurovascular anastomoses to restore lost muscle function, even in the extremities, when strong forces are needed.     

The properties of the extraocular muscles of the frog. II. Pharmacological properties of the isolated superior oblique and superior rectus muscles.

The pharmacological properties of the superior oblique and the superior rectus muscles of the frog's eye were investigated in comparison with those of a skeletal muscle (iliofibularis muscle) of the same animal. Acetylcholine causes sustained contractures of the extraocular muscles; this effect is increased by physostigmine and decreased or abolished by d-tubocurarine. Also the applications of succinylcholine, choline or caffeine are able to evoke contractures. There are no striking differences in pharmacological properties between extraocular and skeletal muscles of the frog. The time-course of the contractures and the sensitivity of the muscle preparations to the drugs which evoke contractures are identical in extraocular and iliofibularis muscles. In comparison with skeletal muscles there is no higher sensitivity of the extraocular muscles against curare-like drugs. The existence of adrenergic receptors could not be found neither in extraocular nor in skeletal muscles of the frog. It is concluded that in frogs no pharmacological differences exist between the muscle fibre types which compose the extraocular and the skeletal muscles.     

Afferent signals from pigeon extraocular muscles modify the vestibular responses of units in the abducens nucleus.

Although the extraocular muscles contain stretch receptors it is generally believed that their afferents exert no influence on the control of eye movement. However, we have shown previously that these afferent signals reach various brainstem centres concerned with eye movement, notably the vestibular nuclei, and that the decerebrate pigeon is a favourable preparation in which to study their effects. If the extraocular muscle afferents do influence oculomotor control from moment-to-moment they should exert a demonstrable effect on the oculomotor nuclei. We now present evidence that extraocular muscle afferent signals do, indeed, alter the responses of units in an oculomotor nucleus (the abducens, VI nerve nucleus, which supplies the lateral rectus muscle) to horizontal, vestibular stimulation induced by sinusoidal oscillation of the bird. Such stimuli evoke a vestibulo-ocular reflex in the intact bird. The extraocular stretch receptors were activated by passive eye movement within the pigeon's saccadic range; such movements modified the vestibular responses of all 19 units studied which were all, histologically, in the abducens nucleus. The magnitude of the effects, purely inhibitory in 15 units, depended both on the amplitude and the velocity of the eye movement and most units showed selectivity for particular combinations of plane (e.g. horizontal versus vertical) and direction (e.g. rostral versus caudal) of eye movement. The results show that an afferent signal from the extraocular muscles influences vestibularly driven activity in the abducens nucleus to which it carries information related to amplitude, velocity, plane and direction of eye movement in the saccadic range. They thus strongly support the view that extraocular afferent signals are involved in the control of eye movement.     

Branching patterns of rabbit oculomotor and trochlear nerves demonstrated by Sihler's stain technique

A modified Sihler's stain technique was used to visualize the branching patterns of oculomotor and trochlear nerves. The levator palpebrae, superior rectus, inferior rectus, medial rectus, inferior oblique, superior oblique and tensor trochlea muscles were isolated from the eyes of normal rabbits and processed using modified Sihler's technique. The distributions and terminal ramifications of the oculomotor and trochlear nerves were observed. Two distinct divisions and terminal branches of the oculomotor nerve were shown in detail together with the trochlear nerve distribution. The application of Sihler's technique enables researchers to trace nerve branching within relatively transparent muscles, whereas the nerve fibers are counterstained and clearly visible. This technique could be useful for detailed studies of the motor control of extraocular muscles.     

Characteristics of the human cardiovascular system in the human diving response

Comparative-evolutional research of diving response showed that mechanisms of its expression had much in common in humans and in animals. Firstly, it involves a reflex bradycardia, vasoconstriction of peripheral vessels, and blood flow centralization. But, unlike animals whose diving response has some typical species peculiarities, human diving response is rather diverse. Four types of cardiovascular system response to face submersion were revealed: over-reactive, reactive, paradoxical, and nonreactive. These types were chosen according to the bradycardia character. It is also supposed that the occurrence of individual maximal R--R-interval, while serving as a signal to apnea stopping, is among the reasons of apnea activity limitation.     

Cranial endothermy and a putative brain heater in the most basal tuna species, Allothunnus fallai

Field studies on the slender tuna Allothunnus fallai revealed cranial temperatures that were 4·8 ± 0·4° C (mean ± s . d .) above the ambient sea surface temperature. Dissections aimed at documenting the cranial heat source revealed a fused extraocular muscle complex positioned beneath the brain of this basal tuna species. The muscle complex is structurally distinct from that documented for any other fish species. In A. fallai , all four extraocular rectus muscle pairs (superior, inferior, medial and lateral rectus) are incorporated into one distinct tissue complex which is positioned between the orbits and in direct contact with the braincase. A combination of morphological, physiological and biochemical techniques were used to characterize the modified muscle tissue, and high-resolution magnetic resonance imaging was used to illustrate its association with the brain and optic nerves. The modified eye muscles lack organized contractile proteins and are perfused by an extensive vascular counter-current system that originates from the internal carotid artery. Vessel diameters, artery–vein configuration, and anatomic position between the systemic circulation and the warm eye muscles all suggest that this system is a heat exchanger. Collectively, these findings suggest that A. fallai has evolved extraocular muscles that may function to warm the brain and eye region. This is the first record of a cranial modification comprised of all four rectus muscles and the only documented occurrence of this mechanism for cranial endothermy among the tunas.     

Afferent signals from the extraocular muscles of the pigeon modify the electromyogram of these muscles during the vestibulo-ocular reflex.

There is no general agreement on whether afferent signals from the extraocular muscles play any part in oculomotor control. However, we have previously shown that they modify the responses of cells in the oculomotor control system during the vestibulo-ocular reflex (VOR). If, as we suspect, these signals have an important role in the control of the VOR from moment-to-moment, we should be able to demonstrate similar, functionally significant, modifications at the output of the reflex. We have recorded the electromyographic activity of several extraocular muscles of the right eye during the VOR and while imposing movements on the left eye. We describe how the activity of the muscles, reflected in the electromyogram, is modified in specific ways depending on the parameters of the imposed eye movements. The effects of the extraocular afferent signals on the eye-muscle responses to vestibular drive during the slow phase of the VOR appear to be corrective. Thus the present results provide strong evidence that afferent signals from the extraocular muscles are concerned in the control of the reflex from moment-to-moment, and suggest that the wider question of their role in oculomotor control merits further consideration.