Syncope and the eye: Difference between revisions

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== Editor's comments ==
== Editor's comments ==
An unexplained attack of syncope in an otherwise healthy individual is an alarming event for the patient.  In order to explain the occurrence of transient loss of consciousness to the patient, knowledge of the involved mechanism is required (1). In our patient, syncope due to sudden pressure on the eyeball (oculocardiac reflex, OCR) was diagnosed. The OCR was first described in 1908 by Bernard Aschner of Vienna and Guiseppe Dagnini of Bologna in almost simultaneous independent reports (2,3). The OCR is a physiological response of the heart to physical pressure on the eyeball and orbital contents, including extraocular muscles.  It is characterized by bradycardia or cardiac arrhythmia, which may lead to cardiac asystole. This is a trigiminal-brainstem-vagal reflex.  Aschner demonstrated that the reflex was abolished by cutting the trigeminal nerve (2).  Gandevia and colleagues showed that vagotomy or atropinization almost abolished bradycardia, and a slight residual bradycardia still evoked by eyeball pressure was eliminated after administration of propranolol.  This suggests that vagus (predominantly) and sympathetic nerves constitute efferent limbs of the OCR (4).
An unexplained attack of syncope in an otherwise healthy individual is an alarming event for the patient.  In order to explain the occurrence of transient loss of consciousness to the patient, knowledge of the involved mechanism is required <cite>Sharpey</cite>. In our patient, syncope due to sudden pressure on the eyeball (oculocardiac reflex, OCR) was diagnosed. The OCR was first described in 1908 by Bernard Aschner of Vienna and Guiseppe Dagnini of Bologna in almost simultaneous independent reports <cite>Aschner</cite><cite>Dagnini</cite>. The OCR is a physiological response of the heart to physical pressure on the eyeball and orbital contents, including extraocular muscles.  It is characterized by bradycardia or cardiac arrhythmia, which may lead to cardiac asystole. This is a trigiminal-brainstem-vagal reflex.  Aschner demonstrated that the reflex was abolished by cutting the trigeminal nerve <cite>Aschner</cite>.  Gandevia and colleagues showed that vagotomy or atropinization almost abolished bradycardia, and a slight residual bradycardia still evoked by eyeball pressure was eliminated after administration of propranolol.  This suggests that vagus (predominantly) and sympathetic nerves constitute efferent limbs of the OCR <cite>Gandevia</cite>.


Besides the usefulness of OCR as a technique in the unarmed combat to produce syncope or death (5), it has been used for several diagnostic and therapeutic purposes. Gastaut found enhanced OCR in patients prone to vasovagal syncope (6).  Lambroso and Lerman demonstrated a sixty-one percent incidence of asystole exceeding two seconds induced by eyeball pressure in infants with pallid breath-holding spells, while twenty-five percent of the infants in the cyanotic group and seven percent of the control group had such a period of asystole (7). Stephenson employed the OCR to differentiate between syncopal and epileptic seizures in infants syncopal group demonstrating hypersensitive OCR with asystole 4 seconds (8). The OCR has been reported to be beneficial in aborting or attenuating attacks of paroxysmal atrial tachycardia. This reflex is routinely elicited by ophthalmologists during strabismus surgery when traction is applied to the extraocular muscles (10).  This can serve as a surgical aid in identifying a slipped or lost extraocular muscle during surgery. More often, however, the OCR can occur as an intraoperative complication of the procedure and may be potentially fatal (9).
Besides the usefulness of OCR as a technique in the unarmed combat to produce syncope or death <cite>Mallinson</cite>, it has been used for several diagnostic and therapeutic purposes. Gastaut found enhanced OCR in patients prone to vasovagal syncope <cite>Gastaut</cite>.  Lambroso and Lerman demonstrated a sixty-one percent incidence of asystole exceeding two seconds induced by eyeball pressure in infants with pallid breath-holding spells, while twenty-five percent of the infants in the cyanotic group and seven percent of the control group had such a period of asystole <cite>Lambroso</cite>. Stephenson employed the OCR to differentiate between syncopal and epileptic seizures in infants syncopal group demonstrating hypersensitive OCR with asystole 4 seconds <cite>Stephenson</cite>. The OCR has been reported to be beneficial in aborting or attenuating attacks of paroxysmal atrial tachycardia. This reflex is routinely elicited by ophthalmologists during strabismus surgery when traction is applied to the extraocular muscles <cite>Baykara</cite>.  This can serve as a surgical aid in identifying a slipped or lost extraocular muscle during surgery. More often, however, the OCR can occur as an intraoperative complication of the procedure and may be potentially fatal <cite>VanBrocklin</cite>.


Although stimulation of the trigeminal nerve at diverse sites, peripheral and central to the trigeminal ganglion, including the trigeminal tract and nucleus, can produce bradycardia, this discussion is confined to ocular stimulation Besides pressure on the globe or traction on the extraocular muscles, OCR can be induced by several other ocular manipulations, including blepharoplasty, laser in situ keratomileusis (lasik), subconjuctival injection, cataract extraction, contact lens insertion, acute glaucoma, removal of a foreign body from the cornea, and insertion of Schirmer’s lacrimation strips (10-15). It is easy to presume that stimulation of the trigeminal afferents induces the OCR in all such patients.  In a patient, in whom application of Schirmer’s lacrimation strips in each conjuctival sac caused vasodepression and cardioinhibition, chemical deafferentation with topical administration of proparacaine hydrochloride did not influence vasodepression or cardioinhibition.  This indicates lack of contribution from trigeminal afferents and raises the possibility that some of the reported cases of bradycardia in response to ocular stimulation belong to vasovagal type of situational syncope (15).
Although stimulation of the trigeminal nerve at diverse sites, peripheral and central to the trigeminal ganglion, including the trigeminal tract and nucleus, can produce bradycardia, this discussion is confined to ocular stimulation Besides pressure on the globe or traction on the extraocular muscles, OCR can be induced by several other ocular manipulations, including blepharoplasty, laser in situ keratomileusis (lasik), subconjuctival injection, cataract extraction, contact lens insertion, acute glaucoma, removal of a foreign body from the cornea, and insertion of Schirmer’s lacrimation strips <cite>Baykara</cite><cite>Kayikcioglu</cite><cite>Gao</cite><cite>Mimura</cite><cite>Awan</cite><cite>Khurana</cite>. It is easy to presume that stimulation of the trigeminal afferents induces the OCR in all such patients.  In a patient, in whom application of Schirmer’s lacrimation strips in each conjuctival sac caused vasodepression and cardioinhibition, chemical deafferentation with topical administration of proparacaine hydrochloride did not influence vasodepression or cardioinhibition.  This indicates lack of contribution from trigeminal afferents and raises the possibility that some of the reported cases of bradycardia in response to ocular stimulation belong to vasovagal type of situational syncope <cite>Khurana</cite>.


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== References ==
== References ==
<biblio>
<biblio>
#Sharpey pmid=13293372
#Aschner Aschner B.  Ueber einen bisher noch nicht beschrieben Reflex vom Auge auf kreislauf and Atmung.  Verschwinden des Radialpulsen bei Druck aut des auge.  Wiener Klinische Wochenschrift 1908; 21:  1529-1530.
#Aschner Aschner B.  Ueber einen bisher noch nicht beschrieben Reflex vom Auge auf kreislauf and Atmung.  Verschwinden des Radialpulsen bei Druck aut des auge.  Wiener Klinische Wochenschrift 1908; 21:  1529-1530.
#Dagnini Dagnini G.  Interno ad un riflesso provocato in alcuni emiplegici colla stimulo della corneae colo pressione sul bulbo oculate.  Bollettino della Scienze Medische 1908; 8:  380.
#Dagnini Dagnini G.  Interno ad un riflesso provocato in alcuni emiplegici colla stimulo della corneae colo pressione sul bulbo oculate.  Bollettino della Scienze Medische 1908; 8:  380.
Line 34: Line 35:
#Awan pmid=1154848  
#Awan pmid=1154848  
#Khurana pmid=12420086  
#Khurana pmid=12420086  
<biblio>
</biblio>

Latest revision as of 20:03, 16 September 2017

W Wieling*, R.K. Khurana #
Department of Medicine, Academic Medical Centre, University of Amsterdam, Amsterdam (The Netherlands); # Division of Neurology, Union Memorial Hospital, Baltimore, Maryland (U.S.A).


A 52-year-old male physician was referred to our syncope unit for evaluation of unexplained loss of consciousness. He had no history of cardiovascular or other medical problems. He was physically active and used no medication. The patient was playing a tennis match when he was hit hard by the tennis ball on the left eye. Immediately after the impact, he dropped to the floor and lost consciousness for a few seconds. On regaining consciousness he felt well and continued playing at his normal capacity.

The next day he visited his general practitioner. His general physical and somatic neurological examination including functions of trigeminal nerves were normal. He was referred to a cardiologist. The electrocardiogram, echocardiogram, 24-hour holter monitor study, and exercise stress test were normal. He was referred to our unit for analysis of unexplained syncope.

The patient declined further laboratory assessment. His only interest was an explanation of the event in order to reassure his concerned spouse. Based on a typical history, syncope due to eyeball pressure was diagnosed. The underlying mechanism was explained to the patient, and he felt reassured.


Editor's comments

An unexplained attack of syncope in an otherwise healthy individual is an alarming event for the patient. In order to explain the occurrence of transient loss of consciousness to the patient, knowledge of the involved mechanism is required [1]. In our patient, syncope due to sudden pressure on the eyeball (oculocardiac reflex, OCR) was diagnosed. The OCR was first described in 1908 by Bernard Aschner of Vienna and Guiseppe Dagnini of Bologna in almost simultaneous independent reports [2][3]. The OCR is a physiological response of the heart to physical pressure on the eyeball and orbital contents, including extraocular muscles. It is characterized by bradycardia or cardiac arrhythmia, which may lead to cardiac asystole. This is a trigiminal-brainstem-vagal reflex. Aschner demonstrated that the reflex was abolished by cutting the trigeminal nerve [2]. Gandevia and colleagues showed that vagotomy or atropinization almost abolished bradycardia, and a slight residual bradycardia still evoked by eyeball pressure was eliminated after administration of propranolol. This suggests that vagus (predominantly) and sympathetic nerves constitute efferent limbs of the OCR [4].

Besides the usefulness of OCR as a technique in the unarmed combat to produce syncope or death [5], it has been used for several diagnostic and therapeutic purposes. Gastaut found enhanced OCR in patients prone to vasovagal syncope [6]. Lambroso and Lerman demonstrated a sixty-one percent incidence of asystole exceeding two seconds induced by eyeball pressure in infants with pallid breath-holding spells, while twenty-five percent of the infants in the cyanotic group and seven percent of the control group had such a period of asystole [7]. Stephenson employed the OCR to differentiate between syncopal and epileptic seizures in infants syncopal group demonstrating hypersensitive OCR with asystole ≥ 4 seconds [8]. The OCR has been reported to be beneficial in aborting or attenuating attacks of paroxysmal atrial tachycardia. This reflex is routinely elicited by ophthalmologists during strabismus surgery when traction is applied to the extraocular muscles [9]. This can serve as a surgical aid in identifying a slipped or lost extraocular muscle during surgery. More often, however, the OCR can occur as an intraoperative complication of the procedure and may be potentially fatal [10].

Although stimulation of the trigeminal nerve at diverse sites, peripheral and central to the trigeminal ganglion, including the trigeminal tract and nucleus, can produce bradycardia, this discussion is confined to ocular stimulation Besides pressure on the globe or traction on the extraocular muscles, OCR can be induced by several other ocular manipulations, including blepharoplasty, laser in situ keratomileusis (lasik), subconjuctival injection, cataract extraction, contact lens insertion, acute glaucoma, removal of a foreign body from the cornea, and insertion of Schirmer’s lacrimation strips [9][11][12][13][14][15]. It is easy to presume that stimulation of the trigeminal afferents induces the OCR in all such patients. In a patient, in whom application of Schirmer’s lacrimation strips in each conjuctival sac caused vasodepression and cardioinhibition, chemical deafferentation with topical administration of proparacaine hydrochloride did not influence vasodepression or cardioinhibition. This indicates lack of contribution from trigeminal afferents and raises the possibility that some of the reported cases of bradycardia in response to ocular stimulation belong to vasovagal type of situational syncope [15].


References

  1. SHARPEY-SCHAFER EP. Syncope. Br Med J. 1956 Mar 3;1(4965):506-9. DOI:10.1136/bmj.1.4965.506 | PubMed ID:13293372 | HubMed [Sharpey]
  2. Aschner B. Ueber einen bisher noch nicht beschrieben Reflex vom Auge auf kreislauf and Atmung. Verschwinden des Radialpulsen bei Druck aut des auge. Wiener Klinische Wochenschrift 1908; 21: 1529-1530.

    [Aschner]
  3. Dagnini G. Interno ad un riflesso provocato in alcuni emiplegici colla stimulo della corneae colo pressione sul bulbo oculate. Bollettino della Scienze Medische 1908; 8: 380.

    [Dagnini]
  4. Gandevia SC, McCloskey DI, and Potter EK. Reflex bradycardia occurring in response to diving, nasopharyngeal stimulation and ocular pressure, and its modification by respiration and swallowing. J Physiol. 1978 Mar;276:383-94. DOI:10.1113/jphysiol.1978.sp012241 | PubMed ID:650462 | HubMed [Gandevia]
  5. MALLINSON FB and COOMBES SK. A hazard of anaesthesia in ophthalmic surgery. Lancet. 1960 Mar 12;1(7124):574-5. DOI:10.1016/s0140-6736(60)92780-x | PubMed ID:14420372 | HubMed [Mallinson]
  6. Gastaut H. Syncopes: generalized anoxic cerebral seizures. In: Magnus O, Haas AM eds. Handbook of Clinical Neurology. vol 15. chapter 42. Amsterdam: North Holland 1974: 915-936.

    [Gastaut]
  7. Lombroso CT and Lerman P. Breathholding spells (cyanotic and pallid infantile syncope). Pediatrics. 1967 Apr;39(4):563-81. PubMed ID:4960778 | HubMed [Lambroso]
  8. Stephenson JB. Two types of febrile seizure: anoxic (syncopal) and epileptic mechanisms differentiated by oculocardiac reflex. Br Med J. 1978 Sep 9;2(6139):726-8. DOI:10.1136/bmj.2.6139.726 | PubMed ID:359095 | HubMed [Stephenson]
  9. Baykara M, Dogru M, Ozmen AT, and Ozcetin H. Oculocardiac reflex in a nonsedated laser in situ keratomileusis patient. J Cataract Refract Surg. 2002 Sep;28(9):1698-9. DOI:10.1016/s0886-3350(01)01113-0 | PubMed ID:12231334 | HubMed [Baykara]
  10. Van Brocklin MD, Hirons RR, and Yolton RL. The oculocardiac reflex: a review. J Am Optom Assoc. 1982 May;53(5):407-13. PubMed ID:7047626 | HubMed [VanBrocklin]
  11. Kayikçioglu O, Kayikçioglu M, Erakgün T, and Güler C. Electrocardiographic changes during subconjunctival injections. Int Ophthalmol. 1999;23(1):37-41. DOI:10.1023/a:1006486207583 | PubMed ID:11008897 | HubMed [Kayikcioglu]
  12. Gao L, Qing W, Haifeng X, higang T, Faliang W. The oculocardiac reflex in cataract surgery in the elderly. Br J Ophthalmol 1997; 81: 64.

    [Gao]
  13. Mimura T, Amano S, Funatsu H, Araie M, Kagaya F, Kaji Y, Oshika T, Yamagami S, and Okada E. Oculocardiac reflex caused by contact lenses. Ophthalmic Physiol Opt. 2003 May;23(3):263-4. DOI:10.1046/j.1475-1313.2003.00114.x | PubMed ID:12753482 | HubMed [Mimura]
  14. Awan KJ. Syncope during the removal of corneal foreign body. Va Med Mon (1918). 1975 May;102(5):387-9. PubMed ID:1154848 | HubMed [Awan]
  15. Khurana RK. Eye examination-induced syncope Role of trigeminal afferents. Clin Auton Res. 2002 Oct;12(5):399-403. DOI:10.1007/s10286-002-0021-2 | PubMed ID:12420086 | HubMed [Khurana]

All Medline abstracts: PubMed | HubMed