The effect of sub-Tenon's bupivacaine on oculocardiac reflex during strabismus surgery and postoperative pain: A randomized clinical trial

Purpose: oculocardiac reflex (ocr),defined as bradycardia induced by manipulation of extraocular muscles,is a serious complication during strabismus surgery for which prevention and proper management is required. in the present study,we investigated the efficacy of sub-tenon injection of bupivacaine for prevention of ocr and postoperative pain. methods: a prospective randomized controlled clinical trial was conducted. fifty patients who were candidates for strabismus surgery were randomized into case (sub-tenon's bupivacaine injection) or control (normal saline injection) groups. standard strabismus surgery was performed for all cases. occurrence and severity of ocr (primary outcome) and postoperative pain (using the visual analog scale) were compared between the two groups. results: both incidence (32% vs. 100%; p = 0.002) and severity of ocr (mean heart rate decrease,10.1 vs. 38.7 beats/minute; p < 0.001) were significantly lower in the study group compared to those in the control group. postoperative pain scores were significantly lower in the case group than in the control group (mean score,2.8 vs. 5.9 at 60 minutes after surgery; p < 0.001). conclusions: sub-tenon injection of bupivacaine as a local anesthetic can significantly prevent ocr and decrease the severity of bradycardia. this technique can also diminish postoperative pain in patients who underwent strabismus surgery. talebnejad mohammad 1 poostchi ophthalmology research center,department of ophthalmology,school of medicine,shiraz university of medical sciences,shiraz khademi saeed 2 shiraz anesthesiology and critical care research center,department of anesthesiology,school of medicine,shiraz university of medical sciences,shiraz ghani milad 3 poostchi ophthalmology research center,department of ophthalmology,school of medicine,shiraz university of medical sciences,shiraz khalili mohammad 4 poostchi ophthalmology research center,department of ophthalmology,school of medicine,shiraz university of medical sciences,shiraz nowroozzadeh mohammad 5 poostchi ophthalmology research center,department of ophthalmology,school of medicine,shiraz university of medical sciences,shiraz dewar km. the oculocardiac reflex. proc r soc med 1976;69:373-374. hahnenkamp k,honemann cw,fischer lg,durieux me,muehlendyck h,braun u. effect of different anaesthetic regimes on the oculocardiac reflex during paediatric strabismus surgery. paediatr anaesth 2000;10:601-608. gupta n,kumar r,kumar s,sehgal r,sharma kr. a prospective randomised double blind study to evaluate the effect of peribulbar block or topical application of local anaesthesia combined with general anaesthesia on intra-operative and postoperative complications during paediatric strabismus surgery. anaesthesia 2007;62:1110-11103. gurkan y,kilickan l,toker k. propofol-nitrous oxide versus sevoflurane-nitrous oxide for strabismus surgery in children. paediatr anaesth 1999;9:495-499. choi sr,park sw,lee jh,lee sc,chung cj. effect of different anesthetic agents on oculocardiac reflex in pediatric strabismus surgery. j anesth 2009;23:489-493. mizrak a,erbagci i,arici t,ozcan i,ganidagli s,tatar g,et al. ketamine versus propofol for strabismus surgery in children. clin ophthalmol 2010;4:673-679. steib a,karcenty a,calache e,franckhauser j,dupeyron jp,speeg-schatz c. effects of subtenon anesthesia combined with general anesthesia on perioperative analgesic requirements in pediatric strabismus surgery. reg anesth pain med 2005;30:478-483. tuzcu k,coskun m,tuzcu ea,karcioglu m,davarci i,hakimoglu s,et al. effectiveness of sub-tenon's block in pediatric strabismus surgery. braz j anesthesiol 2015;65:349-352. deb k,subramaniam r,dehran m,tandon r,shende d. safety and efficacy of peribulbar block as adjunct to general anaesthesia for paediatric ophthalmic surgery. paediatr anaesth 2001;11:161-167. ripart j,lefrant jy,vivien b,charavel p,fabbro-peray p,jaussaud a,et al. ophthalmic regional anesthesia: medial canthus episcleral (sub-tenon) anesthesia is more efficient than peribulbar anesthesia: a double-blind randomized study. anesthesiology 2000;92:1278-1285. ghai b,ram j,makkar jk,wig j,kaushik s. subtenon block compared to intravenous fentanyl for perioperative analgesia in pediatric cataract surgery. anesth analg 2009;108:1132-1138. ramachandran r,rewari v,chandralekha c,sinha r,trikha a,sharma p. sub-tenon block does not provide superior postoperative analgesia vs intravenous fentanyl in pediatric squint surgery. eur j ophthalmol 2014;24:643-649. sethi s,ghai b,sen i,ram j,wig j. efficacy of subtenon block in infants - a comparison with intravenous fentanyl for perioperative analgesia in infantile cataract surgery. paediatr anaesth 2013;23:1015-1020. sheard rm,mehta js,barry js,bunce c,adams gg. subtenons lidocaine injection for postoperative pain relief after strabismus surgery in children: a prospective randomized controlled trial. j aapos 2004;8:314-317. sheard rm,mehta js,barry js,bunce c,adams gw. subtenons lidocaine injection for postoperative pain relief after strabismus surgery in children: a pilot study. j aapos 2003;7:38-41. ateş y,unal n,cuhruk h,erkan n. postoperative analgesia in children using preemptive retrobulbar block and local anesthetic infiltration in strabismus surgery. reg anesth pain med 1998;23:569-574. morris b,watts p,zatman t,absolom m,haider s,hall j. pain relief for strabismus surgery in children: a randomised controlled study of the use of preoperative sub-tenon levobupivacaine. br j ophthalmol 2009;93:329-332. © 2017 journal of ophthalmic and vision research published by wolters kluwer - medknow.