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ANSHI Method: A Newer Approach for Oculocardiac Reflex Prevention

Corresponding author: Tarang Jain* and Lalit Gupta
Maulana Azad Medical College, University of Delhi, New Delhi, India.

Article Information

Article Type: Editorial

Received date  : 25/05/2018
Accepted date  : 22-06-2018
Published date : 27-07-2018  



Dear Editor,

The Oculocardiac reflex was a concept first introduced by Aschner in1908 [1]. It occurs most commonly due to stretching of the extra ocular muscles or increase in eye ball pressure.This reflex, also known as Aschner reflex, or Aschner-Dagnini reflex, is associated with the appearance of sinus bradycardia as the most common manifestation; arrhythmias, reduced arterial pressure, and ventricular fibrillation have also been reported.In extreme cases, such as asystole, cardiopulmonary resuscitation may be required[2]. The oculocardiac reflex starts with the stimulation of the stretch receptors on the extra ocular muscles, the signal then traverses through the short and long ciliary nerves which then merge with the ophthalmic division of the trigeminal nerve at the ciliary ganglion. The signal then passes via the gasserian ganglion to the nucleus of the trigeminal nerve and finally to the nucleus of the Vagus nerve, which leads to stimulation of the vagal efferent fibers. This leads to an increase in the parasympathetic tone, which may present as bradycardia, bigeminy, AV block or asystole. The oculo cardiac reflex can be stimulated by multiple triggers like traction on the extra ocular muscles, pressure on the eyeball, ocular trauma, and orbital compression due to hematoma or orbital injections. The oculo respiratory reflex is also mediated via the same efferent pathway, with the afferent pathway composed of the pneumotacticcentre, leading to shallow breathing, reduced rate and apnea [1].

The Oculocardiac Reflex is commonly encountered in pediatric strabismus surgeries, with a reported incidence of 14 to 90% [3]. It has been associated with cardiac arrest in some cases. The oculocardiac reflex is accentuated by atracurium, remifentanil, hypoxia, hypercarbia. Many maneuvers and methods have been described in literature and clinical practice to prevent this reflex during Strabismus surgery but with limited success[4]. Some commonly used methods are intravenous administration of atropine and glycopyrrolate, intramuscular glycopyrrolate, peribulbar block, topical application of lignocaine, maintenance of normoxia, normocarbia and use of balanced anaesthesia[5].

We would like to bring to your notice, a new method of preventing OCR, the “ANSHI Method”. This method uses Proparacaine eye drops. Proparacaine, also known as proxymetacaine is an amino ester local anaesthetic agent, which is FDA approved for topical use in ophthalmic surgeries, as a hydrochloride salt in a concentration of 0.5%. It is being used extensively for phacoemulsification, glaucoma surgeries and intra vitreal injections[6]. We propose that after the extra ocular muscle has been exposed by the surgeon (the conjuntiva and tenon`s layers have been dissected), two drops of Proparacaine are instilled on the muscle. Traction on the muscle is applied after waiting for a period of 15 seconds. This procedure is repeated on exposure of each muscle.Our experience of 50 cases showed almost negligible occurrence of OCR (being defined as 10 % decrease in heart rate), with no incidence of heart rate less than 60/ minute or arrhythmias following the above method. We recommend further Meta-analysis of this method for its widely acceptance in medical field. 


1. Aschner B (1908)Concerning a hitherto not yet described reflex from the eye on circulation & respiration. Wien, Klin, Woschanschr 21: 1529-30.
2. Galkowska I, Niziennska E (1975) Cardiac arrest during ophthamological operations. AnaesthResusc Intensive Ther 3:197-200.
3. Apt L, Isenberg S, Gaffney WB (1973)Theoculocardiac reflex in stabismus surgery. Amer. J. Ophthamol 76: 533-5.
4. MisuryaV K, Singh S P, Kulshrestha V K (1990) Prevention of oculocardiac reflex (O.C.R) during extraocular muscle surgery. Indian J Ophthalmol 38:85-87.
5. TaghaviGilani, M, Sharifi, M, Najaf Najafi, M, EtemadiMashhadi (2016) M. Oculocardiac reflex during strabismus surgery.
    Reviews in Clinical Medicine 3(1): 4-7.
6. National Center for Biotechnology Information. PubChem Compound Database; CID=4935,
    (accessed June 14, 2018)

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