Br J Ophthalmol 1998;82:589–591 589

ited to experienced and skilled ophthalmolo- arrhythmias and bradycardia. Vrabec et al 3 gists in institutes of higher learning. However, and Eustis et al 4 defined it as a 10% decrease, CORRESPONDENCE retrobulbar block remains a highly popular while Karhunen et al 5 defined it as a 20% procedure with many practising ophthal- decrease in baseline heart. Other reports16 mologists even today. One should be unam- defined it as at least a decrease of 10 beats per biguous when considering the role of retrobul- minute. Because of the instability and conti- bar anaesthesia in producing OCR, as it is the nuity of electrocardiac activity, we divided the The oculocardiac reflex in cataract mainstay of cataract surgery in many countries. natural standard surgery into six procedures surgery in the elderly Any incorrect information sends the wrong sig- according to their suspected disturbance to

1 nals to practising ophthalmologists using retro- the eye and adopted the relative baseline heart EDITOR,—The letter by Gao Lei gives an et al bulbar anaesthesia in cataract surgery in prefer- rate. We believed that notable changes in elec- erroneous impression that retrobulbar injection ence to expensive, potentially dangerous, and trocardiac activity within a shorter period of per se produces oculocardiac reflex (OCR). On technically diYcult general anaesthesia. time would be more significant in the clinical the contrary, retrobulbar anaesthetic infiltration In a control double blind study, Kundra sense. In our original paper published in Chi- is a method of prophylaxis to prevent OCR in 2 demonstrated that combining peribulbar block nese, we suspected that the criteria for the patients under general anaesthesia. In patients with general anaesthesia in children undergoing OCR may be too conservative and incom- operated under retrobulbar anaesthesia, “heart intraocular surgery completely abolished OCR, plete, and they may need revision to assure rhythm and rate become stable once the block reduced the requirement of anaesthetics, and greater clinical significance. It is our desire has taken eVect; occasional ectopics or heart produced early recovery from anaesthesia with that more scientific new criteria for OCR rate changes before this seemingly being due to satisfactory postoperative analgesia (Kundra would be established by ophthalmologists the stimulus of needle prick or the adrenaline in 3 Pankaj, Department of Anaesthesia, JIPMER, cooperating with cardiovascular surgeons. the solution”. The author’s experience is the Pondicherry, personal communication). At the beginning of the next century, more same as described in the last paragraph. Their G SESHUBABU than 10% of the total population in China will definition of OCR as at least a 10% decrease in be over the age of 60. Because of a positive heart rate below relative baseline is arbitrary. In Chief Medical OYcer, JIPMER, Pondicherry 605 006, India association between cataract and age, patients a previous well designed study, Mirakhur et al over 60 years old scheduled for cataract have taken bradycardia of 70 or less heart beats extraction at the practice of one of us (GL) per minute at any time during surgery and per- 1 Gao Lei, Wang Qing, Xu Haifeng, et al. The ocu- locardiac reflex in cataract surgery in the elderly. were eligible for our study. They can be recog- sisting for more than 15 seconds as study crite- Br J Ophthalmol 1997;81:614. nised as random samples. It is true that ria and OCR as slowing of heart rate by more 2 Kirsch RE, Sarret P, Kugel V, Axelrod S. Electro- various factors may influence the OCR. How- cardiographic changes during ocular surgery than 20% or arrhythmia during traction irre- ever, the study that we have conducted was to spective of heart rate.4 They felt that smaller and their prevention by retrobulbar injection. Arch Ophthalmol 1957;58:348–56. determine the true incidence of OCR among decreases in heart rate do not usually require 3 Alexander JP. Reflex disturbances of cardiac certain people, regardless of their sex, general treatment. The findings by Gao et al do not rhythm during ophthalmic surgery. Br J Oph- health condition, medication, etc. mention the duration of arrhythmias or dura- thalmol 1973;59:518–24. 4 Mirakhur RK, Jones CJ, Dundee JW, et al.IMor Owing to a misunderstanding, we incor- tion of drop in heart rate. It has been observed IV atropine or glycopyrolate on the prevention rectly cited one of our references. that development of inherent endogenous â of oculocardiac reflex in children undergoing blockade occurs with increasing age. Therefore squint surgery. Br J Anaesth 1982;54:1059–63. GAO LEI isolated heart rate recording without simultane- 5 Pan MY-M, Hoggman BB, Pershe RA, et al. TAO ZHIGANG Decline in beta adrenergic receptor mediated ous recording of blood pressure is erroneous.5 WANG QING vascular relaxation with ageing in man. J WU FALIANG The various factors that can increase the risk of Pharmacol Exp Thers 1986;239:802. XU HAIFENG OCR reviewed by Scott Lang and van der Val 6 Scott Lang DT, van der Val M. Trigeminocardiac reflexes—maxillary and mandibular variants of Department of Ophthalmology, Yantai Yuhuangding are hypercarbia, hypoxaemia, light anaesthesia, oculocardiac reflexes. CanJAnaesth1991;38: Hospital, Yantai 264000, Shandong Province, P R young age due to higher resting vagal tone, 757–60. China pharmacological agents such as potent narcot- 7 Arndt AG. Death from oculocardiac reflex ics (sufentanil, alfentanil), â blockers and (Reply). CanJAnaesth1994;41:161. 1 Yu Xiumin, Wang Lihua. The oculocardiac reflex 8 Smith RB. Death and the oculocardiac reflex. during ocular operation under various anesthe- calcium channel blockers, and the nature of the CanJAnaesth1994;41:760. sia. Chinese J Ophthalmol 1991;27:34–6. provoking stimulus—namely, strength of 9 Beibuyck JF. Concerning the ethics and accuracy 2 Sun Yuxun. Ocular compressed and oculocar- stimulus, and duration.6 As the patients in the of scientific citations (Editorial). Anesthsiology diac reflex. Chinese J Practical Ophthalmol 1989; 1992;77:1–2. 7:171. study by Gao et al were all over the age of 60 3 Vrabec MP, Preslan MW, Kushner BJ. Oculocar- years and six of 10 patients who had OCR had diac reflex during manipulation of adjustable abnormal preoperative electrocardiograms, the Reply suture after atrabismus surgery. Am J Ophthal- role of pharmacological agents described above mol 1987;104:61–3. 4 Eustis HS, Eiswirth CC, Smith DR. Vagal must be taken into consideration before impli- EDITOR,—Dr Seshubabu raised several points responses to adjustable suture in strabismus cating steps of cataract surgery in triggering with regard to oculocardiac reflex (OCR) and correction. Am J Ophthalmol 1992;114:307–10. OCR. The adoption of preventive strategies the study we conducted. 5 Karhunen U, Cozanitis DA, Brander P. The ocu- described by Scott Lang and van der Val for Retrobulbar injection is a manoeuvre that locardiac reflex in adults. A dose response study of glycopyrrolate and atropine. Anaesthesia avoidance of predisposing factors to the devel- begins with needle prick in the region between 1984;39:524–8. opment of OCR (cessation or modulation of the lateral rectus muscle and optic nerve. 6 Xu Zhaoxu, Luo Wenbin, Zhang Guohui, et al. surgical stimulus by administering intravenous Before the block has taken full eVect, the reflex Oculocardiac reflex and nervus vagus tension. 1988; :733–5. atropine or glycopyrrolate and by retrobulbar may be induced by stimulus of needle distur- Chinese J Practical Ophthalmol 6 anaesthesia) have reduced the incidence of bance, retrobulbar bleeding,1 or even the anaes- OCR during ocular surgery. thetic solution (2.5 ml) which probably has Sub-Tenon’s anaesthesia Sorensen and Gilmore have reported suc- eVects on intraorbital pressure within a short 1 cessful resuscitation by external cardiac mas- time. Ocular compression was found to be the EDITOR,—We congratulate Roman et al on sage following OCR. This was quoted by most common triggering event in precipitating their excellent paper on sub-Tenon’s anaes- Arndt in his reply to Scott Lang and van der the OCR in our study. Five of 30 patients thesia. We concur that it is eYcient, safe, and Val.7 In his reference Smith mentioned that as (16.7%), compared with 14 of 20 patients eVective and we agree that it is a useful form death due to OCR which Gao et al have also (70.0%) reported by Sun Yuxun2 (defined as at of supplementary anaesthesia in patients who incorrectly cited.8 The incorrect reference by least a decrease of 10 beats per minute more experience discomfort during topical anaes- Gao et al raises the issue of obligation to refer- stringent than ours) were noted to have the thesia. However, the issue of sub-Tenon’s ence carefully important points in their OCR during digital pressure of the eyeball. anaesthesia in warfarinised patients has not manuscript.9 This was highly significant by ÷2=14.48, been addressed. The potential for fatality or cardiac arrest p<0.001. The two groups were similar in Between July 1995 and December 1996, we could be chiefly the result of ignoring preven- demographics. In Sun’s study, however, retrob- performed 34 cataract extractions in warfa- tive measures. Cardiac arrest could also be due ulbar anaesthesia had not been applied before rinised patients, using sub-Tenon’s anaesthe- to cardiac toxicity by inadvertent intravascular any manipulation was performed. Therefore, sia. Thirteen of the 34 procedures were injection of local anaesthetic. Considering the we think that local retrobulbar anaesthesia de- performed in patients with prosthetic heart above danger associated with retrobulbar block, creases, not completely abolishes, the OCR. valves who required the maintenance of a high attention now is focused on a safer peribulbar To our knowledge, there are three main cri- international normalised ratio (INR). Mean block. Although peribulbar block is a safe and a teria for the OCR, irrespective of blood INR at the time of surgery was 2.5. No haem- superior procedure, its practice is mostly lim- pressure, cardiac output, and the duration of orrhagic complications were encountered 590 Correspondence, Obituary, Notices, Corrections intraoperatively. The anaesthesia was eVective the original strategy was too conservative, the A consultant post at Eastbourne Eye in all cases. A degree of subconjunctival latter is unwise for the following reasons. Hospital from 1962 was cut short by his haemorrhage was encountered in all patients Azithromycin is eVective against small, appointment at Bristol in 1963. despite the application of cautery before con- short lived, fast reproducing parasites that in The tragedy of an early onset of unrelenting junctival incision. Twelve eyes suVered sub- time will develop resistance to the drug. progressive parkinsonism with marked speech conjunctival haemorrhages involving between Widespread, inadequately controlled use of defect disrupted two lives, his own and that of two and three quadrants of the conjunctiva. azithromycin in mass treatments may trigger his wife Phoebe who nursed him devotedly at Two eyes had haemorrhage involving more early resistance and the manufacturers may home without respite throughout: her loyalty than three quadrants. There were no other forbid further use of the drug for disease con- was unquestioning. Their strength of charac- anaesthetic related complications. trol programmes. Furthermore, such an oc- ter triumphed over many years of adversity: he Warfarinised patients represent a small but currence could compromise future collabora- showed no sign of complaint or resentment, significant proportion of those requiring cata- tion between pharmaceutical companies and ract surgery. Stopping warfarin in anticoagu- although intellectually unimpaired, and en- 2 public health oYcials. couraged Phoebe’s talent for painting. lated patients can be hazardous. Underlying The objective “elimination of trachoma” is medical conditions may also make general His ability to see the logical wood for the misleading. While countries like Morocco can anaesthesia hazardous. Retrobulbar and peri- distracting trees produced swift decisive con- attempt to achieve such an objective, elimina- bulbar anaesthesia, although not contraindi- clusions presented in direct laconic style. His tion of trachoma is unfeasible in countries cated, have obvious dangers. Sub-Tenon’s surgery showed a corresponding economy of anaesthesia avoids the potential complications such as Ethiopia or Mali with drugs available fluent movement, consistent with his skill in of the aforementioned methods. Subconjunc- today. The objective in such countries should piano playing and his undergraduate swim- tival haemorrhage was the only adverse eVect be limited to “elimination of trachoma blind- ming and water polo of which he was captain that we encountered. Haemorrhage from a ness”. If the goal is not clearly articulated, at university. vortex vein is a theoretical risk of the programmes may fail to develop essential He leaves a widow; one son, a consultant technique, but has not been reported to date. techniques such as mapping of the distribu- paediatric cardiologist; and one daughter, a While topical anaesthesia oVersmanyofthe tion and severity of the disease, or methods to teacher of science; and five grandchildren. same safety advantages, sub-Tenon’s anaes- monitor and evaluate initial results. Conven- thesia has significant advantages over topical ience will guide mass treatment. As trachoma C I PHILLIPS anaesthesia in sensitive patients and in eyes is a rural disease, most of the people at risk of which are predisposed to potentially time con- blindness may be overlooked because diYcult suming complications. or expensive to reach. We conclude that sub-Tenon’s anaesthesia Countries aVected by trachoma should be deserves very serious consideration in all war- divided into two groups: farinised patients requiring cataract surgery. (1) those that could attempt to climinate the NOTICES JAMES O’REILLY disease; and PATRICIA LOGAN (2) those that should attempt to climinate Department of Ophthalmology, Mater Hospital, trachoma blindness. Eccles Street, Dublin 7, Ireland A limited number of well planned and care- Glaucoma Society (UK & Eire) fully monitored control programmes, using DAVID COLE TRAVEL FELLOWSHIP 1 Roman SJ, Chong Sit DA, Boureau CM, et al. azithromycin, should be conducted in both Sub-Tenon’s anaesthesia: an eYcient and safe types of countries to gain experience and The David Cole Travel Fellowship, instituted technique. Br J Ophthalmol 1997;81:673–6. develop needed techniques. If these eVorts are by Merck Sharp and Dohme in memory of 2 Stone LS, Kline OR Jr, Sklar C. Intraocular Professor David Cole, will assist a visit to a lenses and anticoagulant and antiplatelet successful, more ambitious programmes may therapy. Am Intra-ocular Implant Soc J 1985;11: be designed. hospital or research centre during the aca- 165–8. demic year starting 1 October 1998. The GDESOLE award will be equivalent to £2000. The 1 Pascoe Avenue, BP 6988, Harare, Zimbabwe purpose of the award is to enable the success- Reply ful applicant to gain experience and knowl- edge in pursuit of a specific project related to 1 De Sole G. Elimination of trachoma. Br J EDITOR,—I thank Drs Reilly and Logan for glaucoma. their comments on our article. Since the paper Ophthalmol 1997;81:518. has been published we have performed a few cataract extractions in anticoagulated patients. THE GLAUCOMA SOCIETY (UK & EIRE) We did not encounter any problems related to RESEARCH GRANT the anaesthesia. However, because of a The Glaucoma Society (UK & Eire) research possible massive subconjunctival haemor- grant, sponsored by the International Glau- rhage and theoretical risk of a vortex vein OBITUARY coma Association will be available for a trauma, we prefer to start the cataract surgery research project clinically orientated to glau- under topical anaesthesia with lignocaine irri- coma for 1998. The award will be equivalent gation to the anterior chamber (Gill’s tech- to £2500. nique). As mentioned by Reilly and Logan in CliVord “Grant” Tulloh, PHD, MD, MS, DO, The grant may be used towards salary or some cases (poor pupillary dilatation) the project expenses or for buying equipment. patients may still experience discomfort, we FRCS ENG, 1926–97 will then supplement the anaesthesia with an CliVord “Grant” Tulloh was consultant oph- THE GLAUCOMA SOCIETY (UK & EIRE) intraoperative sub-Tenon’s injection. We thalmologist at Bristol Eye Hospital and RESEARCH AWARD would not consider peribulbar or retrobulbar Frenchay Hospital from 1963 until Parkin- anaesthesia. son’s disease necessitated his early retirement The Glaucoma Society (UK & Eire) research SJROMAN in 1981. He attended Newcastle Grammar award, sponsored by Alcon Laboratories will Service III, Hopital des Quinze-Vingts, School, followed by the University of Durham be given in support of a research project 28 rue de charenton Paris 12 ème, France with graduation in 1949. As registrar and sen- related to glaucoma. The award will be ior registrar at Moorfields Eye Hospital (High equivalent to £2000. These awards are available to both medical Elimination of trachoma: follow up Holborn Branch) he learned clinical and sur- gical ophthalmology, to which were added graduates and non-medical scientists resident in the United Kingdom or Ireland. They may EDITOR,—In my previous letter on this research achievements in glaucoma and espe- subject,1 I stressed the importance of starting cially retina detachments as research fellow at be held concurrently with other awards. a trachoma control programme, in addition to the Institute of Ophthalmology, University of For further details and application forms the one already planned in Morocco, in one of London (1953–62). These were converted please contact: Dr S Nagasubramanian, Sec- the countries in which the disease poses a into a remarkable score of higher degrees. I retary, Glaucoma Society (UK & Eire), Glau- greater problem. However, I did not intend to was particularly impressed by his cogently coma Unit, Moorfields Eye Hospital, City support widespread implementation of tra- argued evidence that raised ocular tension, Road, London EC1V 2PD. choma elimination programmes by non- complicating iridocyclitis betrayed a predispo- The closing date for applications is 10 June governmental or other organisations. While sition to so called primary glaucoma. 1998. Correspondence, Obituary, Notices, Corrections 591

Eye injuries worldwide Nürnberg, Germany. (Tel: +49-911-393160; details: Professor I M Logai, Director, The fax: +49-911-331204). Filatov Institute, 49/51 Boulevard Francais, The latest issue of the Journal of Community Odessa, 270061, Ukraine. (Tel:+38-0482-22 Eye Health (no 24) concerns the magnitude of 20 35; fax: +38-0482-68 48 51). injuries worldwide. It covers the causes and 9th British Association of Day Surgery prevention, health promotion and eye injuries, Annual Scientific Meeting and ocular injury pattern in Pakistan, primary care Exhibition ICOP 98 of eye injuries, and epidemiology in practice. For further information please contact Journal The 9th British Association of Day Surgery The next International Conference in Ophthal- of Community Eye Health, International Annual Scientific Meeting and Exhibition will mic Photography (ICOP) will be held on 19–21 Centre for Eye Health, Institute of Ophthal- take place at the Harrogate International September 1998. Further details: Mrs Gillian mology, 11–43 Bath Street, London EC1V Centre on 4–6 June 1998. Further details: Bennerson, Senior Ophthalmic Photographer, 9EL. (Tel: (+44) 171 608 6910; fax: (+44) Kite Communications, The Silk Mill House, Bristol Eye Hospital, Lower Maudlin Street, 171 250 3207; email: [email protected]) 196 Huddersfield Road, Meltham, W Yorks Bristol BS1 2LX. (Tel: 0117-928-4677). Annual subscription £25. Free to workers in HD7 3AP. (Tel: 01484 854575; fax: 01484 developing countries. 854576; email [email protected]) VIth International Symposium on Graves’ Ophthalmology Residents’ Foreign Exchange XVIIIth International Congress of Ophthalmology The VIth International Symposium on Programme Graves’ Ophthalmology will be held on 27–28 Any resident interested in spending a period The XXVIIIth International Congress of November 1998 in Amsterdam. Further of up to one month in departments of Ophthalmology will be held in Amsterdam on details: Amsterdam Thyroid Club, Depart- ophthalmology in the Netherlands, Finland, 21–26 June 1998. Further details: Eurocon- ment of Endocrinology, F5-171, Academisch Ireland, Germany, Denmark, France, Austria, gres Conference Management, Jan van Goy- Medisch Centrum, Meibergdreef 9, 1105 AZ or Portugal should apply to: Mr Robert Ache- enkade 11, 1075 HP Amsterdam, Nether- Amsterdam, Netherlands. son, Secretary of the Foreign Exchange lands. (Tel: +31-20-6793411; fax: +31-20- Committee, European Board of Ophthalmol- 6737306; internet http://www.solution.nl/ico- ogy, Institute of Ophthalmology, University 98/) XII Congress European Society of College Dublin, 60 Eccles Street, Dublin 7, Ophthalmology Ireland. First Combined International The XII Congress European Society of Oph- Symposium on Ocular Immunology and thalmology will be held in Stockholm, Sweden Wilmer Ophthalmological Institute Inflammation on 27 June–1 July 1999. Further details: Con- gress (Sweden) AB, PO Box 5819, S-114 86 The Johns Hopkins Medical Institution/ The First Combined International Sympo- Stockholm, Sweden. Tel: +46 8 459 66 00; Residents Association of the Wilmer Ophthal- sium on Ocular Immunology and Inflamma- fax: +46 8 661 91 25; email: [email protected]; mological Institute is holding its 57th clinical tion will be held in Amsterdam on 27 June–1 http://www.congrex.com/soe/ meeting at the Baltimore-Turner Auditorium, July 1998. The meeting is sponsored by the JHH on 1–2 May 1998. Further details: Ms International Ocular Immunology and In- Sharon Welling, Conference Coordinator, flammation Society, the International Uveitis Wilmer B20 - Johns Hopkins Hospital, 600 Study Group, and the Immunology and North Wolfe Street, Baltimore, MD 21287- Immunopathology of the Eye Organisation. 5001, USA. (Tel: 410-955-5700; fax: 410- Further details: Professor Aize Kijlstra, The 614-9632). Netherlands Ophthalmic Research Institute, CORRECTIONS PO Box 12141, 1100 AC Amsterdam, Neth- erlands (email: [email protected]) 4th International Vitreoretinal Meeting Errors occurred in the article by Cleary et al The 4th International Vitreoretinal Meeting that appeared in the March issue of the BJO 2nd International Conference on Ocular will be held in Parma, Italy on 29–30 May (1998;82:225–31). 1998 at the University Eye Clinic. Further Infections In the results section, para 3 all the degree details: C Cantù and M A De Giovanni, Insti- The 2nd International Conference on Ocular signs (°) relating to the deviation measure- tute of Ophthalmology, University of Parma, Infections will be held on 22–26 August 1998 ment should be replaced by “prism dioptres”. Via Gramsci 14 - 43100 Parma, Italy. (Fax: in Munich, Germany. Further details: Profes- Similarly, in para 4 the degree signs (°) refer- ++39.521.292358; email: sor J Frucht-Pery, 2nd International Confer- ring to the 4 dioptre test should be replaced by [email protected]) ence on Ocular Infections, PO Box 50006, Tel “prism dioptres”. Aviv, 61500, Israel. (Tel: 972 3 5140000; fax: An error occurred in the article by McCarty 972 3 5175674 or 5140077; email: et al that appeared in the April issue of the 11th Annual Meeting of German [email protected]) BJO (1998;82:410–14). Ophthalmic Surgeons In Table 3 the percentage of people without The 11th Annual Meeting of German Oph- diabetes that have seen an ophthalmologist thalmic Surgeons will be held on 28–31 May XVI Tuebingen Detachment Course should be 25.4%, not 55.6%. The numbers 1998 in the Meistersingerhalle, Nürnberg, The XVI Tuebingen Detachment Course in (746/2933) are correct. Germany. Further details: Organisation retinal and vitreous surgery will be held 4–5 Nürnberg GmbH, Wielandstrasse 6, D-90419 September 1998 in Odessa, Ukraine. Further We apologise for these errors.