When brakes fail you: Oculocardiac reflex elicited by a retained foreign body in a penetrating orbital injury

Abstract

Purpose: To report a case of oculocardiac reflex following penetrating orbital injury with entrapment of extraocular muscle secondary to a retained orbital foreign body. Observation: A 19-year-old man with no known comorbidities presented with a foreign object in his right orbit following a motor vehicle accident. Visual acuity was 20/20 bilaterally with positive relative afferent pupillary defect for the right eye. A motorcycle brake lever was embedded in the right inferotemporal conjunctival fornix, missing his globe. He was bradycardic in the emergency department, with a pulse rate ranging between 45 and 48 beats per minute. An urgent computed tomography scan of the orbit confirmed the penetrating injury with a linear hyperdense foreign body extending from the right inferior orbit into the right maxillary sinus. This foreign body was seen abutting the right lateral rectus and the globe inferiorly. Fractures involving the inferior and medial wall of the right orbit were seen with the inferior rectus, and orbital fat herniated into the maxillary sinus.The patient underwent urgent orbit exploration with foreign body removal and orbital floor repair under general anesthesia. Immediately after removing the foreign body, his pulse rate returned to normal, within 72–80 beats per minute. Six months postoperatively, visual acuity was 20/20 for both eyes. Although he had persistent diplopia on upgaze, he refused any other interventions. Conclusion and importance: Prompt detection of the oculocardiac reflex and removal of the inciting stimulus is vital to prevent any life-threatening events.

Keywords

• Oculocardiac reflex
• Penetrating orbital injury
• Intraorbital foreign body
• Orbital floor fracture