A pediatric case of significant oculocardiac reflex activation with orbital edema

Oculocardiac reflex activation is a rare potential cause of severe hypotensive and/or bradycardic events that threaten hemodynamic stability. It is typically observed after facial trauma, but it can also result from edema secondary to orbital pseudotumor and myositis, sarcoidosis, IgG4 disease, and Graves' orbitopathy. A previously healthy 10-year-old girl with no history of trauma presented with a 2-week history of right eyelid swelling, "drooping," and photophobia, with significant bradycardia on lateral gaze. She did not tolerate initial eye examination because of worsening bradycardia, which required admission. Extraocular muscle biopsy revealed scarring and fibrosis of the right lacrimal gland and medial rectus muscle. She was found to have elevated serum IgG4 level and was treated with intravenous methylprednisolone, with subsequent improvement in her hemodynamic status.