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Headaches in Ophthalmology

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Headaches in Ophthalmology: A presentation on Headaches - How to diagnose and treat ophthalmic causes of headache.

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Subhead Headaches in Ophthalmology HEADLINE TO GO HERE Dr Paula Berdoukas General Ophthalmologist
symptoms for the optometrist Pain concentrated around the eye Headache with any associated ophthalmic symptom blur, double vision, redness, photophobia, visual aura 2
aim of assessment Diagnose and treat ophthalmic causes of headache Recognise benign headache patterns with ophthalmic feature Recognise ophthalmic symptoms or signs of intracranial or systemic cause of headache Know when to refer 3
assessment VA Refraction under corrected hypermetropia, overcorrected myopia, presbyopia Slit Lamp examination IOP Neurologic assessment VF, EOM, Cranial Nerves, Pupils Skin/Scalp rash, temporal A 4
ophthalmic causes of headache Visible corneal abrasion/ infection, iritis, scleritis Refractive error mild frontal headache, worse with prolonged visual task Heterophoria/ Heterotropia mild frontal headache, intermittent blur or double vision Angle Closure Glaucoma Severe pain around eye, haloes, loss of vision, redness Pigment dispersion Syndrome intermittent blur, haloes and eye pain after exercise or pupil dilation Herpes Zoster Ophthalmicus pain, hyperesthesia, rash or vesicles in Vi +/- ocular inflammation 5
benign headache patterns Migraine +/- aura, nausea, vomiting, photophobia, phonophobia Cluster Headache tearing, rhinorrhoea, sweating, ptosis +/- miosis Tension headache Sinus disease 6
What not to miss: headache with an intracranial origin Causes tumors, inflammation, infection (meninges or paranasal sinuses), arterial dissection or aneurysm, benign intracranial hypertension History recent onset or increasing severity, constant, worse with coughing, straining or lying down normal vision, transient obscurations of vision, visual field defects Examination anisocoria, ptosis, disc swelling, cranial nerve palsy 7
Pupil Involving IIIrd nerve Palsy IIIn function EOM: MR, IR, IO, SR, Levator PARA to iris sphincter and ciliary mm Symptoms Acute headache, double vision, nausea, neck stiffness Signs Ptosis, EOM limitation (SO and LR work unopposed), pupil dilated Dx: Post Communicating A aneurysm DDx: vasculopathic, GCA, demyelination, stroke, metastasis, trauma 8
Down and out 9 Image courtesy of www.aao.org: 4 Neuro Conditions Not to Be Missed By Marianne Doran, Miriam Karmel, and Annie Stuart
giant cell arteritis age > 50 years headache recent temple/ frontal headache and tenderness vision acute severe vision loss, amurosis fugax, diplopia systemic jaw claudication, polymyalgia, malaise, weight loss, fever, sweats Signs field loss or blur RAPD swollen, pale or hyperemic disc retinal ischemia EOM defect tender non-pulsatile temporal artery 10
Mr SN 58 yr old 1 week of headaches and right ear ache 1 year of shoulder pain and cervical spine spurs, sees chiropractor. On his most recent visit, prior to any manipulation, chiropractor noted L pupil was dilated and R lid droopy: referred to optom who referred to ophthl. 11
Mr SN BCVA 6/5 OU pupils light: OD 3mm, OS 4mm pupils dark: OD 4mm OS 6mm lids: MRD OD 3mm, OS 5mm RUL 2mm ptosis EOM full, no diplopia 12 image courtesy www.reviewofophthalmology.com
Provisional Diagnosis: Horners Syndrome secondary to ICA dissection DDx: Malignancy, stroke, aneurysm, Image courtesy of younglivingforum.com 13
Image courtesy of mmcneuro.wordpress.com MRI/ MRA: dissection of the RIGHT cervical ICA extending into the proximal carotid canal Treatment: emergency admission for anticoagulation: heparinisation then warfarin. 14

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Headaches in Ophthalmology

  • 1. Subhead Headaches in Ophthalmology HEADLINE TO GO HERE Dr Paula Berdoukas General Ophthalmologist
  • 2. symptoms for the optometrist Pain concentrated around the eye Headache with any associated ophthalmic symptom blur, double vision, redness, photophobia, visual aura 2
  • 3. aim of assessment Diagnose and treat ophthalmic causes of headache Recognise benign headache patterns with ophthalmic feature Recognise ophthalmic symptoms or signs of intracranial or systemic cause of headache Know when to refer 3
  • 4. assessment VA Refraction under corrected hypermetropia, overcorrected myopia, presbyopia Slit Lamp examination IOP Neurologic assessment VF, EOM, Cranial Nerves, Pupils Skin/Scalp rash, temporal A 4
  • 5. ophthalmic causes of headache Visible corneal abrasion/ infection, iritis, scleritis Refractive error mild frontal headache, worse with prolonged visual task Heterophoria/ Heterotropia mild frontal headache, intermittent blur or double vision Angle Closure Glaucoma Severe pain around eye, haloes, loss of vision, redness Pigment dispersion Syndrome intermittent blur, haloes and eye pain after exercise or pupil dilation Herpes Zoster Ophthalmicus pain, hyperesthesia, rash or vesicles in Vi +/- ocular inflammation 5
  • 6. benign headache patterns Migraine +/- aura, nausea, vomiting, photophobia, phonophobia Cluster Headache tearing, rhinorrhoea, sweating, ptosis +/- miosis Tension headache Sinus disease 6
  • 7. What not to miss: headache with an intracranial origin Causes tumors, inflammation, infection (meninges or paranasal sinuses), arterial dissection or aneurysm, benign intracranial hypertension History recent onset or increasing severity, constant, worse with coughing, straining or lying down normal vision, transient obscurations of vision, visual field defects Examination anisocoria, ptosis, disc swelling, cranial nerve palsy 7
  • 8. Pupil Involving IIIrd nerve Palsy IIIn function EOM: MR, IR, IO, SR, Levator PARA to iris sphincter and ciliary mm Symptoms Acute headache, double vision, nausea, neck stiffness Signs Ptosis, EOM limitation (SO and LR work unopposed), pupil dilated Dx: Post Communicating A aneurysm DDx: vasculopathic, GCA, demyelination, stroke, metastasis, trauma 8
  • 9. Down and out 9 Image courtesy of www.aao.org: 4 Neuro Conditions Not to Be Missed By Marianne Doran, Miriam Karmel, and Annie Stuart
  • 10. giant cell arteritis age > 50 years headache recent temple/ frontal headache and tenderness vision acute severe vision loss, amurosis fugax, diplopia systemic jaw claudication, polymyalgia, malaise, weight loss, fever, sweats Signs field loss or blur RAPD swollen, pale or hyperemic disc retinal ischemia EOM defect tender non-pulsatile temporal artery 10
  • 11. Mr SN 58 yr old 1 week of headaches and right ear ache 1 year of shoulder pain and cervical spine spurs, sees chiropractor. On his most recent visit, prior to any manipulation, chiropractor noted L pupil was dilated and R lid droopy: referred to optom who referred to ophthl. 11
  • 12. Mr SN BCVA 6/5 OU pupils light: OD 3mm, OS 4mm pupils dark: OD 4mm OS 6mm lids: MRD OD 3mm, OS 5mm RUL 2mm ptosis EOM full, no diplopia 12 image courtesy www.reviewofophthalmology.com
  • 13. Provisional Diagnosis: Horners Syndrome secondary to ICA dissection DDx: Malignancy, stroke, aneurysm, Image courtesy of younglivingforum.com 13
  • 14. Image courtesy of mmcneuro.wordpress.com MRI/ MRA: dissection of the RIGHT cervical ICA extending into the proximal carotid canal Treatment: emergency admission for anticoagulation: heparinisation then warfarin. 14

Editor's Notes

  • #3: General History: associated neurological symptoms, nausea, vomiting, GCA symptoms, BP, medications
  • #6: Refractive error: mild frontal/ ocular ache. Absent on waking. Precipitated by prolonged visual tasks. Should respond well to glasses Heterophoria/ Heterotropia: mild frontal headache, intermittent blur or double vision. Difficulty adjusting focus. Worsens through the day. Angle Closure Glaucoma: may be intermittent. Severe pain around eye, haloes, loss of vision, reddness, Elevated IOP and shallow angle Herpes Zoster Ophthalmicus: pain or hyperesthesia in Trigeminal distribution. Rash or vesicles. Ocular inflammation: conjunctivitis, keratitis, iritis, elevated IOP