headaches in ophthalmology
DESCRIPTION
Headaches in Ophthalmology: A presentation on Headaches - How to diagnose and treat ophthalmic causes of headache.TRANSCRIPT
HEADLINE TO GO HERE
• Subhead
Dr Paula BerdoukasGeneral Ophthalmologist
Headaches in Ophthalmology
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”
9Image 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 dissectionDDx: Malignancy, stroke, aneurysm,
Image courtesy of younglivingforum.com13
• MRI/ MRA: dissection of the RIGHT cervical ICA extending into the proximal carotid canalTreatment: emergency admission for anticoagulation: heparinisation then warfarin.
Image courtesy of mmcneuro.wordpress.com
14