Presentation diag dilemma


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  • He admitted
  • At times classical differential diagnosis is not enough to explain the etiology of severe painful red eye with headache. Today I will present two patients presented with complaints of severe painful red eye with severe headache.
  • I report two cases initially diagnosed, investigated and treated variously as glaucoma, partial third nerve paresis due to diabetes and meningitis. The correct diagnosis became apparent when all investigations were normal and the patient did not respond to treatment appropriate for the initial, presumed diagnoses.
  • And excluded the possibility of keratitis, glaucoma, iritis, scleritis and orbital inflammatory diseases presenting as painful red eye
  • Sequence of events are as follow
  • This photograph of case no 2 shows the ocular findings during attack of cluster headache.
  • On ophthalmic examination following observation were made.
  • Presentation diag dilemma

    1. 1. Clinical Challenge <ul><li>Episodes of headache in past </li></ul><ul><li>BUT </li></ul><ul><li>Nature of current headache was entirely different from previous episodes </li></ul>Weapons of mass Destruction were Not found Hurricane KATERINA Created havoc Due to mismanagement OPEC denies to raise Oil production RECESSION IS RUINING US ECONOMY
    2. 2. Case presentation Dr. Sunil Kumar FRCS MS
    3. 3. Classical Differential Diagnosis <ul><li>Painful red eye </li></ul><ul><ul><li>Microbial keratitis </li></ul></ul><ul><ul><li>Acute iridocyclitis </li></ul></ul><ul><ul><li>Acute congestive glaucoma </li></ul></ul><ul><li>Painful red eye with headache </li></ul><ul><ul><li>Migraine </li></ul></ul><ul><ul><li>Sinusitis </li></ul></ul><ul><ul><li>Orbital inflammatory diseases </li></ul></ul>
    4. 4. Clinical Challenge Painful red eye with Severe headache
    5. 5. Clinical Challenge <ul><li>At 2 AM. </li></ul><ul><li>35 year-old-male </li></ul><ul><li>Unbearable pain in right eye </li></ul><ul><li>Severe headache </li></ul><ul><li>vomiting </li></ul>
    6. 6. <ul><li>Apparently the patient was restless and suffering. </li></ul>
    7. 7. Clinical Challenge <ul><li>Presumed diagnosis- MIGRAINE ATTACK </li></ul><ul><li>Inj. Diclofenac was given </li></ul><ul><li>Advised to consult internist in morning </li></ul>
    8. 8. Patient came back in morning With agonizing pain in Rt. eye, severe headache, vomiting and watery rhinorrhea
    9. 9. Patient was admitted For further evaluation
    10. 10. Detailed systemic examination Not rewarding
    11. 11. Clinical Challenge <ul><li>CBC </li></ul><ul><li>ESR </li></ul><ul><li>Renal function test </li></ul><ul><li>Liver function test </li></ul><ul><li>Serum electrolyte were within normal limit. </li></ul>
    12. 12. ENT examination was unremarkable
    13. 13. Detailed ocular examination during pain-free period was normal except for the conjunctival congestion
    14. 14. Normal CT Scan of brain EXCLUDED Intracranial space occupying lesion presenting as headache
    15. 15. Meanwhile patient was treated <ul><li>Parenteral antibiotics, metroclopramide and diclofenac for presumed diagnosis of meningitis for three days </li></ul>
    16. 16. Symptom complex resolved & <ul><li>Patient was discharged in morning </li></ul>
    17. 17. Patient came back again <ul><li>Patient returned again same day with similar complaints and he was re-admitted </li></ul>
    18. 18. Patient was re-evaluated <ul><li>History was revised again & patient revealed </li></ul>
    19. 19. Clinical Challenge <ul><li>The pain started suddenly along superior orbital margin </li></ul><ul><li>In no time spreaded to whole head but more intense in right half </li></ul><ul><li>Within minutes pain was excruciating, eye become red and he started vomiting </li></ul>
    20. 20. During episode of pain <ul><li>1mm drooping of right upper lid (ptosis) </li></ul><ul><li>Extra-ocular movements were full </li></ul><ul><li>Conjunctiva was congested & chemosed </li></ul><ul><li>Mild anisocoria with right pupil was smaller </li></ul><ul><li>Bilateral disc were pink and well defined </li></ul>
    21. 21. Normal MRI of brain excluded <ul><li>Pseudo-tumor of orbit </li></ul><ul><li>Tolosa Hunt syndrome </li></ul>
    22. 22. In the clinical settings of <ul><li>Agonizing pain in and around congested eye </li></ul><ul><li>Mild ptosis </li></ul><ul><li>Anisocoria </li></ul><ul><li>Rhinorrhea </li></ul><ul><li>Severe headache </li></ul><ul><li>Normal systemic examination </li></ul><ul><li>Normal biochemical profile </li></ul><ul><li>Normal CT brain </li></ul><ul><li>Normal MRI brain and orbit </li></ul>
    23. 23. Diagnosis was revised
    24. 24. Patient was thought of suffering from Rectuls headache
    25. 25. Treatment was commenced and episode of pain didn’t recur
    26. 26. Patient came back again 9 months later with similar complaints Symptom-complex resolved dramatically on same treatment
    27. 27. Clinical Challenge Case number 2
    28. 28. Clinical Challenge <ul><li>52 year-old-female </li></ul>
    29. 29. Clinical Challenge <ul><li>Episode of excruciating pain around left eye with severe headache for last three days </li></ul>
    30. 30. Clinical Challenge <ul><li>Pain started suddenly along left supra-orbital margin </li></ul><ul><li>Within minutes pain spreaded to scalp, around the eye and became unbearable </li></ul><ul><li>Redness of eye closely followed onset of pain and lid became ptotic </li></ul><ul><li>But vision remain unaffected </li></ul>
    31. 31. Clinical Challenge <ul><li>Inj. Diclofenac sodium was given to treat the symptom-complex at Talimi. </li></ul>
    32. 32. Clinical Challenge <ul><li>Past medical and ophthalmic history was not remarkable </li></ul><ul><li>She didn’t suffer episode of similar nature in the past </li></ul><ul><li>She was not on any chronic medication </li></ul>
    33. 33. Detailed systemic examination Was within normal limit
    34. 34. Work up <ul><li>Overt diabetic </li></ul><ul><li>Fasting blood sugar 286 mg% </li></ul>
    35. 35. Work up <ul><li>CBC </li></ul><ul><li>ESR </li></ul><ul><li>RFT, LFT </li></ul><ul><li>VDRL non reactive </li></ul><ul><li>Antinuclear antibodies were not detected </li></ul>
    36. 36. ENT examination and x-ray para-nasal sinus view excluded sinusitis
    37. 37. She was diagnosed suffering from Painful partial third nerve paresis with diabetes
    38. 38. Ophthalmic consultation was advised
    39. 39. Attack of cluster headache
    40. 40. Ophthalmic examination <ul><li>Mild ptosis </li></ul><ul><li>Conjunctival congestion </li></ul><ul><li>Intra ocular pressure </li></ul><ul><ul><li>32 mm Hg in right eye </li></ul></ul><ul><ul><li>30 mm Hg in left eye </li></ul></ul><ul><li>Well defined optic disc with CD ration of </li></ul><ul><li> 0.7 & 0.6 in right and left eye respectively </li></ul>
    41. 41. Diagnosis was revised to Painful third nerve paresis with diabetes with glaucoma
    42. 42. Automated perimetry was done <ul><li>Field changes were consistent with the diagnosis of glaucoma </li></ul>
    43. 43. Treatment was commenced with Timolol meleate 0.5% eye drops twice per day
    44. 44. IOP dropped down to 20 mm Hg But episode of symptom-complex recurred
    45. 45. Patient was revaluated again <ul><li>BCVA 6/6 in both eyes </li></ul><ul><li>No proptosis </li></ul><ul><li>Extra-ocular movements full </li></ul><ul><li>No clinical evidence of iritis or scleritis </li></ul><ul><li>Pupil were reactive without any afferent pupillary defect </li></ul>
    46. 46. Gonioscopy <ul><li>Grade 3 open angle in all quadrants </li></ul><ul><li>Absence of blood in schlemm’s canal excluded the possibility of </li></ul><ul><li>Low flow carotid-cavernous fistula </li></ul>
    47. 47. Normal contrast enhanced CT brain & orbit excluded <ul><li>Intracranial space occupying lesion </li></ul><ul><li>Orbital inflammatory diseases </li></ul>
    48. 48. In the clinical setting of <ul><li>Unbearable peri-ocular pain </li></ul><ul><li>Conjunctiva congestion </li></ul><ul><li>Mild ptosis </li></ul><ul><li>Normal contrast enhanced CT orbit & brain </li></ul>
    49. 49. Diagnosis was revised to Rectules headache
    50. 50. Treatment was commenced & Episode of pain didn’t recur
    51. 51. Final diagnosis Both patient were suffering from CLUSTER HEADACHE Both patient were suffering from CLUSTER HEADACHE
    52. 52. Both patient were treated as per Campbell protocol (Mayo clinic) <ul><li>Tablet prednisolone 60 mg/day for three days and tapered by 10 mg every third day </li></ul>
    53. 55. Cluster headache as a cause of painful red eye with headache may be missed both by internist as well as ophthalmologist.
    54. 57. Non clinic, Population based internet survey in US <ul><li>Average delay of 6.6 year </li></ul><ul><li>Average number of incorrect diagnosis 3.9 </li></ul><ul><li>Average 4.3 physician were consulted before diagnosis was made </li></ul>
    55. 58. Non clinic, Population based internet survey in US <ul><li>Average 4% of patients undergo sinus or </li></ul><ul><li>deviated septum surgery </li></ul><ul><li>Antibiotics, Propanolol and Amitryptiline were commonly prescribed </li></ul><ul><li>Klapper JA, Klapper A, Voss T. The misdiagnosis of cluster headache: a nonclinic, population-based, internet survey. Headache </li></ul><ul><li>2000;40:730-5. </li></ul>
    56. 59. CLUSTER HEADACHE <ul><li>Most painful primary headache </li></ul><ul><li>Episodic pattern </li></ul><ul><li>Attacks occur in series lasting for few days </li></ul><ul><li>Remission period lasting for months to years </li></ul>
    57. 60. International Headache Society criteria for diagnosis of cluster headache D. Pain not attributable to any other disorder. C. Attacks occur in a frequency of one every other day to eight per day 6. A sense of restlessness and agitation 5. Ipsilateral ptosis and miosis 4. Ipsilateral forehead and facial sweating 3. Ipsilateral eyelid edema 2. Ipsilateral nasal congestion and/ or rhinorrhea 1. Ipsilateral conjunctival injection and/or lacrimation B. Headache accompanied by at least one of the following: A. Severe or very severe unilateral orbital or supra-orbital and or temporal pain lasting 15-180 minutes if untreated. At least five attacks fulfilling criteria A-C:
    58. 61. Cluster headache episode <ul><li>Severe unilateral supra-orbital, orbital or temporal pain which may extend to scalp or neck </li></ul>
    59. 62. Cluster headache episode <ul><li>Pain start without any warning, </li></ul><ul><li>intensify rapidly and </li></ul><ul><li>becomes agonizing in short time </li></ul>
    60. 63. Cluster headache episode <ul><li>Frequency of attack may vary from six per day to once in a week </li></ul>
    61. 64. Cluster headache episode <ul><li>Attack of pain tend to occur at the same hour every day during a bout although additional attack may occur randomly throughout the day in some patients. </li></ul>
    62. 65. Cluster headache episode <ul><li>More than three attacks per day may mask the episodic nature of pain. </li></ul><ul><li>It seems that headache recur when the effects of analgesics wears off. </li></ul>
    63. 66. Exact etio-pathology of cluster headache Still unknown
    64. 67. Ipsilateral ventral hypothalamus Seems to play important role.
    65. 68. Cluster headache is a clinical diagnosis <ul><li>History of recurrent episode </li></ul><ul><li>Description of pain </li></ul><ul><li>Temporal profile of event </li></ul><ul><li>Accompanying autonomic menifestations </li></ul>
    66. 69. Prednisolone & cluster headache <ul><li>Corticosteroids are the most rapidly acting agent to break the cycle of cluster headache </li></ul><ul><li>1. Silberstein SD. Pharmacologic management of cluster headache.  CNS Drugs 1994; 2: 199-207 </li></ul><ul><li>2. Jammes JL. The treatment of cluster headaches with prednisone.  Dis Nerv Syst.1975;36:375-376 3. Couch JR, Ziegler DK. Prednisone therapy for cluster headache.  Headache 1978;18:219-221 </li></ul>
    67. 70. Sumatriptan & cluster headache <ul><li>6 mg. Sumatriptan has been shown to abort the attack of cluster headache </li></ul><ul><li>But it is contraindicated in patients with hypertension and ischemic heart diseases </li></ul><ul><li>If a patient suffer more than two attack per day the dosage exceed the recommended limit </li></ul>
    68. 71. Take home recipe <ul><li>High index of suspicion </li></ul><ul><li>Take detailed information about sequence of events </li></ul><ul><ul><li>Severe pain starting around the eye followed by redness of eye and headache consider cluster headache in d.d. </li></ul></ul><ul><li>Try prednisolone or sumatriptan as therapeutic test if not contraindicated. </li></ul>
    69. 72. Thank you thank you
    70. 73. Fodder for the thought Courtesy: Sunil Kumar FRCS,MS
    71. 74. Traditional D.D. of painful red eye <ul><li>Microbial keratitis </li></ul><ul><li>Acute iridocyclitis </li></ul><ul><li>Angle closure glaucoma </li></ul>
    72. 75. Painful red eye with headache <ul><li>Migraine </li></ul><ul><li>Acute sinusitis </li></ul><ul><li>Orbital infection and inflammatory disease </li></ul><ul><ul><li>Orbital cellulitis </li></ul></ul><ul><ul><li>Orbital pseudotumor </li></ul></ul>
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