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

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
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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
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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
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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
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6. benign headache patterns
• Migraine
– +/- aura, nausea, vomiting, photophobia, phonophobia
• Cluster Headache
– tearing, rhinorrhoea, sweating, ptosis +/- miosis
• Tension headache
• Sinus disease
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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
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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
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9. “Down and out”
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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
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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.
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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
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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.
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