The document discusses the assessment and management of headaches in ophthalmology, detailing symptoms, diagnostic processes, and identifying potential ophthalmic and intracranial causes. It highlights conditions such as migraines, cluster headaches, and the significance of recognizing alarming signs indicative of serious conditions like tumors or vascular issues. It concludes with a case study illustrating a diagnosis of Horner's syndrome due to internal carotid artery dissection requiring immediate anticoagulation treatment.

1. • Subhead
Headaches in Ophthalmology
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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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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,
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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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