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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

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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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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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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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benign headache patterns

• Migraine– +/- aura, nausea, vomiting, photophobia, phonophobia

• Cluster Headache– tearing, rhinorrhoea, sweating, ptosis +/- miosis

• Tension headache• Sinus disease

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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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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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“Down and out”

9Image courtesy of www.aao.org: 4 Neuro Conditions Not to Be MissedBy 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

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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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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

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

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