Role of Ophthalmologist – Headache and Vertigo
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Transcript of Role of Ophthalmologist – Headache and Vertigo
Role of Ophthalmologist
– Vertigo and headache
Dr Suresh K Pandey
Dr. Vidushi Sharma,
MD (AIIMS), FRCS (UK)
SuVi Eye Hospital,
C 13 Talwandi, KOTA, RAJ., INDIA
www.suvieye.com
PHONE +91 9351412449
Dr. Vidushi, MD (AIIMS), FRCS
Role of Ophthalmologist
Refer timely and appropriately!
Include maximum information
Dr. Vidushi, MD (AIIMS), FRCS
Vertigo vs. other types of dizziness
Time course - vertigo is rarely continuous
Provoking factors - spontaneously or with positional changes
Aggravating factors - all vertigo is made worse by moving the head
Light-headedness, pre-syncope, fainting, disequilibrium
Dr. Vidushi, MD (AIIMS), FRCS
Vertigo
40% Peripheral vestibular dysfunction 10% Central brainstem vestibular
lesion 25% Presyncope or disequilibrium 15% Psychiatric disorder 10% Unknown cause
Dr. Vidushi, MD (AIIMS), FRCS
Medicines
Some medication can produce symptoms mimicking vestibular disorders
Vestibulotoxicity: aminoglycosides, methotrexate atiepileptics,
CNS depression : benzodiazepines, antihistamines, tricyclics,
Hypotension : antihypertensives, diuretics Inner ear haemorrhage : anticoagulants
Dr. Vidushi, MD (AIIMS), FRCS
Vertebro-basilar insufficiency
TIAs with bilateral and simultaneous blurring of vision
Flickering, flashing bright lights similar to migraine
Gaze palsy Nystagmus Visual field defects with infarction
Dr. Vidushi, MD (AIIMS), FRCS
Ocular cause of possible dizziness
Astigmatism Nerve palsy New glasses
Dr. Vidushi, MD (AIIMS), FRCS
Headache
Primary – migraine, tension and cluster headache
Secondary – due to an underlying structural lesion
Cranial neuralgias, facial pains
Dr. Vidushi, MD (AIIMS), FRCS
Good History taking
“Listen to the patient, He is telling you the diagnosis” -
Dr William Osler
We interrupt in 30 secs**Svab I. The time used by the patient when he/she talks without
interruptions. Aten Primaria 1993;11: 175-7. Blau JN. Time to let the patient speak. BMJ 1989;298: 39.
Dr. Vidushi, MD (AIIMS), FRCS
Ocular causes of headache
Angle closure glaucoma, acute elevation of IOP
Temporal arteritis
Dr. Vidushi, MD (AIIMS), FRCS
Ocular causes of possible headache
Uncorrected refractive errors, sp astigmatism and presbyopia
Convergence insufficiency Dry eyes Any glaucoma Eye inflammation like scleritis
Dr. Vidushi, MD (AIIMS), FRCS
Role of ophthalmologist
Always look at fundus of any patient with headache – disc edema, hypertensive changes etc.
Subhyaloid, preretinal hemorhages with subarachnoid nemorrhage (Terson syndrome)
Mild weakness of lateral rectus with doubtful swelling of the disc
Dr. Vidushi, MD (AIIMS), FRCS
Migraine
Common cause of headache including around eyes
Visual aura Ophthalmic migraine without
headache Associated with nausea, vomiting,
sensitivity to bright sounds and lights
Dr. Vidushi, MD (AIIMS), FRCS
Migraine
May be precipitated by some foods (cheese, banana, chocolate, preservatives, alcohol, coffee etc.)
Estrogen, oral contraceptives, hormonal changes
Bright light, glare, loud noises may trigger headache
Dr. Vidushi, MD (AIIMS), FRCS
Migraine
Migraine with aura (Classical migraine) only 10-35%
Migraine and without aura > 50%, upto 80% (Common migraine)
Positive family history Not related to eye work
Dr. Vidushi, MD (AIIMS), FRCS
Migraine
Prodrome Aura Headache Headache termination Postdrome
Dr. Vidushi, MD (AIIMS), FRCS
Giant Cell Arteritis
Immune mediated disorder
Constant throbbing pain in the temples, scalp tenderness
Associated with weight loss, fatigue arthritis (shoulder), jaw claudication
Anterior ischemic optic neuropathy
Dr. Vidushi, MD (AIIMS), FRCS
Vision..
Uncorrected refractive error Untreated hyperopia/Presbyopia Overcorrected Myopia Accommodative spasm (eye pain,
myopia, and miosis) 20/20 vision doesn’t mean “No
glasses”
Dr. Vidushi, MD (AIIMS), FRCS
Near correction “Jitni door se hamesha kaam karte
hain” Do not change the type of bifocal
segment Do not change the axis which has
been used for years/ introduce new axis
Do not change a comfortable refraction just because of optometrist
Dr. Vidushi, MD (AIIMS), FRCS
Dr. Vidushi, MD (AIIMS), FRCS
Dr. Vidushi, MD (AIIMS), FRCS
Clinical scenarios
Student, 17 year old with headache, specially on studying Cycloplegic refraction Convergence insufficiency Dry eyes May also have superimposed migrainous
symptoms Psychogenic!
Dr. Vidushi, MD (AIIMS), FRCS
Clinical Scenarios
Female, 30 year old with recurrent attacks of pain, unilateral, associated with nausea and vomitting and visual disturbances as well, better with sleep Migraine Subacute ACG
Dr. Vidushi, MD (AIIMS), FRCS
Clinical Scenarios
Elderly male, 60 year old with hypertension, irregular treatment and poorly controlled, old and frail, previous history of stroke, presents with headache and blurred vision both eyes, has bilateral cataracts Cataract with headache due to HT Giant cell arteritis with AION causing
visual disturbance
Dr. Vidushi, MD (AIIMS), FRCS
Do not miss a life or eye threatening cause
Severe, localized Projectile vomitting With papilledema
Corneal epithelial edema
Pupillary reactions
Dr. Vidushi, MD (AIIMS), FRCS
Ophthalmologists are usually the first doctors to see a patient of headache
Some headaches are symptoms of medical emergencies.
Dr. Vidushi, MD (AIIMS), FRCS
Severe Headache
Half sided (HemiKrania=Migraine) ? Photophobia/phonophobia/scintillating
scotoma/nausea? Association - near work stress ,travel
aur …aur…aur…aur..aur
Dr. Vidushi, MD (AIIMS), FRCS
Severe Headache…
Remember!!
Migraine with aura (Classical migraine) only 10-35% Migraine and without aura > 50%
(Common migraine) [1]
Dr. Vidushi, MD (AIIMS), FRCS
Complete examination is MUST
Systemic/neurological Psychological analysis (Non verbal
clues) Vision Motility Pupils Fundus Field defects
Dr. Vidushi, MD (AIIMS), FRCS
All Ocular pathologies
Referred headache ACG Retro bulbar
neuritis
Dr. Vidushi, MD (AIIMS), FRCS
Refraction tips
Correct cylcloplegic Relax accomodation in A
refractometer Myopics:Do the ‘Duochrome” test
(each eye) High power glasses in last cell of trial
frame See for pantascopic tilt
Dr. Vidushi, MD (AIIMS), FRCS
Tips for refraction…
Undercorrect Myopes (Sply high minus)
Do not overcorrect H metropes Reduce quarter of Cylindrical power Graded wear/increase of Cylindrical
power (except pseudophakes)
Dr. Vidushi, MD (AIIMS), FRCS
See the IPD Prismatic effect Ensure good
centration Sply Large power Children Large heads Spectacle /Frame
change Anisometropia (walk
around test)
Dr. Vidushi, MD (AIIMS), FRCS
Strabismus
Latent Manifest All gaze positions Near and distance
Dr. Vidushi, MD (AIIMS), FRCS
Convergence deficiency
Orthophoria for distance and exophoria for near show
Primary/H metropia/Myopia/presbyopia
NPC: Normal 8 cms “Pencil push up” Over minus and less plus Base in prism/bifocals.
Dr. Vidushi, MD (AIIMS), FRCS
Activation of the trigeminal autonomic reflex arc also accounts for Holmes adie pupil on the symptomatic side.
Eyelid edema, redness, lacrimation, or nasal congestion, during the migraine attacks are more likely to respond to sumatriptan, a serotonin receptor agonist.
Dr. Vidushi, MD (AIIMS), FRCS
Cluster headache, also known as histamine headache severe and unilateral typically are located at
the temple and periorbital region. Associated with ipsilateral lacrimation, nasal
congestion, conjunctival injection, miosis, ptosis, and lid edema.
Each headache is brief in duration, typically lasting a few moments to 2 hours. Cluster refers to a grouping of headaches, usually over a period of several weeks.
To fulfill criteria for diagnosis, patients must have had at least 5 attacks occurring from 1 every other day to 8 per day and no other cause for the headache.
Dr. Vidushi, MD (AIIMS), FRCS