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


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


Vertigo

40% Peripheral vestibular dysfunction 10% Central brainstem vestibular

lesion 25% Presyncope or disequilibrium 15% Psychiatric disorder 10% Unknown cause


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


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


Ocular cause of possible dizziness

Astigmatism Nerve palsy New glasses


Headache

Primary – migraine, tension and cluster headache

Secondary – due to an underlying structural lesion

Cranial neuralgias, facial pains


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.


Ocular causes of headache

Angle closure glaucoma, acute elevation of IOP

Temporal arteritis


Ocular causes of possible headache

Uncorrected refractive errors, sp astigmatism and presbyopia

Convergence insufficiency Dry eyes Any glaucoma Eye inflammation like scleritis


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


Migraine

Common cause of headache including around eyes

Visual aura Ophthalmic migraine without

headache Associated with nausea, vomiting,

sensitivity to bright sounds and lights


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


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


Migraine

Prodrome Aura Headache Headache termination Postdrome


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


Vision..

Uncorrected refractive error Untreated hyperopia/Presbyopia Overcorrected Myopia Accommodative spasm (eye pain,

myopia, and miosis) 20/20 vision doesn’t mean “No

glasses”


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


Clinical scenarios

Student, 17 year old with headache, specially on studying Cycloplegic refraction Convergence insufficiency Dry eyes May also have superimposed migrainous

symptoms Psychogenic!


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


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


Do not miss a life or eye threatening cause

Severe, localized Projectile vomitting With papilledema

Corneal epithelial edema

Pupillary reactions


Ophthalmologists are usually the first doctors to see a patient of headache

Some headaches are symptoms of medical emergencies.


Severe Headache

Half sided (HemiKrania=Migraine) ? Photophobia/phonophobia/scintillating

scotoma/nausea? Association - near work stress ,travel

aur …aur…aur…aur..aur


Severe Headache…

Remember!!

Migraine with aura (Classical migraine) only 10-35% Migraine and without aura > 50%

(Common migraine) [1]


Complete examination is MUST

Systemic/neurological Psychological analysis (Non verbal

clues) Vision Motility Pupils Fundus Field defects


All Ocular pathologies

Referred headache ACG Retro bulbar

neuritis


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


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)


See the IPD Prismatic effect Ensure good

centration Sply Large power Children Large heads Spectacle /Frame

change Anisometropia (walk

around test)


Strabismus

Latent Manifest All gaze positions Near and distance


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.


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.


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.

Role of Ophthalmologist – Headache and Vertigo

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