Lecture: Headaches in Optometry From Routine to Sinister: A Case Based Presentation

>> HUSAIN PATANWALA: So, greetings, everyone. Thank you for joining in today. And before I start, I would like to thank Cybersight for giving me this opportunity to present on a topic that is quite commonly seen by eye care professions across the globe. I’ll start my presentation first. So the topic for today is headaches in optometry, from routine to sinister. My journey started in India. I’ve always been intrigued with the variety of headache presentations that I eye care professionals see every day. During that time, there wasn’t a guide or a kind of a battery of tests that existed. So I started my journey in a hospital setting, and I worked in an institute, and after that I worked in a private hospital in India. And currently I work at Specsavers in the United Kingdom. The definition of optometry says that you are a primary health care professional. And I didn’t quite understand that, initially, until I started seeing patients in day to day practice, and I realized that actually we are the first point of contact for many patients with different visual complaints, including headaches. And it’s so, so important for us to differentiate or understand where this headache is coming from. And that stems from very strong communication that you portray in front of the patient, and also comes with a little bit of clarity, of what are the headache presentations that are commonly seen in day to day practice. And so for today’s presentation, we are going to look at some of the cases that I have seen throughout the years. Before that, we’ll just talk a little bit about some facts. So almost 50% of the population suffers with some kind of headache. So if you imagine, in a week’s time, you’ll actually see half of your patients will have some kind of, you know, headache. And it could be related to refractive error. It could be related to their general health, to some kind of medication that they’re using. And like I said, optometrists are often the first point of contact for patients with headaches. Also when we talk about headaches in general, nowadays, because the population in general and especially children are consuming and processing information, we are seeing new variants of headache every single day. Even if we talk about a basic thing like migraines, even that is such a huge topic, because there are different triggers that keep coming up every single day. And it’s important for to us keep updated of what kind of trigger exists in society, in our day to day life, and what kind of population is affected by it, be it the young population or the millenials or the older population. And age is a great way to start, you know? So why is this presentation case-based? So the reason is because evidence-based practice is something which is invited now. And we first used to look at textbook knowledge, whatever we see is the textbooks is basically the gospel for us. But nowadays people are leaning into more about case-based discussions, because the reality is a bit different from what we see or read in textbooks. Also optometry, and eye care education in general, is so different in different parts of the world, that sometimes fresh graduates, like I was when I started out, they are kind of confused when it comes to clinical management guidelines. And this can lead to a lack of co-management between specialists and optometrists or general physicians. And this can be a bit frustrating for patients. So we’ll try and understand that a little bit better. So, our first poll question. Which of these is the most common cause of neurological disability globally? So let’s see. We’ll just give a few seconds for you to answer that question. Right. So we have a good split of options here. Most of you, 64% of you, have said migraine, which is correct, because migraine is very, very common. Migraine can actually cause a bit of disability to the patient. This is something we need to identify for the patient. So we come to our first case of the day. So over here we have a 30-year-old social media manager who comes for an eye test with many episodes of zigzag lights, half moon shape, in the last two months, which lasts about 30 minutes, which covered part of her vision. She reported a left sides headache that lasted a few hours. She also reported intolerance to indoor lighting. She slept it off. No medications, no family history of eye disease or systemic ailments, no eye redness, no nausea, does not wear glasses. Her media use is quite high, she is a social media manager so she works on computer screens a lot. So her vision is great. Her pressure is also quite normal. When we look at the anterior segment, it looks unremarkable. The anterior chamber is deep, iris is flat, vitreous, negative Shaffers. We need to understand that, hey, is this something pathological or is this something related to her getting a bit of a headache? And so we need to differentiate that. Irrespective of a patient who comes with or without headache, if they have flashes or floaters in vision, or they see scintillating lights, we have to do a dilated examination, which was unremarkable again. The pupils were reacting normally and the color test was normal. Eye muscles were also working properly. We did a formal field test as well. In this case you can actually do a confrontation test as well, which is 70% of the time it actually gives us a good amount of knowledge that, okay, are there any vision field defects that we need to be worried about. Because again, if there is a problem of headaches and the patient is having a vision field defect, that changes the game. But over here there is no vision field defect, that is good. Now she was referred to the GP with a probable diagnosis of migraine. This is a diagnosis of exclusion, because we did a thorough eye examination and found that actually she doesn’t have any kind of retinal abnormality. Now, she did go to GP, she ended up going to the headache specialist as well. We followed up with her off three months, and she was very happy, actually. So we were surprised to know that because the GP directed her and because she had made some lifestyle changes and also dietary changes, that greatly improved her condition. She wanted to avoid taking any medications like topiramate, a very common medication given for migraines, but she was getting less migraines day by day, which was great, because over here we kind of sign-posted her to a specialty and she got great advice from them. Now, riboflavin and magnesium supplementation is said to improve migraines. So that is something that is generally beneficial for most migraine patients. Not all, because we also have to identify the trigger for it. For this patient, the trigger was probably excessive VDU use, and again, regular relief pattern and stress relief, these lifestyle modifications greatly improved her symptoms. Indirectly, an optometrist could help her get rid of the migraines or manage them so they wouldn’t become so frequent, and slowly she will realize, okay, are there any changes in her diet? There are some foods that are also kind of migraine triggers ranging from chocolate to cheese to alcohol, also smoking. So these are the things that probably a person should avoid or we should ask as a screening question for them. Let’s move on. Right. So there is another type of headache which is called as cluster headaches. Both migraines and cluster headaches can present with pain that is around the eye and behind the orbit. And this can be a bit of a confusing situation for us. We need to understand, what is cluster headache? Cluster headache is actually a trigeminal autonomic cephalgia, short lasting unilateral neuralgiform headache. It can cause puffiness around the eyes. It can cause ipsilateral ptosis, conjunctival injection, and lacrimation. We need to differentiate what a cluster headache versus what is a migraine, because the management may be slightly similar, but we will understand if the cluster headache is causing any kind of lacrimation or conjunctival inflammation or is actually some kind of an infection that is causing that lacrimation. So in this case it will be a headache that is causing the lacrimation. That is really important to know. Cluster headache also is closely related to lifestyle modification. So smoking, dietary changes that a person can make in their lifestyle, alcohol intake can also cause cluster headaches. So that’s why migraines and cluster headaches are quite similar. In addition to pain around the orbit, the migraines can also cause blurry vision, scintillating lights in the vision. This can occur before the headache can occur. There is another type of migraine which you just get the aura, you just get lights in your vision but sometimes you don’t get the headache. And that is also sometimes called as an ocular migraine. And as the intensity peaks, then you can get a headache or you may not get a headache. Mostly, you get a headache. This is called a visual aura, scintillating lights that you see. This can last for five to 60 minutes and it can cause sensory or speech disturbances. A common misconception is that the aura can happen prior to a headache. This is often not the case, it can happen any time during the migraine. This is a good acronym when you look at symptoms which might be related to migraine but we don’t know whether it is a migraine or not. So PEANUT is a good acronym. Photophobia, episodic, it comes and goes in episodes, and there is usually a trigger attached to it. It is important to ask the patient what is their lifestyle and activities they were doing before they got the migraine or the headache. The visual aura may or may not be present. Sometimes there can be nausea and vomiting as well, because it is a neurological phenomena, and it can cause nausea and vomiting as well. It can be on either side, it can alternate, it can be on one side or the other side. Less commonly, it can be bilateral as well. So that is a rare case. There is always an exception to a rule. The headache will be a throbbing kind of a headache. Because it’s episodic and because you have photophobia, we can kind of confidently say that, okay, this sounds like a migraine. And especially if they are not wearing any glasses or they don’t have any other kind of blurriness of vision or reading difficulties and stuff like that. So that was about migraines. And now we move to our second case. So the case is called nocturnal pain. So here we have a 46-year-old female who came for her annual test with episodes of right side pain in the temple area and also behind the eye since a few months. She noticed it first when she was watching a movie. It has happened at least eight times. She Googled and self-diagnosed it as a tension headache and she has planned to go to the headache specialist. Her systemic health is good and she’s not on any medications. No family history of eye disease or systemic ailments. No eye redness, discharge, or nausea. She is a plus 4.25, plus 4.50. This gives us an indication what the anterior segment would look like. No infections or hospital visits. So over here we can see that, again, her vision is 6/6 and 5. Pressures are 31 in the right eye and 24 in the left eye, measured in GAT, the gold standard for eye measurement. Her Van Herick’s is grade 1. We dilated her, and obviously we have to be careful before we dilate such a patient. Probably you can instill one drop, just to get a little bit of dilation, just enough to check the disc. It’s important to check the disc in this patient. And I show the photos, we also did her field test with no defects seen. Pupils were normal. Now, this was her photo. You can see in the right eye there is a bit more cupping that you can see compared to the left eye. In the right eye I would say it’s like a .65 to .7 cup, in the left eye, .3, .25. There is a bit of optic neuropathy going on. This is a closure, essentially. The patient was referred for glaucoma management. Her IOPs are stable now and she’s not getting any headaches. Whenever we think about textbook, we say that angle closure attack, you have a hard eye and you have like intense pain and you have halos in the vision, but that’s not always the case in clinical practice. Sometimes the patient might get episodes of pain, especially at nighttime. So in this patient we found that she was having pain when she was in the cinema or probably in an area where the pupil was dilating, so that was triggering an angle closure scenario. And that was causing the pain, because the pressures rise. And this is important to differentiate, because if we classify it as a primary headache and treat her, that would be — that wouldn’t make sense, because it wouldn’t cure her for headaches. When we did the laser PI, her IOPs were stable and we followed her up and her IOPs have been normal. So she was very grateful. Now we come to a second poll question. Which of the following ethnic groups have the highest prevalence of angle closure glaucoma? Is it Africans, European descent, Inuit Eskimos, Arab or Middle East descent? We’ll give you a little bit of time before we look at the poll answers. So we have a good split of answers. I like to explain a little bit about why I chose these options. So in Africans, actually primary open angle glaucoma is most commonly seen. And actually angle closure is seen in east Asian populations and also Inuit Eskimos as well as because their anterior segment is angular compared to other groups. They have the highest prevalence of angle closure glaucoma. East Asians, Japanese, Chinese, Southeast Asian populations, also have high prevalence of angle closure glaucoma because of the anterior segment or how anatomically placed the angle is for them. So hopefully that makes sense now. Our third case, this is a case I actually saw earlier in my career. So 14-year-old male came for an eye test complaining of frontal headaches since a few weeks and difficulty in seeing the board in class. He had just given his exams. Unaided vision was 6/18 and 6/12. The other factor reading was minus 5 and minus 4, quite high, high amount of myopic correction is shown. And the retinoscopy reflex was fluctuating, definitely something going on. We found in the cycloplegic refraction there wasn’t any myopia, it was basically a spasm of the ciliary body which was causing this. We checked his anterior segment, everything was fine, the pupils were fine. Motility, eye muscles, no double vision or anything like that. So we diagnosed him with accommodative spasm, it’s called pseudo myopia, that’s why the word “false alarm.” Obviously it differs from country to country. In some country atropine is legally used but in some countries it may not be allowed in a primary eye care settling. Atropine 1% therapy was initiated every alternate day at bedtime for the first two weeks, then gradually tapered down for four weeks to prevent rebound accommodation. Atropine knocks off the accommodation. We need to make sure if the patient has any side effects of atropine because atropine is a bit of a stronger medication. But it does knock off the ciliary body and in this case that’s needed. At ten weeks refraction was needed and the symptoms were significantly improved. Although we found very little myopia after that, so we refracted her almost after three months. But, you know, the spasm had gone down, and both eyes’ vision was good. We gave him plus 1 lenses for reading to reduce the accommodation. These children can have a spasm accommodation again, they can be susceptible to have spasm accommodation. We also advised reduced prolonged near tasks, outdoor activities, and reduce screen time. This is important as well because excessive screen time is a big trigger for spasm of the ciliary body and this can cause pseudo myopia. So in this case, this was a reason for the headaches. So we managed him in our practice. So what are the other treatments? If you’re a bit apprehensive about choosing atropine because obviously we find, okay, the younger the kid, probably atropine would be better to knock off the ciliary body. You can use cyclopentolate and homatropine. If the child is quite young, around five to six years old, vision therapy also helps, to train the accommodative facility, to control the accommodation and not allow the accommodation to go into a spasm. And it’s best for students and long term improvements. And like we said, plus lenses for near work, in combination with vision therapy, will be very good for long term results. So that is something that can be done if, say, for example, there is a high near work demand. So that’s for students, and even for professionals, sometimes, you know, electricians, jewellers, they are at near distances. Cycloplegics shouldn’t be given for long term to break the spasm, they should be given a short while to break the spasm and provide immediate relief. And later on, vision therapy and plus lenses are used to rebuild healthy accommodation. Lifestyle, ergonomics, and VDU are used to prevent recurrent episodes of accommodative spasm. This is something we see in practice, especially optometrists are seeing. Sometimes it’s something like a hidden spasm of the muscle which needs to be managed. Now, the most popular cause of pseudomyopia is definitely excessive near work. And that leads us to our third poll question. Which of these can be a cause of pseudomyopia? Is it anxiety/stress, head trauma, excessive near work, or all of the above? Again, I’ll just give a few seconds for you guys to answer it. Right. So we’ve got our answers here, and so we have 48% who said all of the above. And all of the above is the correct answer. So if look at case reports you’ll find case reports of patients with anxiety, stress, where they have triggered an accommodative spasm. And that could be some kind of activity they’re doing when they’re anxious or stressed. And that could include excessive near work. And head trauma is also one of the causes. It’s very, very less common but it’s still there. And head trauma basically affects the parasympathetic nervous system which affects the ciliary body and it can spasm, so it can stimulate the ciliary body. We’ve seen case reports of pseudomyopia in all three cases. It’s helpful to remember that if your patient is suffering from anxiety, stress, or if the patient has had a head trauma or has been in a traffic accident, for example, or like we discussed in the case, excessive near work, all these reasons can be potential cause of headaches and pseudomyopia. So hopefully that makes sense to you. And so we go to our fourth case. So over here we have a 32-year-old female, came for routine eye test complaining of random frontal and temporal headaches which are worse in the morning, and it started a few weeks ago, it’s every day. She’s also got ringing sensation in her ears, ringing sound, which makes her vision blurry for a few minutes. She’s been taking paracetamol which occasionally helps. Again, we notice that there’s no flashes, floaters, curtain, or gray patches in vision. It’s important to ask these questions, you know, because we need to differentiate whether the blurring of vision or the headache is related to some kind of migraine. Is it a migraine? Or is it some kind of, you know, activity in the vitreous, is that causing a headache to them? Are they seeing any kind of gray patches in vision or shadow in vision which again could mean some kind of retinal tear or detachment? It’s important to ask these questions. Nausea is also important to ask, it’s causing ringing sensation so we want to understand this more deeply. She’s a new mother, she’s taking care of her six-month-old baby, her systemic health is good and she’s not on any medications. What are the key points in history-taking? We need to understand in terms of LOFTSEA, which is a great tool for history-taking especially when you want to identify something beyond your routine kind of headache cause. So let’s walk through this case report because a great case to understand LOFTSEA. We can see it’s not connected to one eye, it’s both sides. And we rate that as 7 out of 10, not your normal headache. It’s a little bit annoying which can cause a little bit of disability as well. Since a few weeks every day, associated systems, ringing sound in the ears. Type of and severity, frequency, she said it’s every day. Self-treatment, she says she’s using paracetamol. It makes her vision blurry and it’s in the morning, so that is kind of something to worry about. And associated symptoms, like she said it’s blurry vision. So you kind of summarize everything in kind of a few lines, when you use LOFTSEA. It’s a great tool to understand where the headache is coming from, what could be the timing and frequency of the headache, how severe it is, and are there associated symptoms. It’s going to be really helpful for us to join the dots. So this was her fundus images, right? So as you can see over here, it’s not a normal fundus picture. You can ignore the shadow on the macula, but you can see the optic nerve. The optic nerve is something I wanted to show you. We can see there is a bit of blurry margins here and tortuosity of the vessels. There is a pressure on the nerve, this kind of clinical picture can arise. This makes us a bit suspicious that there is some kind of pathology involved. As you know, the eyes, the ears, the nose, are kind of connected. Sometimes when people have any kind of of issues with cerebrospinal fluid, sometimes they have a leaking nose as well. That’s something you need to keep in mind. So these are the clinical findings. Her vision is great, 6/6 and 5. Pressures are normal. Anterior segment is fine. We did saturation and she did fine in one eye. The color is slightly washed out compared to another eye. Red desaturation is important tool, if there is a shift in the perception color vision. We did field vision test, I don’t have that for you today but there was enlarged blind spots, swelling of the nerve here. Both eyes blurry and elevated disc margins with torturous blood vessels with no obscure vessels and no patons lines. We used 78D indirect lens. Because the Van Herick is deep, we’re not looking at glaucoma or anything like that, we are definitely not looking at migraines because there’s no photophobia or anything like that. The headaches are worse in the morning. Probably a positional change is something we’re looking at which can make the headaches worse. How do we grade this fundus picture? So that brings us to our fourth poll question. So which of the following scale is used to grade optic nerve swelling? Is it Shaffers, Frisen, Smith’s, or Spaeth? If you’ll be kind of enough to answer and we’ll look at the answers. So we have a good split of answers, again. So just to reiterate, Shaffers grading system and Spaeth grading system are actually used to measure the angle of the anterior chamber. Smith’s grading system is used to measure the depth. The Frisen scale is the exact answer. What is Frisen scale? You may not have heard about it, it’s not a popular scale. But this is the Frisen scale. Is out of grade 1 to grade 5 over here. This is quite popularly used by neuroophthalmologists and hospital eye settings as well. So what’s the first grade? If there is a C-shaped halo surrounding the disc and sparing of temporal dismargin, and there is a bit of a disruption in the radial null fiber layer, what superficially exists in the disc. A C-shaped halo will be grade 1. The grade 2, the halo will become circumferential. If there is a swelling of the optic nerve, it may mean the nerve fiber is affected and it will cause swelling of the nerve fiber. In grade 3 there is obscuration of the vessels on the disc. You’ll find the vessel has become a bit hazy. That is because of the swelling of the nerve fiber layer and the compression on the vessels. Now, when the vessels get compressed, that’s when you will find hemorrhages. These are disc-shaped or flame-shaped hemorrhages which are kind of restricted around the disc. These are because of the pressure gradient behind the eye and within the nerve, which causes this kind of swelling. And grade 5, you have obscuration of all the vessels, all the vessels that are leaving the disc, you can’t see them, they’re hazy around the edges. This would indicate grade 5. When do we — the most common conditions where we would see disc swelling would be capillary edema, increased hypertension, it causes this. And also hypertensive retinopathy. Malignant hypertension can also present with very severe headache which can be caused by raised high blood pressure. It can cause swelling of the disc. It can be unilateral or bilateral. This is one of the conditions we need to watch out for because this is a red flag. And the patient was seen as an emergency to hospital eye service for further investigations, head scans and treatment. For the followup, the diagnosis of IIH, idiopathic intracranial hypertension, mostly due to recent weight gain. Also if there is any kind of fluid in the head, for example if the mass lesion in the head or there is a compression of the nerve due to an aneurysm, that can also cause kind of headache symptoms. And that also warrants a neurological examination. So we need to refer this patient for MRI, CT scans, because this is something that needs to be managed immediately, because the patient can actually lose their life if not managed properly or not referred properly. A lumbar puncture is used, it’s a little bit painful procedure where the cerebrospinal fluid is actually drained. So the lumbar puncture is above 200, 250 in obese patients, a classical clinical picture of IIH. It’s also diagnostic as well, and therapeutic as well, because if the pressure reduces, it’s therapeutic for the patient and they can get rid of the headaches. A patient might need multiple lumbar punctures. If his idiopathic, due to a mass lesion, that needs to be operated on as well. So optometrists need to be aware of how to manage this kind of a patient. For example, if someone comes with morning headaches and they have started suddenly, a few weeks, if there is a whooshing sound in the ears, if it is causing dizziness, transient blurriness, if it is causing field loss, that is a red flag. That means this patient is not your routine refractive patient, this patient has some pathology going on probably around the head or the spinal cord. This patient can also present with some kind of recent head trauma which has caused hemorrhage or they can present reason routinely. Sometimes they have a family history of probably a tumor or a family history of IIH. So it’s important to understand there are different kinds of pressures that affect the eye. So one is the intraocular pressure. Second is the cerebrospinal fluid pressure in the head. This is something that optometrists need to differentiate. Everything is normal but the discs are blurry or swollen, then something is going on in the back of the eye. These are the classical symptoms. So we have headache. When there is a positional change, which the patient is waking up, that can cause a bit of a headache. Nausea and vomiting. If the rise in intracranial pressure is severe, nausea and vomiting may occur because it also triggers the inner ear and that can cause nausea and vomiting sensation and be followed by loss of consciousness and death. This is a serious condition that primary eye care professionals should be aware of. Ringing of the ears, another word for pulsatile tinnitus. If you see papilledema-like appearance, if the disc margins are elevated, we need to different that from drusens which are deposits change over time, they grow and cause a papilledema-like appearance. We need to photograph them after two or three months. If it’s the same, we don’t need to do anything because it’s probably drusen. If you have OCT in your practice, that’s a great tool, it lets you differentiate papillary edema and optic disc drusen as well. In papilledema, will you see the nerve fiber layer is very swollen and you will see the fiber layer around the disc. That’s a great tool to differentiate between drusen and papillary edema. If it’s drusen, that’s going to cause unnecessary frustration and stress to the patient if you refer for surgery. So it’s important to understand the difference. Now we come to our final case for the day. So a 56-year-old male came for an eye test with a recent history of throbbing headache to one side along with mild neck pain since one day. The pain, again, was 7 out of 10, a bit more. He was playing tennis when it started and might have had a fall but he does not remember. He finds his right eye looks a little bit funny in the mirror. He has got some one-sided headaches in the past but this was worse. So again, we find that no flashes, floaters, curtain, or gray patches in vision or nausea. Systemic health is good, not on any medications. On questioning, there was an absence of sweating on right side of the face. He is a chronic smoker since 20 years. So this is something that’s, again, it’s a bit of a red flag because he’s having these unusual headaches, which are throbbing and which are quite severe. He was playing tennis, he might have had a fall, but he does not remember. So probably there’s some kind of a blunt trauma or some kind of stretching of one side of the neck or head that’s involved here. And on questioning there was absence of sweating on one side. This is really helpful, and we’ll understand why. So here is the clinical picture. You can see there is ptosis on one side. You can see that the pupils don’t look normal, there is a bit of isocoria going on there. He was right in seeing that the right side of his face looks a little funny. What is this? This is caused by disruption of the pathway. Classic sign is ptosis of the same side. That results in anisocoria. Why ptosis and anisocoria? Because this patient had a carotid artery, we did the scans for him and found out he had a carotid artery in this section. The carotid artery is supplying to the oculosympathetic nerve. When the carotid artery suffers damage it causes swelling and bleeding and pushes the sympathetic nerves. The sympathetic pathway is supplying the Muller’s muscle and dilator pupil to the eye. This is why the carotid artery is affecting the sympathetic nerve and the sympathetic nerve is causing same side ptosis and miosis. So we understand a little bit more about this case now. So routine test was done, however due to classic signs of anisocoria, ptosis and anhidrosis, he was immediately referred for neuro-ophthalmology for MRI and CT scans. Horner’s syndrome can have multiple causes. It can be due to stroke. It can be due to a head trauma, road traffic accident, also sometimes if they pull their neck too much that can cause a carotid artery dissection. Right carotid artery dissection was found out in this episode. Apraclonidine is an alpha II antagonist but also has some alpha I activity. It is enervated by the sympathetic nerve to stimulate the alpha I receptors. Because the sympathetic nervous system is disrupted in Horner’s syndrome, there is lack of sympathetic stimulation and this leads to super sensitivity of the alpha I receptors. In this case it causes dilation. What will happen if we instill topical apraclonidine? This reversal of anisocoria is a diagnostic test for Horner’s syndrome. First, apraclonidine affects the sympathetic nervous system, and the ocular sympathetic nervous system is affected in this case, the carotid artery dissection. Because the hemorrhaging and trauma is affecting the sympathetic pathway. Now, MRI, it provides detailed images of neck arteries. It’s good for vessel visualization without exposing patients to radiation. Treating Horner’s syndrome requires a personalized approach because it can present in different ways, you know? But we need to understand these features. So ptosis, small pupil, anhydrosis, is the main sign that we look for. Now, what is carotid artery dissection? Carotid arteries are major blood vessels that supply blood to the brain. Dissection means there’s a tear in the inner wall of the artery. And this causes the blood to leak between the layers and create a blockage. Now, next to the carotid artery there is a bundle of nerves, the sympathetic nervous pathway. These nerves control pupil size, eye position and sweating. These nerves become damaged causing ipsilateral Horner’s syndrome. This is basically the mechanism or pathophysiology of Horner’s syndrome. Now, this is a bit of statistics to analyze because Horner’s syndrome is not straightforward in all patients. It is estimated that 25% of patients with carotid artery dissections experience Horner syndrome due to the damage of oculosympathetic pathway. It’s basically a diagnostic for us. Up to 56% of patients with carotid dissections can experience cerebral ischemia and in the form of a transient ischemic attack or stroke. Mind you, these patients already have headache, but these are the additional findings we’re seeing. Another study, 28% also suffered from transient monocular visual loss due to ischemic optic neuropathy and 16% experienced scintillations thought to be due to acute choroidal hypoperfusion. 36% of patients subsequently experienced a nonreversible ocular or hemispheric stroke. It can cause irreversible vision loss. In this case, fortunately there wasn’t any vision loss. So it’s just because he found it looks a little funny, that’s why he came to us, and he found out there was Horner’s syndrome and we could save his vision and also prevent a further stroke. So even a mild neck trauma in a patient with ipsilateral pain, monocular visual symptoms, and/or Horner’s syndrome, should trigger further evaluation because it can potentially prevent permanent deficits. That’s why it’s important that we immediately refer Horner’s syndrome as an emergency. So this is basically an outline. So we as optometrists, we do not treat these, we monitor and refer for followup. Blood thinners are used to prevent stroke. Regular followups are done with CT and MRI scans. Stenting may be required to stop the blockage of blood flow. So that brings us to the end of the cases. Now we look at headaches, and kind of summarize and understand that how we can modify our history and symptoms, how we can modify our workup, especially the questions that we ask the patient about their lifestyle, and to identify whether it’s a routine or a bit of a sinister kind of headache. So like we said, migraines with or without visual aura, there should be photophobia, one sided, typically, pulsating, nausea. It may or may not present with nausea. There is usually a family history of migraine and zigzag lines in their vision. Migraines is a huge topic. There are different types of migraines, due to different triggers. It can range between age groups as well. So it’s important to ask firstly, identify what kind of age group it is and then go for it, because sometimes we need to understand, okay, where did the headache come, what were you doing before, you know, the headache, what were you doing one day before you got the headache. You also need to understand the age of the patient, especially women. So if there is — sometimes it’s around the menstrual cycle they’re getting migraines. We need to ask them, okay, when did you get the migraine, did it coincide with your menstrual cycle or not? This will help us identify whether it’s a visual complaint or related to migraines or not. On the contrary, if there is a mix of flashes and floaters in vision, the high headache can be due to trauma or it can be a coincidence. So we need to dilate and check as well. The other type of headache which is quite common, so migraines and tension-type headaches are very, very common. We need to understand the characteristics of making rains and tension-type headaches, because almost 50% of headaches that I have seen are usually like migraines or tension-type headaches. Tension-type headache is also bilateral, it’s episodic, it usually has a trigger attached to it. Usually if the patient is anxious, stressed, hunger, if, say, for example, they have not slept, this can trigger a tension headache and it can also trigger a migraine as well. So it’s important to identify, okay, is this a migraine, is this a tension-type headache. Then we come to cluster headache, which we discussed a little bit about. This is also unilateral. It causes nasal stiffness and puffiness around the eyes with occasional tearing. This is quite common in smokers as well. Also it’s common in people who take a lot of stress or are quite anxious. Now, temporal arthritis is a sinister kind of headache which is very, very important to diagnose. So the keywords are if there’s elderly patient and they have a one-sided pain, and the scalp looks tender, it’s basically the temporal artery which is kind of triggered. It could be due to some kind of a stroke or some kind of inflammation which is causing that one-sided ache. It can also cause jaw claudication, or pain while chewing. It can cause blackout vision. This is a red flag for us, an emergency to forward to the stroke clinic and also potentially to an ophthalmologist to manage and monitor the patient. This patient will also require thorough systemic workup and may also require medications as well. Painful Horner’s syndrome is something we discussed in the case. So sudden headache, unilateral miosis, ptosis, and anhydrosis are typical signs. If you see a unilateral dilated pupil without any drops, sudden headache, internal ophthalmoplegia is a red flag, you need to refer them to the stroke clinic because this patient may be having a stroke, he can lose his vision and potentially also lose his life as well. So internal ophthalmoplegia is affecting the nerve which supplies the eye muscle. Trigeminal neuralgia is quite commonly seen, stabbing pain on the temple, triggered by chewing. If this patient is a young patient, we can expect trigeminal neuralgia. The trigeminal nerve is a very important nerve, because in cluster headache, in migraines, in trigeminal neuralgia, the trigeminal nerve is affected. It’s kind of a trigger point for many patients. So basically, if we kind of have to categorize all the kinds of headaches we are seeing, and if we had to divide them as routine, urgent, and emergency, how would we do that? So this is just a summary of different kinds of headache presentations that I have listed down over the years. So this includes optometry presentations as well. So as you can see in the routine type, we have migraines, we have tension type, we have a retinal migraine like we discussed, cluster headache, uncorrected refractive error or pseudomyopia, convergence insufficiency, convergence excess, divergence insufficiency, decompensated phoria can cause headaches, accommodative dysfunction, medication overuse, sinusitis, which is typically around the sinuses over here, when you apply pressure over here it feels a bit better. It’s usually if the patient had an infection or hay fever, sometimes people get sinus headaches. Substance abuse or withdrawal, even caffeine, withdrawal of caffeine can also cause headaches. These are routine kind of headaches because these headaches are not life-threatening or sight threatening. When we look at the optometric management, it’s usually doing refraction, doing a binocular vision refraction, refracting them properly, and measuring the ACA by ratio. These are the things that in a refractive sense will be very, very helpful to kind of manage your routine headache presentations. Urgent, like we discussed, acute angle closure, post-traumatic headache, any person who has had an injury. Trigeminal, we discussed about that, systemic infection, patients suffering from chronic illnesses like cancer, chronic kidney disease, can also lead to headaches. This can be due to the systemic condition. Fibromyalgia can cause headaches as well. Anterior uveitis. Third nerve palsy with headache, again, we have to understand if there is a dilated pupil or not. If the pupil is not dilated, it’s probably just a third nerve palsy. Internal is more sinister and requires emergency referral. If the patient is doing some kind of activity which is causing kind of a blackout of vision or transient blackout of vision, that is a red flag as well. So this patient will need urgent referral to GP as well just to check out their systemic health. If it causes any kind of headache or transient vision loss in an elderly patient with jaw claudication, it’s an emergency. If you see a patient and they are getting morning headaches, but apart from that you do the visual fields and the visual fields are normal, but this seems a bit unusual, that would be, again, urgent referral because probably it’s too early for us to say that, okay, is this something due to a tumor or not. They will have to have some scans done anyway. So that is something which is a red flag neurologically. Now, emergency, any kind of suspect intracranial hypertension, like we saw in the case. Subarachnoid hemorrhage, a hemorrhage causing a thunder clap headache. If a patient comes to you and says I’ve had the worst headache of my life, and that is instantly a red flag. If it’s an elderly patient, and if they’ve had the worst headache of their life, even if the patient is not elderly, they’re middle-aged and they’re having the worst headache of their life, that is an emergency right away. Hypertensive emergency, usually a sudden headache which is due to a raised high blood pressure. Because of that, they can have a headache, and usually if it’s affecting the eyes will you see bilateral disc swelling as well. Pituitary apoplexy, this is generally because of swelling of the pituitary gland, that can cause a bitemporal field test. Any kind of headache which is coming with field loss, you have to refer them immediately. Venous sinus thrombosis as well. Sinus thrombosis can cause compression and compression can cause headaches. Unilateral dilated pupil can present with third nerve palsy or without. In either case, it’s an emergency. So what are the questions that we need to ask? So we did cover that in our cases, but just to kind of summarize, these are the questions. So any kind of eye pain or redness, any recent head or neck injury, change in pupil size, flashes in floaters in vision, double vision is a red flag. Changes in visual field is also a red flag. Blurred or blackout of vision is a red flag. Nausea or whooshing sound in the ears, like we discussed, it shows there’s something going on inside the head. Eye pain or redness, we will come to it. There’s another classification I will be showing you. You can screenshot this. This is a rudimentary classification, this is for optometrists to understand, what could be the probable diagnoses? How do we identify the signs for it? If you have a red eye with a skin rash, they’re having tearing and lacrimation and red eye, if there’s Hutchinson sign, you’re seeing the lesion on the tip of the nose, there’s something like herpes, which could be the case for this patient. Any kind of skin rash, it raises a red flag for you. Now, if there is any kind of thyroid eye disease or vital inflammation, there could be proptosis. If there is proptosis, you’re probably looking at swelling of the musculature around the eyes. That could indicate thyroid eye disease or inflammation as well. Like we saw in Covid in India, we did see that people were getting fungal infections. In the inner canal of the nasal cavity, because of the oxygen supplied through the tubes, they were getting a fungal infection and the fungal infection was spreading all over because obviously the ear, nose, and throat are connected, and was spreading to the eyes as well, to the extent that sometimes they had to have enucleation done. We saw that in the Covid infection where people were given a lot of oxygen therapy. If they have a dilated pupil and they’re seeing halos in their vision, with headache, if it’s a red eye, you’re probably suspecting angle closure, because what happens is angle closure, because the pressure gradient inside the eye, the pupil does not react very well, and that causes a sluggish pupil. People see halos of light, in dark rooms they get this headache, that indicates an angle closure attack. If there’s irregular pupil, headache or pain around the eyes, the eyes are embedded into the skull, so some people may say that, okay, I have headache, but it actually can be a pain around the eyes. Scleritis or epi scleritis can cause headache, pain, nodular appearance of the sclera. Now, for example, if there’s a quiet eye with headache, what are the different possibilities? So if it is an elderly patient and sudden vision loss and temporal pain, tenderness of the skull and jaw pain, then you’re expecting AION or giant cell arteritis. If it’s a cluster headache, there might be some watering, puffiness, but there may not be red eye. These people sometimes wake up with a headache in the middle of night. This can be classified as a cluster headache, that’s a possible cause. If there’s a young patient and they have AIPD and color vision loss, so washed-out colors, red desaturation, normally optic neuritis is pain on eye movements but that may not be the case, they may present with headache or eye pain as well. If there’s acute onset diplopia, if the patient has come in and you see an exotropia, unilateral, this is causing double vision, or if the eye is up and, you know, in, we are suspecting a third, sixth, or fourth nerve palsy. Bilateral disc swelling could be IIH or hypertension. So these are the final takeaway tips for eye care professionals. Looking at patients’ symptoms as a whole and knowing other headache subtypes will help the referral process for us. There is actually a source, it’s called the Complete Headache Chart by National Headache Foundation, it’s a valuable quick guide to refer. If you search it, it will show you all the headache types listed in ophthalmology and optometry as well, they’ve covered a wide range of headaches. We need to identify the red flags. That can sometimes save a person’s life. Optometrists are not just eye care traders but also health care providers and that’s what will differentiate from you the mainstream opticians, because health care and being the first point of contact for patients will really be beneficial to you as a professional, it will help you grow, it will improve your knowledge. So for example, even I have always looked at clinical signs and symptoms, and this is how I’ve kind of articulated these cases, which I’ve seen throughout hospital settings. I’ve seen them in High Street opticians as well. These patients can come to you at any point in time and any place. So optometrists should be well-equipped. This is our final poll of the day. It might be a bit overwhelming for some optometrists, you can just give your feedback, that would really help us. So how confident are you in dealing with headache subtypes now? So that’s good. 51% of you have said very confident, which is really good. It means that you have taken away something from this webinar and hopefully, if you go on to the Internet and look at Google as well, you will see a lot of case reports of headaches in ophthalmology and see, some of you have also said fairly confident, so that’s also a good sign, it means that you can actually, you know, identify the symptoms of headache and what are the red flags. So these are my references. You can, you know, feel free to screenshot this and you can go into the different articles that I’ve seen, especially in Horner’s syndrome. So overall, we can look at some of the questions now. So we can open up the Q&A session. So I’m just going to stop screen sharing now. So over here, there are a few questions. So many patients come to us with severe cluster headaches, watery eyes, halos, what should be the treatment? First of all, this patient should have a thorough eye examination to rule out if the halos around the lights are due to something going on with the pressure of the eye or the angle of the anterior chamber or not. Then this patient needs to be referred to the GP to have a systemic evaluation and subsequently a headache specialist as well. Also we need to make the patient aware of any kind of lifestyle triggers. Like we discussed, alcohol intake, smoking, dietary, any kind of diet that they’re following or they changed their diet slightly or are taking something excessive, caffeine intake. Lifestyle modifications are also triggers for cluster headache, because it’s basically a neurological trigger. Any kind of lifestyle changes can have an effect neurologically. This is important for optometrists or any kind of eye care providers to be aware of. So someone has asked how about vertigo, this patient needs to be referred to the neurologist to have a head scan done. Why is headache worse in hyperopia? If the plus prescription is not there, the muscles need to work more to overcome the near point of accommodation. So the eyes are accommodating more. Because of this, the eye is causing stress to the eyes and this can cause headaches or typically frontal headaches. I think we’ve got about five minutes left to go. So differentiating headache due to migraine was acute angle closure glaucoma. It’s important to do Van Herick technique. If they’re narrow angles or if, you know, the pressure is high, then you’re looking at angle closure glaucoma. And also you can look at the disc as well to see if there’s any kind of cupping present there. So could you please explain the migraine with aura, risk factors that may compound — so no, migraine is a separate category. It’s not entirely related to strokes. People with migraines are at risk of having strokes. That’s not something that’s relevant to migraines, because the strokes are generally like sudden, and usually there is a field loss when it comes to — so it’s different from migraines. So can you elaborate, headache in which part is common in eye-related issues? Location of headaches or most commonly optometric practices, frontal headaches, headaches around the temple, if it’s a one-sided headaches or bilateral, posterior headache, then it is sort of a primary headache, or it can be a secondary headache if there are other pathological signs like you see giant cell arteritis, you see temporal headache with jaw claudication. Can [indiscernible] be used to treat accommodative spasm? Yes, it can be used. But the effectivity might be less. If the patient is slightly older, you can use cyclopentolate. Nowadays, every student is complaining of migraine. We’re seeing VDUs, specifically gaming, has become quite popular, and we are seeing that’s triggering a lot of migraines. That lifestyle modification is important. If you encounter someone with GCA as well as emergency referral should we start them on steroids? So we need to send them to the stroke clinic and optometrists in some countries are not licensed to prescribe steroids. So you will need to check with your clinical management guidelines, if you’re allowed to prescribe steroids, or else you need to refer to the ophthalmologist who can prescribe steroids. Yes, ophthalmologists can start steroids. So please explain the photo in the last case. In the last case you can see in the right eye there was a ptosis, so a droopy lid in the right eye. It had a miosis. The left eye was a normal pupil. If there is ptosis and miosis and anhydrosis, loss of sweating on one side of the face, that is typical to Horner’s syndrome. So you mentioned something about prescribing atropine for those with accommodative spasm. So atropine is available in 1% as well as 0.1%. If you’re dealing with someone with severe accommodative spasms, if you see the level is quite high, you can do atropine 1%, but you need to taper it down and follow them up after probably ten weeks as well. There should be a close followup if you’re increasing the atropine. So what is the management for patient with runny nose and sinuses. This is probably something to do with sinusitis, this is triggering the sinuses. This patient needs to be sent to the GP to manage the sinuses and potentially they can be sent to an ENT specialty as well, if they need any kind of scans to be done or if they need any kind of surgical treatment for the sinuses. Sometimes the sinuses are a bit narrow. So management of Horner’s syndrome. The outline of management is blood thinners. Carotid artery stenting can be done as well because there is a blocked artery. It can compress the sympathetic nerve. This can be potentially life-threatening as well. So it’s important that a CT scan or MRI scan is done in the followup as well to manage that. If it is getting managed with blood thinners and the systemic health is good, the patient is not at risk of stroke. Otherwise they might require stenting. So yes, I can see that some of these questions — so I just wanted to clarify that I’m an optometrist so I have worked in hospital settings, I have seen clinical cases, but some of these — I’m not a headache specialist or stroke specialist so some of these questions are relating to the treatment. It’s best that a stroke specialist or a headache specialist or a GP would know better how to treat patients who present with red flags. But it’s important for optometrists to refer red flags. I may not be the best person to answer questions relating to the treatment of a person potentially having a stroke. But thank you for asking these questions. It’s really nice that there is so much interest around this topic. And yes, someone asked what is the role of neuroimaging. Neuroimaging is used to image the head, around the neck. Depending what you’re seeing, you will have to send for some kind of scans. Usually you have CAT scan, used for any suspicion of hemorrhage. If there is a bone issue, a fracture or trauma, again, a CAT scan is quite helpful. MRI is also very good, which is helpful in tumors, in vascular anomalies, it is helpful in inflammations or inflammation of the meninges. It is helpful in any malformations. Lesions that cause inflammation, MRI is very helpful, because it kind of shows up the soft tissues very well, and also can suggest any kind of systemic issues as well. So that’s really good. Any kind of vascular abnormalities, like venous sinus thrombosis, the MRI and CTV is very helpful. MRA or CTA, like we said in Horner’s syndrome, it’s used in any kind of dissection or aneurysm around the head or neck. So LOFTSEA stands for laterality, rating the headache from 1 to 10, T stands for self treatment, are they using any kind of self treatment or self diagnoses, is it affecting their lifestyle, is it getting triggered by activity, is it getting better with activity, do they do something which makes it lesser, are they sleeping it off, what are they doing, that effect on the patient. Blurriness of vision or nausea or vomiting, along with the headache, or any kind of redness or lacrimation, where the patient might not present with a red eye or might say when I get the headache I get a red eye and lacrimation, that could indicate a cluster headache. It’s important to ask LOFTSEA because it gives you a good insight on when the attack happened and what happened, what the patient went through. It’s really important. So I think we’ve answered most of the questions. My apologies if I have not answered any questions. Of course there are many questions and also during the registration there were a lot of questions. But again, I would like to thank Cybersight for giving me this opportunity to present my work around this topic. And a big thanks to the audience as well. You all have been really attentive. We’ve had a very good turnout, about 479 participants have joined the session, which is really encouraging. It’s really nice to know if optometrists are part of this webinar as well because optometrists are often not very confident on clinical cases and how to does go clinical conditions, be it headaches or red eye or watery eye, so it’s important that optometrists, being primary eye care professionals, are equipped with the skill set to manage these conditions and also if they are unable to manage them.