1.1.2 Elicits the detail and relevance of any significant symptoms.

Question 1

Risk factors for papilledema

How would you manage?

Answer 1

young obese women aged 20-40, children, bilateral

How would you manage? Emergency referral, acetazolamide for AAC if on hand

Question 2

Decompensated phoria manage:

Answer 2

push screen back, less screen time

Question 3

H&S - Questions for headaches

Answer 3

• Tell me about them - Open question
• Are these headaches normal for you?
• Have they become worse? Do they become worse when leaning body forwards/during head movement/changing posture? (linked with papilledema)
• Which part of the head is the headache?
• When did they first come on? Any particular time of the day? How long do they last?
• During any particular task? (concentrated task?)
• How painful would you describe them? Sharp or dull, throbbing pain?
• Have you done anything to treat them?
• Any other symptoms (nausea/sickness/vomiting - AAC, Papilloedema,) photophobia, double vision (transient in GCA), blurred vision, visual auras like zig zags (ask one or both eyes), haloes around lights (coloured), shimmering lights (how long do they last?), pain on chewing, flashes?
• Any pain at or around the eyes? Redness? Watering?
• Any head trauma?
• Any FH of migraines?

Question 4

What else to look for in history?

headaches

Answer 4

• Vision - papilledema, GCA - sudden VA loss (AAION), amaurosis fugax, shingles (one month gradual onset), AAC, Visual Migraines
• General Health - Inflammation like Rheumatoid artheritis (nagging, morning pain), Ankylosing spondylitis, Herpes Zoster, Malignant hypertension
• Medications - May cause HAs! Painkillers for HA treatment can actually rebound & cause further HAs!
• Ocular History -
• Family History - Migraines
• Lifestyle - VDU (conc task; high use - glare, eyestrain etc), Hobbies

Question 5

What Part of the Head?

Parts of the head for Each HA Type:

Answer 5

• Refractive Error —> Bilateral, frontal, dull, throbbing
• Papilledema —> Diffuse or unilateral throbbing, usually severe HA
• GCA —> Sharp pain at temporal areas but can sometimes be frontal or occipital
• Migraine —> Unilateral, dull or sharp pain increasing in intensity & spread
• AAC —> Sudden, severe pain within one eye and an ache around your eye
• Tension —> Bilateral, steady (non throbbing) pain, around frontal or occipital region
• Cluster —> Unilateral at oculo-temporal region, sudden, sharp pain
• Pituitary Tumour —> Sudden-onset, severe headache at the front of the head (either located on one side of the head or both) and/or behind one or both eyes.

Question 6

Tests to do:

For headaches

Answer 6

• Visions Aided & Unaided - if Rx improves vision then potentially refractive error as cause, if not then potentially different cause. If AAION then monocular VA loss. For papilledema, transient visual obscuration’s lasting 30 seconds or more, worsening on bending, coughing, posture change.
• CT at distance & near - diagnose convergence insufficiency, decompensation (questions for decompensation: Cover one eye? Towards end of day?)
• NPC - convergence insufficiency
• Accommodation - Accommodative spasm/insufficiency
• Motility - 6th nerve palsy can follow after papilledema with H diplopia
• Pupils - AAC, Accommodative spasm??,
  
  • PERLA, DCN, RAPD
• IOPs - raised intracranial pressure, AAC
• VFs - enlarged blind spot in papilledema, migraines, brain tumours
• Colour vision - e.g. if complaining of HAs with VF defect, then could be pituitary tumour so desaturated red & colour vision worth checking monocularly (can be acquired - tritan)
• Anterior eye - ipsilateral conjunctival injection, ptosis (cluster), signs of AAC, VHs
• Fundoscopy - observe optic nerve (blurred margins, patton lines, hyperemia), malignant hypertension may mean flame haems/cotton wool spots etc in far periphery

Question 7

Differential diagnosis:

Worrying Vs less worrying features

Headaches

Answer 7

Worrying features
* Short history
* Continuous
* Worsening
* General malaise (sickness, other things making HA worse)

**Less worrying features **
* Long history
* Intermittent
* Steady
* Good
* No other problems

Migraines last between 4-72 hours whereas papilloedema is continuous

Question 8

Differential diagnosis:

Single acute vs acute recurrent

Headaches

Answer 8

Single acute
* Raised ICP
* Subarachnoid haemorrhage
* Referred pain from sinus, teeth, eye
* Herpes zoster

Acute recurrent
* Migraine
* Cluster HE
* Trigeminal neuralgia

Question 9

Differential diagnosis:

Subacute vs Chronic

Headaches

Answer 9

Subacute
* Temporal arteritis
* Raised ICP

Chronic
Tension
Psychiatric
Ankolysing spondylitis

Question 10

Causes of Headaches (threatening):

Answer 10

• GCA - AAION
• Acute angle-closure glaucoma
• Increased intracranial pressure
• Ocular ischemic syndrome
• Malignant hypertension
• Infectious CNS disorder (meningitis or brain abscess
• Structual abnormalitiy of the brain (e.g. tumour, aneurysm, arteriovenous malformation
• Subarachnoid haemorrhage
• Epidural or subdural hematoma

Question 11

GCA - AAION

Answer 11

• Inflamation of arteries, most often affects arteries in head
• Age 55> years, scalp tendernes (combing hair), recent HA (frontal, temporal occipital or more generalized), Jaw claudication (ischaemia of the masseter muscles), thick tender inflammed temporal artery and pulsating.
• Weight loss, fever, malaise depression
• Sudden painless monocular VA loss (on waking), with amarousis fugax attacks
• Potential diplopia
• Pale oedematous disc, flame haemorrhages
• Visual field defect, inferior altitudinal, can be central, paracentral, quadrantic & arcuate
• Ocular motor nerve palsies manifest - 3rd nerve potentially
• TREATMENT - emergency referral, steroids
• If above 48hrs, still refer urgent to stroke specalist and eye unit

Question 12

DD between AAION + NAAION

Answer 12

• NAAION - associated with small corwded discs, hypertension, diabetes, hyperlipidemia whereas AAION do not normally have same vascular risk factors
• Px with GCA are typically order than those with NAION (i.e. 8th-9th decade vs 6th-7th decade)
• in NAION, patients will usually not note any associated systemic symptoms such as headache, jaw claudication, scalp tenderness, weight loss, anorexia, fever or myalgias/arthralgias
• VA worse in GCA, 1/3rd patients having 6/60 or worse
• Unlike NAION, AAION patients demonstrate a diffuse “chalky” white edema, eventual cupping of the disc, and possible coexistent retinal ischemia. NAION often demonstrates segmental optic nerve edema with eventual sectoral or total flattening & pallor

Question 13

Acute angle-closure glaucoma

Answer 13

• Caused by iris bulging forward, causing block or narrowing of drainage angle between cornea and iris. Fluid cant escape, resulting in pressure increase
• Pain, blurred vision, haloes around lights, vomitting, frontal headache
• Fixed pupil
• Critial - closed angle in involved eye, acutely raised IOP, microcystic corneal oedema. Narrow or occludable angle in fellow eye if primary eitiology
• Other signs: Conjunctival injection; fixed, mid dilated pupil

Question 14

Increased intracranial pressure:

Answer 14

**Papilledema: **
* Papillledema is swelling of optic nerve as enters back of eye due to intracranial hypertension.
* Signs: Disc hyperaemia, elevation, indistinct margins, Patton lines, venous engourgement, flame haemorrhages, cotton wool spots.
* Increase in ICP due to space occupying lesion, causes unilateral or diffuse throbbing severe headache, worse in morning, and worse when bending over or coughing, changing posture.
* Causes vomiting, nausea
* In early stages, vision/pupils may not be affected, in later stages may be affected amaurosis fugax

Question 15

Infectious CNS disorder (meningitis or brain abscess)

Answer 15

• Non-specific HE with neck stiffness
• Pain is severe and throbbing
• Onset can either be gradual or sudden

Question 16

Structural abnormality of the brain (e.g., tumour, aneurysm, arteriovenous malformation)

Answer 16

• Pituritary - Gradual HA, desaturated red alternates between eyes, VF defect (bitemporal hemianopia/superior quadrantanopia if tumour still expanding)

Question 17

Subarachnoid haemorrhage

Answer 17

• Extremely severe headache, stiff neck, mental status change; rarely sub hyaloid haemorrhages seen on fundus examination, usually from a ruptured aneurysm - can cause 3rd nerve palsy
• The pain is present on walking, and owrsens when coughing

Question 18

Epidural or subdural hematoma

Answer 18

Follows head trauma; altered level of consciousness; may produce anisocoria

Question 19

Causes of Headaches (less serious):

Answer 19

• Refractive error/Asthenopia
  
  • Dull, frontal, during concentrated tasks & uncorrected Rx
• Convergence insufficiency
  
  • Most commonly young adults
  • An exophoria at near in the presence of poor near-fusional convergence amplitudes, a low accommodative convergence/accommodation (AC/A) ratio, and a remote near point of convergence.
• Accommodative spasm
• Migraines
• Cluster
• Tension
• Sinus disease

Question 20

Management

Answer 20

• Advice: refer to GP (if not ocular issue), refractive error, antireflective coating, regular breaks (20-20-20) etc
• Migraines - avoid cheese, chocolate, alcohol, caffeine/excess sleep/stress/long intervals without food; treat with aspirin, codeine, ergotamine (not for pregnant women)/prophylactic measures - beta blockers, ACE inhibitors
• Convergence Insufficiency - exercises or even prism
• Accommodative spasm - Reading gls?
• Cluster - hard to treat due to sudden onset but many resolve after few weeks/months
• Tension - less stress, anxiety, poor sleep; paracetamol & glasses may help