Heent - Headaches And Eyes

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Headaches

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One of the most common symptoms in clinical practice, and can be most difficult to diagnose the correct etiology. Can be primary or secondary.

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Primary headaches

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A. Migraine
B. Tension
C. Cluster

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Secondary headaches

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A. Analgesic Rebound (from taking too much medicine to control a previous headache, can be associated with narcotics or migraine medications)
B. Secondary to Eye disorder
C. Sinus (often complain of this, but it’s actual a migraine)
D. Meningitis
E. Subarachnoid hemorrhage
F. Tumor/Mass
G. Giant Cell (Temporal) Arteritis
H. Posttraumatic
Cranial Neuralgias

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Migraines

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Typically present with similar quality, location, associations, and prodrome each time for a patient. Primary neuronal dysfunction, possibly of the brainstem origin, causing imbalance of excitatory and inhibitory neurotransmitters and affecting craniovascular modulation

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Aura with migraines

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A feeling or sensation that precedes the migraine. May be associated with visual changes called Scintillating Scotomas – an alteration in vision typically described as flickering or zigzagging lines or light.

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Classic migraine symptoms

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Unilateral 70%, bifrontal or global 30%
Throbbing or aching with severity variable from 0-10/10
Onset- rapid
Duration – 4-72 hours
First occurrence usually in mid adolescence
More common in women
Associated with: nausea, vomiting, photophobia, phonophobia, aura
Aggravating factors: alcohol, foods, menstruation, loud noise, bright lights, tension, stress, anxiety, etc.
Relieving factors: quiet, dark room; sleep

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Tension headaches

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etiology is unknown but may be associated with muscular contractions or vasoconstriction
Usually bilateral, occipital and upper neck/shoulders, or bi-temporal
Pressing or bandlike; severity is mild to moderate 0-6/10
Onset gradual
Duration minutes to weeks, dull, repetitive
Associated factors: occasionally phono and photophobia
Aggravating factors: muscular tension
Alleviating factors: massage and relaxation

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Cluster headaches

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Rare form of headaches with intense pain in cyclic patterns (called clusters)
Etiology – Unknown, possibly extra cranial vasodilation from neural dysfunction with trigeminovascular pain
Unilateral or behind or around an eye
Deep continuous pain that is severe
Onset- rapid
Duration – clusters may last 15 minutes to hours, typically episodic course with several each day for 4-8 weeks. Then relief for months
More common in men
Associated factors: lacrimation, rhinorrhea, mioisis, ptosis, eye lid edema, corneal injection
Aggravating factors: during attack alcohol sensitivity may increase

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Analgesic rebound headache

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Due to withdrawal from analgesic (pain treating) medicine.

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Secondary to eye disorder

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Typically associated with eye musculature. Steady and aching.

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Sinus headaches

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Usually bi-frontal or over maxillary sinus, throbbing

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Meningitis

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Due to infection of the meninges surrounding the brain. Generalized location with steady throbbing pain associated with fever and other meningitis symptoms

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Subarachnoid hemorrhage

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Due to bleeding into the subarachnoid space. Generalized location with very severe pain. “the worst headache of my life”

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Tumor/Mass

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Due to displacement or traction on pain sensitive areas of the brain. Variable location. Constant ache

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Giant cell (temporal) arteritis

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Due to vasculitis from immune response to elastic lamina of artery. Near to involved artery, typically temporal. Throbbing

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Posttraumatic

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Dull ache near injured area or contralateral to area of injury.

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Cranial neuralgias

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Trigeminal Neuralgia – compression of cranial verve V, often by aberrant loop of artery or vein. Located over cheek, jaw, lips, or gums (divisions of the nerve 2 and 3 >1). Shock-like, lancinating, stabbing, burning; typically severe. Commonly confused with TMJ because of the area. Tx: medication or surgery.

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Eyes

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Inspect position and alignment, eyebrows, eyelids and nasolacrimal ducts
Palpate lacrimal apparatus, upper and lower eyelids

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Ptosis

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Drooping of the upper eyelid.
Causes include: myasthenia gravis, damage to the oculomotor nerve (III) extraocular eye movements/lid movement/pupil change, damage to the sympathetic nerve supply Horner’s syndrome. Other causes are weakened muscle, relaxed tissue, and herniated fat.

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Horner's syndrome

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A constellation of symptoms that result from alterations of one side of the cervical or thoracic sympathetic chain.
Symptoms: Unilateral, ptosis of the eyelid, possible loss of sweating on the forehead (anhidrosis), pupil constriction (miosis) with preserved pupillary reflex

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Congenital Horner's syndrome

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Heterochromia is seen

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Entropion

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Inward turning of the lid margin.
The lower lashes, which are often invisible when turned inward, irritate the conjunctiva and lower cornea

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Ectropion

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The lower lid margin is turned outward, exposing the palpebral conjunctiva

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Lid retraction

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Usually an area of visible sclera between the upper lid margin and the iris

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Exophthalmos or Proptosis

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Anterior displacement of the eye globe.
Causes: Grave’s hyperthyroidism if bilateral, congenital, intracranial trauma, edema of the orbit, tumor, trauma, and possible Grave’s hyperthyroidism if unilateral

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Stye/Hordeolum

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A painful, tender red infection in the gland at the margin of the eyelid

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Chalazion

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A subacute nontender and usually painless nodule involving a meibomian gland. Unlike a sty usually points inside the lid rather than on the lid margin

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Xanthelasma

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A slightly raised, yellowish, well-circumscribed plaque that appear along the nasal portions of one or both eyes. May be due to lipid disorders

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Dacryocystitis

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Inflammation of the nasolacrimal duct by either obstruction or infection. Causes painful red area over the nasolacrimal area.

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Blepheritis

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Inflammation or irritation of the eyelid or boarder. Characterized by red, flaking, and crusting of the eyelid margin.

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Inspect conjunctiva and sclera

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Inspect with the lid retracted in opposite direction of gaze
Color, vascular pattern, nodules, and swelling
Bulbar conjunctiva
Palpebral conjunctiva – visualized by everting the lid

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Conjunctivitis

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Diffuse dilatation of the conjunctival vessels with redness that tends to be maximal peripherally. Vision may be blurry due to discharge. Watery, mucoid, or mucopurulent discharge. No change on pupils.
Causes: viral, bacterial, allergic, or irritant

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Scleral icterus

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Yellowing of the sclera indicates jaundice, buildup of bilirubin that causes discoloration of the skin and eyes.

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Subconjunctival hemorrhage

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Leakage of blood outside of the vessels, producing a sharply demarcated, red area that fades over days to yellow then disappears.
No pain, vision not affected, pupil not affected.
Cause: trauma, cough, sneeze from increased venous pressure

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Pterygium

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A triangular thickening of the bulbar conjunctiva that grows slowly across the cornea, usually nasal side. May interfere with vision.

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Pinguecula

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A harmless yellowish triangular nodule in the bulbar conjunctiva on either side of the iris. Does not affect vision (stops at the limbus). Direct correlation with UV exposure.

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Episcleritis

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A localized ocular redness from inflammation of the episcleral vessels. Vessels appear pink and are movable over the scleral surface. Abrupt onset of mild pain, itching, watery eyes, and doesn’t affect vision.

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Light reaction

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Cranial nerve II afferent limb of the reflex (sensory)
Cranial nerve III efferent limb of the reflex (motor)
A light shining into one eye causes bilateral pupil constriction. Direct reaction for the eye the light was shined in and consensual reaction for the opposite eye.

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Miosis

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Pupil constriction (parasympathetic) CN III control

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Mydriasis

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Pupil dilation (sympathetic)

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Near reaction

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Mediated by the Oculomotor nerve III – the pupil constricts when moving gaze from one object to another at different distances.

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Convergence

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The extraocular movement involved

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Accommodation

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The increased convexity of the lens caused by contraction of the ciliary muscles, changing the shape of the lens bringing near objects into focus.

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Anisocoria

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Unequal pupils.

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Anisocoria in bright light

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When anisocoria is greater in bright light than in dim light, the larger pupil is unable to constrict.
Causes: eye trauma, open angle glaucoma, impaired parasympathetic supply to the iris (Tonic pupil and Oculomotor nerve palsy)

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Anisocoria in dim light

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When anisocoria is greater in dim light than in bright light, the smaller pupil cannot dilate properly.
Causes: Horner’s syndrome

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Argyll Robertson's pupils

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Small irregular pupils that accommodate (near reaction) but do not react to light

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Corneal abrasion/Ulceration

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Injury or infection of the cornea resulting in ciliary injection: dilation of deeper vessels that are visible as radiating vessels around the limbus. Moderately painful, decreased vision, watery or purulent discharge. No pupil changes. Visible ulceration of abrasion with fluorescein staining.

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Acute Iritis

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Inflammation of the iris and the anterior chamber. Ciliary injection. Moderate pain, vision decreased, minimal to no discharge. Pupil changes – may be small and irregular.
Causes: infectious and systemic disorders (autoimmune)

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Glaucoma

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Increased intraocular pressure that can lead to permanent vision loss.

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Open angle glaucoma

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Does not have acute attacks, accounts for most glaucoma's in the US. Painless gradually progressive visual field loss, increased cup-to-disc ratio (CTD ratio)

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Acute closed angle glaucoma

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Ciliary injection, severe aching pain, vision decreased, no discharge. Fixed dilated pupil with steamy/cloudy cornea. MEDICAL EMERGENCY
Test Iris at 90 degrees: crescent shadow opposite of light due to abnormal angle between iris and cornea

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Cataract

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Opacities of the lenses visible through the pupil.

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Corneal arcus

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A thin grayish white arc or circle near the edge of the cornea. Normal aging, but could represent hyperlipoproteinemia.

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Hyphema

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Blood in the anterior chamber of the eye. Can affect vision and cause permanent vision loss.
Causes: trauma, surgery, tumor, vascular disorders

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Wilson's disease

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A genetic disease in which copper accumulates in liver, brain, and tissues, causing liver, neurologic, and psychiatric manifestations.

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Kayser-Fleischer ring

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A brownish stained ring on the edge of the iris present in Wilson’s disease.

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Visual fields

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The entire area seen by an eye when it looks at a central point

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Testing visual fields by confrontation

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Ask the patient to gaze at your eyes and ask to identify fingers moving .
The patients visual fields should compare similarly to yours
Further testing:
Cover each eye one at a time and test all fields to localize the area of abnormality
Normal blind spot can be found 15 degrees temporal to the line of gaze

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Visual field defects

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Homonymous hemianopsia - Both R or L visual fields gone
Bitemporal hemianopsia - peripheral vision gone
Quadrantic defects - quarter section missing

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Extraocular Eye Movements (EOM)

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Test the six cardinal directions of gaze - controlled by CN III, IV, and VI. LR6(SO4)3

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CN III: Oculomotor

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Medial movements and laterally superior and inferior

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CN IV: Trochlear

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Controls Superior Oblique and moves the eye down and inward (falling while walking down stairs)

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CN VI: Abducens

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Controls Lateral Rectus and moves the eye laterally

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Strabismus

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A condition of the eyes in which their gaze is asymmetric.

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Esotropia

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A form of strabismus in which one or both eyes point inward.

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Exotropia

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A form of strabismus in which one or both eyes point outward

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Cover test

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Helps differentiate problematic eye and differentiate from palsy.

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Testing central vision

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Snellen eye chart position patient 20 feet from the chart (small chart at 6 feet)
Patients should wear glasses if needed
Test one eye at a time

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Testing near vision

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Hand-held card (can also use to test visual acuity at the bedside); hold 14 inches from patient’s eyes

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Normal vision

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Normal is 20/20
Meaning at 20 feet the patient can read what a normal vision person could at 20 feet
20/200 patient can read at 20 feet what a normal vision person could read at 200 feet

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Myopia and Presbyopia

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Myopia - impaired far vision (nearsightedness)
Presbyopia - impaired near vision (farsightedness)

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Red reflex

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A reflection of light off the retina
Absence suggests: opacity (cataract) or of the vitreous, detached retina, or retinoblastoma if in children.

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Fundus

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The posterior part of the eye seen with ophthalmoscope

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Retina

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inner layer of the eye containing light sensitive receptors

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Choroid

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vascular layer of the eye between the retina and the sclera

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Fovea

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a darkened circular area around the point of central vision that sits laterally and inferiorly to the optic disc

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Macula

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a roughly circular yellowish area surrounding the fovea

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Optic disc

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Location at which the optic nerve exits the eyeball. Yellowish orange to creamy pink oval structure. Typically measures about 1.5mm. Inspect – sharpness/clarity of outline, and color of the disc, and size of physiologic cup.

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Physiologic cup

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Yellowish/white area within the disc where vessels appear to emerge from. Usually horizontal diameter is < ½ the disc horizontal diameter (cup to disc ratio <1:2)

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Papilledema

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Due to increased intracranial pressure from disorder of the brain, meningitis, subarachnoid hemorrhage, trauma, masses. The increased pressure increases the edema of the optic nerve head.

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Glaucoma cupping

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increased intraocular pressure causing increased cupping (CTD ratio >1:2)

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Arteries on retina

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light red and smaller, lay over veins
Walls are transparent only seeing the blood with in

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Veins on retina

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Dark red and larger

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Artery/vein crossings (AV crossing)

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AV nicking – seen in hypertension with hypertensive retinopathy.

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Drusen bodies

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Undigested cellular debris resulting in yellowish round spots that vary from tiny to small. Edges may be soft or hard. Causes; normal with age, including age related macular degeneration.

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Soft exudate

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Cotton Wool patch – white colored or grayish, ovoid lesions with irregular soft boarders. Usually smaller than the disc in size. Infarcted nerve fibers. Causes: hypertension and other.

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Hard exudates

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Creamy or yellowish lesions with well define or hard boarders. Small and round and coalesce into larger irregular spots. Causes: Diabetes and hypertension

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Superficial retinal hemorrhage

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Small linear flame shaped red streaks in the fundus. Causes: hypertension, papilledema, retinal vein occlusion, others

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Preretinal hemorrhage

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Blood escapes into potential space between retinal and vitreous. Causes: sudden increased intracranial pressure

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Deep retinal hemorrhage

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Small round irregular red spots (blot hemorrhage) Causes: diabetes

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Microaneurysms

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tiny round red spots, typically in macula
Causes: diabetes and other

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Neovascularization

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formation of new blood vessels. Numerous, tortuous, narrow vessels. Causes: diabetic retinopathy

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Diabetic retinopathy

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Deterioration of the retina due to microvascular damage that can lead to permanent vision loss.

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Stages of diabetic retinopathy

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Nonproliferative Moderately Severe
Nonproliferative Severe
Proliferative – neovascularization occurs. Normal vision but risk of vision loss is high.
Proliferative Advanced – visual disturbance

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Retinal artery occlusion

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Occlusion of the retinal artery typically secondary to carotid artery disease or emboli
Sudden onset of painless vision loss unilaterally
Cherry red spot on exam, pale retina
Permanent vision loss occurs with in minutes to hours
Ophthalmic Emergency due to vision loss

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Central retinal vein occlusion

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Typically due to atherosclerosis of the overlying arteries leading to increased pressure and occlusion of the vein. Results in increase intraocular pressure (glaucoma), neovascularization, macular degeneration, and edema. Causes: diabetes, hypertension, tobacco use, hyperlipidemia, other
Sudden onset of painless, unilateral, blurry, partial to complete vision loss. “Mars look”.
Pools of blood and indistinct margins, minimal to no vessels
With treatment will regain some degree of vision