Eyelid Eye Pain – Cornea Headache

Home , Pterygium (conjunctiva)

Patient Complaints Swollen Eyelid with Redness 10 year old playing baseball with friends 62 year old male with increasing Pain Fever Nausea Malaise yesterday, possible trauma? maybe mild periorbital discomfort 1‐2 days, URI, periorbital changes increased over upper lid edema, otherwise 24 hours. systemically well Depression Headache Joint Pain Thirst

Weight gain Cough Insomnia Chest Pain

Rash Dysphagia Diarrhea Anxiety

Eye Complaints to Primary Care Providers Eyelid Skin Abnormalities with Swelling

• 36 yo female with red, itchy, scaly eyelid skin over 1‐2 weeks worse in Eyelid the morning Eye Pain –Cornea Headache

Eyelid Complaints Swollen Eyelid

• Swollen • Hordeolum/Chalazion • Redness • Preseptal Cellulitis • Skin Changes • Herpes Zoster Ophthalmicus • Malposition • Contact Dermatitis

• Preseptal Cellulitis • Contact Dermatitis • Warm compresses with massage do work • Oral antibiotics +/‐ but ABX ointment helpful if draining • Months to resolve, not days, recurrences rates high • Triamcinolone Acetonide (TA) Injection vs Incision and Drainage (I/D) Close to equal cure 60‐84% vs 79‐97% Simon GB et al. Am J Ophthal. 2011:151:714‐718. • Herpes Zoster Ophthalmicus • Hordeolum/Chalazion

Hordeolum/Chalazion Eyelid Malposition

Entropion Ectropion

Chalazion Anatomy/Pathology Droopy Eyelid

• Stye/Hordeolum vs Chalazion‐ Pathology different Dermatochalsis not Ptosis Ptosis • Clinically Similar • Margin‐Reflex Distance

Pupil Abnormality Motility Abnormality

Eye Pain‐ Cornea Foreign Body Sensation

• 27 yo auto mechanic with odd • 18 yo female rollerblading with • Redness sensation with blinking starting friend feels something go into • Foreign Body Sensation about dinner time last night her eye, excruciating pain • Changes in Vision • Burning • Photophobia

Red Eye Here is BUG in your EYE!

• Conjunctivitis • Subconjunctival Hemorrhage • Inflamed Pinguecula • Pterygium

• 6.8% of US Population, approx. 16 million people • Increases with Age 18‐34 2.7% >75 18.6% • More Common in Women 8.8% female 4.5 % male Farrand KF, et al. American Journal of Ophthalmology © 2017 (AAO) (2017), doi: 10.1016/j.ajo.2017.06.033.

Burning w/wo Changes in Vision Photophobia‐ Ocular Rosacea

Eyelid margin vascularization, chronic chalazion, chronic blepharoconjunctivitis, marginal corneal infiltrates, sterile corneal ulceration, leading to corneal vascularization and scarring

Dry Eye Photophobia Punctal Plug Herpes Simplex • We all harbor HSV, primary infection goes unrecognized • Reactivation unilateral • Epithelial disease with dendrites, geographic ulcers resolve with ghost dendrites • Stromal keratitis most common cause of infectious blindness in © 2017 (AAO) US © 2017 (AAO) Headache‐ Glasses Misalignment Take Home Points Eye Pain‐Cornea Getting Glasses on‐line

Induced Prism Bifocal Segment • History is key • You can evert the lid, fix the problem and be the hero © 2017 (AAO) • Contact lens wearers special consideration, need slit lamp exam • Redness does not rule in or rule out severity • Loss of corneal reflex is not good • Dry eye is very common, USE ARTIFICIAL TEARS QID • Herpes simplex possible recurrent unilateral symptoms

Headache‐ Ophthalmologic Perspective Muscle Imbalances‐ Fix on Distance Target

Tropia‐ Manifest deviation Phoria – Non manifest deviation • DMV is not an eye exam • Need for Glasses • Astigmatism • Latent hyperopia • Eye MD to check Glasses RX before and after dilation • Wrong glasses, misalignment • Eye Muscle Imbalances • Papilledema • Vasculitis

Glasses and Headache Headache

• 27 yo female with new onset of HA and nausea. Pt has normal visual acuity, 20/20, but notes changes in vision upon rising in the morning from bed. Does wake well‐rested. Occasional horizontal diplopia. Pt is overweight, but not diabetic. She takes BCP, vitamins, and acne medications. Headache Headache Take Home Points

• Disc edema‐ bilateral • Needs dilated eye exam, MD or OD good starting point • Consider poorly made glasses • Look for muscle issues, eye should not move on cover testing • Look for disc edema, neuro imaging maybe urgently indicated

Pseudotumor Cerebri = Idiopathic Intracranial Hypertension (IIH) Eye Complaints to Primary Care Providers • Disc edema – swelling of unmyelinated nerve fibers • Definition Papilledema Eyelid • IIH‐ third decade, female, obese • Symptoms‐ HA, nausea, transient visual obscurations, possible diplopia, pulsatile Eye Pain –Cornea tinnitus • Visual Field Loss 60 % of baseline VF with localized nerve Headache fiber bundle loss Localized inferior hemifield loss greater than superior Keltner et.al Invest Ophthal Vis Sci. May 2014;55(5);3200‐3207.

Headache‐ Vasculitis