| Affiliation |
(AGL) Chairman, Department of Ophthalmology, The Methodist Hospital, Houston, Texas; Professor of Ophthalmology, Weill Cornell Medicine, New York City, New York; (EL) Class of 2023, Baylor College of Medicine, Houston, Texas |
| Transcript |
So today we're going to be talking about facial and in particular, eye pain for the ophthalmologist and normally one of the first things we want to do is make sure it's not the eye. In order to do that, we have to do a complete eye examination. So, before we talk about the facial syndromes that can cause pain, we want to make sure we don't have a problem in the eye and that means looking at the cornea-it's a very pain sensitive structure-uveitis, angle closure glaucoma, all the normal things that can occur from the intraocular exam standpoint. Sometimes the eye exam is normal because the patient's symptoms are intermittent. So, it's super important that we try to measure the patient during the pain syndrome because intermittent angle closure can occur, intermittent uveitis can occur, inflammation can occur intermittently like the Posner-Schlossman Syndrome where we don't actually see anything in between the episodes. So, we want to look for both evidence of active and prior disease like keratic precipitates or synechia, evidence that we've had something in the past including gonioscopy for the angle. Assuming the eye exam is normal, then we want to make sure that it's not the orbit. The orbital causes are thyroid eye disease and orbital inflammatory pseudotumor. The eye could be normal in the front, but the problem might be in the posterior sclera, like posterior scleritis. So orbital evaluation including Hertel exophthalmometry, careful attention to the orbital signs, and imaging if necessary. Usually we're going to start with orbital ultrasound to look for distinctive findings, intraocular muscle enlargement. But you could do a CT or MRI in this setting. Thyroid eye disease is actually a very common and underrecognized cause of eye pain from an orbital standpoint. Once you've done these three things, it's not the eye, it's not the orbit, if we still have facial pain that's involving the eye, we want to be thinking about the trigeminal nerve. So, the trigeminal as you know is cranial nerve number V and V1 is the one that covers the eye. So, we want to be thinking about the trigeminal syndromes, either trigeminal neuropathy or the syndromes that are well defined for International Headache Society criteria for headache symptoms that happen to involve the face. So we want to be looking at those criteria to determine whether they're uncommon presentations of common disorders that cause headache like migraine and tension, greater occipital neuralgia, these all can be felt in the eye. So, we're going to be asking about those criteria which are the duration, the severity, the associated findings, like sonophobia or photophobia, autonomic dysfunction. Looking for Horner's syndrome, cluster, and the short acting and longer acting trigeminal autonomics cephalgias syndromes. These are all criteria defined. You don't have to memorize the criteria but you do need to know that criteria exist, so I would recommend that you just Google these things and make sure they don't meet the criteria. If you have a trigeminal neuralgia, we're going to be testing the cranial nerve V, that's the corneal sensation and the cutaneous sensation in the distribution of V1, 2, and 3. We really want to make sure the trigeminal nerve is working. Because if it's pain and numbness, or pain and corneal dysfunction, that's really going to be an indication for imaging because we are going to worried about a structural lesion in a young person that might be multiple sclerosis and in an older person, we're going to think about tumors and compressive lesions, especially a cavernous sinus. If you don't meet the criteria, it's not a trigeminal defined syndrome, the eye and the orbit examined are normal, and the MRI scan shows no lesion, then these people we are going to just treat empirically. Normally we're going to be starting with nonsteroidal anti-inflammatory drugs, you could also use the trigeminal neuralgia and the anti-migraine therapies. I would recommend in these settings that you consult with a neurologist so that they can work through the side effect profile and try to determine what the best treatment is. In addition, in elderly patients we want to be thinking about giant cell arteritis so I would recommend that a sed rate and a CRP be done on any patient who's elderly who has facial or eye pain if there's no obvious explanation. If the pain is in the trigeminal dermatomal distribution, I always warn those patients that the pain might precede the development of the rash. So that's herpes zoster sine herpete, which is a fancy way of saying they don't have the rash yet. So, they can have the pain without the rash at all or the pre-eruption phase, where they have the pain and then the vesicular continuous eruption develops days later. So we want to make sure to warn the patients to call us about that because in an elderly patient who has an elevated sed rate and has V1 distribution pain, you might be thinking it's giant cell and you're giving the patients steroids but then comes the rash and the shingles. In summary, in patients who have facial/eye pain, we want to do a normal eye exam, look for intermittent, current, active, and past inflammatory disorders or intraocular disorders. We're going to make sure it's not the orbit and think about orbital inflammatory pseudotumor and thyroid eye disease. We're going to think about checking the trigeminal and looking for those trigeminal syndromes. Looking at the IHS criteria for defined headache syndrome that happens to involve the face and eye. Doing an MRI scan if you think the pain is from a structural lesion and thinking about a sed rate and CRP in elderly patients, and herpes zoster with or without the rash. |
