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What Causes Headache During Eye Movement Along With Blurry Vision?
Question: Hi, I have had a very painful 'headache' when I move my right eye to the left or right, up or down. The pain is under the brow area and to the inside corner of my eye. Also, I have had a lot of sinus pressure along the ethmoid sinus on that side. I have been on antibiotics - which don't seem to be doing much (I am on Augmentin day 2 after a couple of days on 100/mg day of Doxycycline). The pain in my eye area has been about 11 days - building to very painful and now sort of leveling off to moderately painful. The other issue along with it is blurry vision in this same eye (colors are muted and darker and I cannot read all the words in front of me with the affected eye). I have seen the opthomologist yesterday and she prescribed the higher dosage of antibiotic. I have had no fever since this started, no other cold symptoms (however, I did have a very bad cold a few weeks ago which lasted about 10 days before this started a week later). I am at my wit's end over it. I just started taking corticosteroids today for six days. I have been using Flonase, Sudafed, Advil to control pain. Imitrex did not resolve any head pain. I am scheduled for a CT scan on Monday. Any ideas??? I would like to return to normal. Can a virus cause these symptoms? I am wondering about that. I am 46 years old, and otherwise in good health.
Brief Answer:
I recommend an MRI instead of CT scan
Detailed Answer:
Good afternoon. My name is Dr. Saghafi. I am an adult neurologist and headache subspecialist from XXXXXXX OH.
In a nutshell, your pain on eye movement together with blurry vision and dampened color appreciation which has not responded to any standard treatments or therapies directed at migraine headaches or sinus headaches doesn't XXXXXXX me since the symptoms in my opinion are not suggestive of either of those conditions.
Proof of that fact is everything you've already confirmed by way of stating that none of those standard treatments are working.
I don't know exactly how to explain that an ophthalmologist could've really thought to be sinusitis given your symptoms. Did they get a visual acuity on you? I'd expect it to be abnormal if not significantly abnormal. The fact, that you're now on steroids suggests that somebody is thinking of other diagnoses.
What I believe you need to have done is not a CT scan as that very well may be negative and the radiologist is not even going to be looking for much of anything given the presumptive diagnoses of sinusitis or migraine headaches. What you should have done at this point is an MRI of the brain and I would also include the C-spine so you don't have to go back and have things done twice that could've been done in the same sitting. They will want to inject you with either gadolinium or even double dose gadolinium and they will want to do a protocol of getting "fine cuts of the optic nerve all the way through the optic chiasm.
We are looking for evidence of an optic neuritis. That is my primary working diagnosis solely based upon the information you've presented. Of course, other things are possible, however, I very much doubt that a viral illness would be likely based upon your description of things. Viral illnesses tend to cause rather vigorous and generalized inflammatory reactions...nothing this specific and classic for optic nerve affectation.
You should also be tested for your renal function and creatinine clearance with an EGFR at least calculated to make sure your kidney function won't be compromised by the gadolinium XXXXXXX
If this information has been helpful and I've answered your questions would you do me the favor of some written feedback and a STAR RATING of the answer.
Should you have no further questions or comments to place- CLOSING THE QUERY would be greatly appreciated as well.
In the future I'm happy to answer more concerns personally if you'd allow me this privilege by going to the following website and sending me your questions:
bit.ly/drdariushsaghafi
This query required 53 minutes of physician specific review, research, and final draft documentation for envoy.
P.S. I see from the locator map of where you're contacting us from that you are close to XXXXXXX NJ. Our family lived in XXXXXXX until I was about 2 or 3 years old. I was born in New Brunswick at what used to be called Middlesex General Hospital....now the XXXXXXX Wood XXXXXXX Foundation.
I recommend an MRI instead of CT scan
Detailed Answer:
Good afternoon. My name is Dr. Saghafi. I am an adult neurologist and headache subspecialist from XXXXXXX OH.
In a nutshell, your pain on eye movement together with blurry vision and dampened color appreciation which has not responded to any standard treatments or therapies directed at migraine headaches or sinus headaches doesn't XXXXXXX me since the symptoms in my opinion are not suggestive of either of those conditions.
Proof of that fact is everything you've already confirmed by way of stating that none of those standard treatments are working.
I don't know exactly how to explain that an ophthalmologist could've really thought to be sinusitis given your symptoms. Did they get a visual acuity on you? I'd expect it to be abnormal if not significantly abnormal. The fact, that you're now on steroids suggests that somebody is thinking of other diagnoses.
What I believe you need to have done is not a CT scan as that very well may be negative and the radiologist is not even going to be looking for much of anything given the presumptive diagnoses of sinusitis or migraine headaches. What you should have done at this point is an MRI of the brain and I would also include the C-spine so you don't have to go back and have things done twice that could've been done in the same sitting. They will want to inject you with either gadolinium or even double dose gadolinium and they will want to do a protocol of getting "fine cuts of the optic nerve all the way through the optic chiasm.
We are looking for evidence of an optic neuritis. That is my primary working diagnosis solely based upon the information you've presented. Of course, other things are possible, however, I very much doubt that a viral illness would be likely based upon your description of things. Viral illnesses tend to cause rather vigorous and generalized inflammatory reactions...nothing this specific and classic for optic nerve affectation.
You should also be tested for your renal function and creatinine clearance with an EGFR at least calculated to make sure your kidney function won't be compromised by the gadolinium XXXXXXX
If this information has been helpful and I've answered your questions would you do me the favor of some written feedback and a STAR RATING of the answer.
Should you have no further questions or comments to place- CLOSING THE QUERY would be greatly appreciated as well.
In the future I'm happy to answer more concerns personally if you'd allow me this privilege by going to the following website and sending me your questions:
bit.ly/drdariushsaghafi
This query required 53 minutes of physician specific review, research, and final draft documentation for envoy.
P.S. I see from the locator map of where you're contacting us from that you are close to XXXXXXX NJ. Our family lived in XXXXXXX until I was about 2 or 3 years old. I was born in New Brunswick at what used to be called Middlesex General Hospital....now the XXXXXXX Wood XXXXXXX Foundation.
Above answer was peer-reviewed by :
Dr. Prasad
Hi Dr. Saghafi,
Thank you for your reply, and yes we are about 15 mins from XXXXXXX in the Princeton suburbs. My in-laws live near XXXXXXX (and my mother-in-law worked for the XXXXXXX Clinic for a bit - small world). I know RWJ well. I have a son with cerebral palsy and we started out at the clinic there for follow up after his birth.
My Opthomologist did do a visual acuity yesterday and dilated me and checked the optic nerve, etc. with nothing unusual to report. She really didn't have any other ideas about what might be happening. I did read about ON on-line but I do not appear to have these symptoms according to my opthomologist. The steroids are helping my headache a bit but not the visual issues.
One important note is that I did have an MRI this past Summer as I was suspected to have a prolactinoma on my pituitary gland (slightly elevated prolactin level); however, after visiting with a pituitary specialist in NYC at XXXXXXX and one locally, I was told this was nothing - couldn't even be seen on the scan, but reported by the radiologist as "suspicious for prolactinoma". I was told to forget about it.
I might be a case study for the strange and unusal symptoms it seems. Any other thoughts appreciated!
Thank you,
XXXXXXX
....Also, to add the visual acuity was slightly different on each eye - worse in the affected eye. I remember one number difference....
Thank you for your reply, and yes we are about 15 mins from XXXXXXX in the Princeton suburbs. My in-laws live near XXXXXXX (and my mother-in-law worked for the XXXXXXX Clinic for a bit - small world). I know RWJ well. I have a son with cerebral palsy and we started out at the clinic there for follow up after his birth.
My Opthomologist did do a visual acuity yesterday and dilated me and checked the optic nerve, etc. with nothing unusual to report. She really didn't have any other ideas about what might be happening. I did read about ON on-line but I do not appear to have these symptoms according to my opthomologist. The steroids are helping my headache a bit but not the visual issues.
One important note is that I did have an MRI this past Summer as I was suspected to have a prolactinoma on my pituitary gland (slightly elevated prolactin level); however, after visiting with a pituitary specialist in NYC at XXXXXXX and one locally, I was told this was nothing - couldn't even be seen on the scan, but reported by the radiologist as "suspicious for prolactinoma". I was told to forget about it.
I might be a case study for the strange and unusal symptoms it seems. Any other thoughts appreciated!
Thank you,
XXXXXXX
....Also, to add the visual acuity was slightly different on each eye - worse in the affected eye. I remember one number difference....
Brief Answer:
One day I will share my story with you on my days at XXXXXXX College
Detailed Answer:
Happy New Year- to someone else who shares this small world! LOL.
Well, I suppose I can do nothing but defer to someone who has examined you, however, in my opinion as you've presented your case I still put Optic Neuritis rather high on the list of differential possibilities. Lack of physical signs on a dilated fundal examination does not rule out the disease. It is entirely consistent with ON that visual acuity should be different in the affected eye.
I'd like to know if the ophthalmologist appreciated what is referred to as an AFFERENT PUPILLARY DEFECT or not. Also, can you tell me if your saccadic eye movements are normal and symmetric or is one eye slower than the other?
Color desaturation and pain upon eye movements are all highly suspicious for a retrobulbar form of neuritis. If an MRI with gadolinium has NOT been ordered then, as a neurologist I feel this should be ordered. If that turns out to be absolutely clean when FINE CUTS are done through the optic nerves back to the chiasm then, I'll be more willing to accept the clinical impression of the ophthalmologist as having ruled out ON as much as humanly possible.
Steroids are the number one treatment of choice for ON but do not really improve the final baseline of function in the affected eye so much as they simply increase the speed to that baseline.
I will list for you a few other conditions that are associated with eye pain in what is referred to as a "quiet (Non-red) eye". So, things like orbital conditions often seen in Grave's disease can cause eye pain but it is not simply with movements, does not typically involve color desaturation, nor changes in visual acuity, especially one side vs. the other. Another reason for eye pain could be an aneurysm which is irritating the 3rd cranial nerve which could cause referred eye pain. However, this pain is going to be constant whereas your symptoms seem to revolve around movement. Again, the idea of color desaturation is not caused by aneurysmal irritations nor should visual acuities. Giant cell or temporal cell arteritis is also another reason for eye pain, it DOES RESULT in reduced visual acuity BUT NOT color desaturation. Giant Cell arteritis is almost unheard of in patients less than age 55-60 years.
In conclusion and will all due respect to the examining ophthalmologist I must state that clinically I believe that your presentation is most consistent with a form of optic neuropathy which could be an optic neuritis and at least deserves an imaging study of quality such as an MRI with gadolinium. If it is negative then, that takes a lot of different things off the table and then, one can take time to consider other possibilities. Also, did the ophthalmologist get any blood work such as a sedimentation rate or a C-reactive protein?
Although it is a bit romantic to think that one could be a case study for strange and unusual symptoms--- I don't think you'd really prefer to be in that category as much as the category of the "well known and described entities" which we understand and have treatments to offer! LOL.....just my opinion....unless of course, you're looking for a XXXXXXX Producer to make the movie version-- HA!
If this information has been helpful and I've answered your questions would you do me the favor of some written feedback and a STAR RATING of the answer.
Should you have no further questions or comments to place- CLOSING THE QUERY would be greatly appreciated as well.
In the future I'm happy to answer more concerns personally if you'd allow me this privilege by going to the following website and sending me your questions:
bit.ly/drdariushsaghafi
This query has required 224 TOTAL minutes of physician specific review, research, and final draft documentation for envoy to this point.
One day I will share my story with you on my days at XXXXXXX College
Detailed Answer:
Happy New Year- to someone else who shares this small world! LOL.
Well, I suppose I can do nothing but defer to someone who has examined you, however, in my opinion as you've presented your case I still put Optic Neuritis rather high on the list of differential possibilities. Lack of physical signs on a dilated fundal examination does not rule out the disease. It is entirely consistent with ON that visual acuity should be different in the affected eye.
I'd like to know if the ophthalmologist appreciated what is referred to as an AFFERENT PUPILLARY DEFECT or not. Also, can you tell me if your saccadic eye movements are normal and symmetric or is one eye slower than the other?
Color desaturation and pain upon eye movements are all highly suspicious for a retrobulbar form of neuritis. If an MRI with gadolinium has NOT been ordered then, as a neurologist I feel this should be ordered. If that turns out to be absolutely clean when FINE CUTS are done through the optic nerves back to the chiasm then, I'll be more willing to accept the clinical impression of the ophthalmologist as having ruled out ON as much as humanly possible.
Steroids are the number one treatment of choice for ON but do not really improve the final baseline of function in the affected eye so much as they simply increase the speed to that baseline.
I will list for you a few other conditions that are associated with eye pain in what is referred to as a "quiet (Non-red) eye". So, things like orbital conditions often seen in Grave's disease can cause eye pain but it is not simply with movements, does not typically involve color desaturation, nor changes in visual acuity, especially one side vs. the other. Another reason for eye pain could be an aneurysm which is irritating the 3rd cranial nerve which could cause referred eye pain. However, this pain is going to be constant whereas your symptoms seem to revolve around movement. Again, the idea of color desaturation is not caused by aneurysmal irritations nor should visual acuities. Giant cell or temporal cell arteritis is also another reason for eye pain, it DOES RESULT in reduced visual acuity BUT NOT color desaturation. Giant Cell arteritis is almost unheard of in patients less than age 55-60 years.
In conclusion and will all due respect to the examining ophthalmologist I must state that clinically I believe that your presentation is most consistent with a form of optic neuropathy which could be an optic neuritis and at least deserves an imaging study of quality such as an MRI with gadolinium. If it is negative then, that takes a lot of different things off the table and then, one can take time to consider other possibilities. Also, did the ophthalmologist get any blood work such as a sedimentation rate or a C-reactive protein?
Although it is a bit romantic to think that one could be a case study for strange and unusual symptoms--- I don't think you'd really prefer to be in that category as much as the category of the "well known and described entities" which we understand and have treatments to offer! LOL.....just my opinion....unless of course, you're looking for a XXXXXXX Producer to make the movie version-- HA!
If this information has been helpful and I've answered your questions would you do me the favor of some written feedback and a STAR RATING of the answer.
Should you have no further questions or comments to place- CLOSING THE QUERY would be greatly appreciated as well.
In the future I'm happy to answer more concerns personally if you'd allow me this privilege by going to the following website and sending me your questions:
bit.ly/drdariushsaghafi
This query has required 224 TOTAL minutes of physician specific review, research, and final draft documentation for envoy to this point.
Above answer was peer-reviewed by :
Dr. Bhagyalaxmi Nalaparaju
Thank you, and Happy New Year to you as well!
My vision issues have resolved with the use of oral steroids - nearly on day 1. Color and acuity are back, still have varying sinus pressure. I did mention the MRI to my primary doc early on (as I was thinking pressure from a potential prolactinoma) however he is intent on beginning with the CT scan of my brain and sinuses.
Thank you for your expertise in this area. It is very helpful.
Best wishes for 2015.
My vision issues have resolved with the use of oral steroids - nearly on day 1. Color and acuity are back, still have varying sinus pressure. I did mention the MRI to my primary doc early on (as I was thinking pressure from a potential prolactinoma) however he is intent on beginning with the CT scan of my brain and sinuses.
Thank you for your expertise in this area. It is very helpful.
Best wishes for 2015.
Brief Answer:
Glad you're feeling better
Detailed Answer:
Thanks for the update and I'm very glad to hear that things are improving back to normal.
Just be aware of the relative insensitivity of a CT scan for optic nerve issues and the fact the color desats occurred must place the problem within the optic nerve given your symptoms. My expectation is that the CT scan (as far as the optic nerve is concerned) will likely be normal. I'd be on guard of any diagnosis which looks to blame sinus congestion for any of this picture.
A proloactinoma causing pressure anywhere to affect the eyes would also be expected to cause Visual Field Losses or "Cuts" without any issues with pinful movements of the eyes, color desaturations, or chanes in visual acuity. That's because the prolactinoma would be in the pituitary gland and growing outwardly to contact some element of the optic chiasm or possible one of the nerves as they come into the chiasm....but those would be easy to see on an imaging study because of their size.
Have an OCULARLY PAIN FREE 2015 my dear and you know where to find me! LOL....
Could you also not forget to rate this query, close her out, and not forget to leave your STARS before you turn off the lights in the room? Thanks a bunch.
If you send me your email address I will return to you a little flow diagram on the Approach to patients with painful Eyes that are NOT RED--- Very nice little ditty that you and maybe even your PMD can appreciate if this were to happen again.
And as always, "Here's my number.....call me....maybe?" :)
bit.ly/drdariushsaghafi
This query has required 240 TOTAL minutes of physician specific review, research, and final draft documentation for envoy to this point.
Glad you're feeling better
Detailed Answer:
Thanks for the update and I'm very glad to hear that things are improving back to normal.
Just be aware of the relative insensitivity of a CT scan for optic nerve issues and the fact the color desats occurred must place the problem within the optic nerve given your symptoms. My expectation is that the CT scan (as far as the optic nerve is concerned) will likely be normal. I'd be on guard of any diagnosis which looks to blame sinus congestion for any of this picture.
A proloactinoma causing pressure anywhere to affect the eyes would also be expected to cause Visual Field Losses or "Cuts" without any issues with pinful movements of the eyes, color desaturations, or chanes in visual acuity. That's because the prolactinoma would be in the pituitary gland and growing outwardly to contact some element of the optic chiasm or possible one of the nerves as they come into the chiasm....but those would be easy to see on an imaging study because of their size.
Have an OCULARLY PAIN FREE 2015 my dear and you know where to find me! LOL....
Could you also not forget to rate this query, close her out, and not forget to leave your STARS before you turn off the lights in the room? Thanks a bunch.
If you send me your email address I will return to you a little flow diagram on the Approach to patients with painful Eyes that are NOT RED--- Very nice little ditty that you and maybe even your PMD can appreciate if this were to happen again.
And as always, "Here's my number.....call me....maybe?" :)
bit.ly/drdariushsaghafi
This query has required 240 TOTAL minutes of physician specific review, research, and final draft documentation for envoy to this point.
Above answer was peer-reviewed by :
Dr. Ashwin Bhandari
Answered by
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