Dr Jo-Anne Pon. Consultant Ophthalmologist and Oculoplastic Surgeon Southern Eye Specialists Christchurch

Transcription

1 Dr Jo-Anne Pon Consultant Ophthalmologist and Oculoplastic Surgeon Southern Eye Specialists Christchurch 12:15-12:30 Visual Migraines to be Worried About

2 Visual Migraines To Be Worried About Jo-Anne Pon Ophthalmologist

3 Mr CS (57yo) Right visual field loss RE only Like looking through water Shimmering Lasted 60mins Associated with headache Started day before visual symptoms lasted 48hrs General ache/tension Visual sx s resolved Headaches Gets them intermittently (yrs) Not severe No assoc nausea or need to lie down Assoc with tiredness No further episodes No history of migraine

4 Mr CS Normal ocular examination Management? Neuro-imaging? HVF normal No investigations Didn t return with symptoms

5 Outline Visual Migraine symptoms Typical Red flags/ who needs neuro-imaging Patterns of transient vision loss

6 Perspective Migraine with visual symptoms - common Lifetime prevalence in general population 18% 1-3% of general population or 1/3 of migraineurs will present c/o visual aura Which ones to worry about? Very few Moorfields/St Thomas study over 23 years, 9 cases Literature 31 cases 1950 to 2009 (59yrs)

7 International Classification of Headache Disorders 3 (ICHD-3) Prodromal phase Aura Headache Postdromal phase

8 Typical visual aura of migraine Biphasic aura 1. Positive visual phenomenon Fortification spectra (Teichopsia) Scintillations (flashing lights) C-shape or semicircle surrounding scotoma 2. Negative symptoms minutes later Blank scotoma Hemianopia

9 Visual symptoms

10 Diagnostic criteria for typical migraine visual aura Develops gradually over 5mins Duration 5 to 60 mins Headache begins during or follows aura

11 Moorfields / St Thomas Hospital 9 cases

12 Focal cerebral pathology Moorfields / St Thomas Hospital 9 cases Cavernous haemangioma (2) Capillary haemangioma (1) Infarction (1) Meningioma (3) AVM (1) Oligodendroglioma (1) Literature 31 cases 1950 to 2009 AVM (16) Subependymoma Intracranial calcification Metastatic adenocarcinoma Astrocytoma Unspecified mass Head injury Meningioma Cavernous haemangioma Aneurysm Infarction (ICA dissection, occlusion) Abscess

13 Differentiate Migraine vs Structural Lesion?

14 Migraine vs Occipital lesion Both can have Scintillating scotoma/teichopsia Past history cannot reliably exclude occipital lesion Duration 5-60mins in both Visual aura recurring in same hemifield Occipital Lesion Visual symptoms Brief <5 mins, Unformed Photopsia Flicker rapidly Remain stationery Location Same location in visual field, contralateral to lesion

15 Migraine vs Occipital lesion Red Flags > 40yo, esp no past history of migraine DDx TIA if < 50 yo, Acephalgic (Migraine-like visual aura without headache ) Duration brief (seconds) or < 5 mins (seizure related) Prolonged (persist) Symptoms exclusively negative e.g. hemianopia

16 Mr MK 68yo Left visual field loss with zigzag lines x 10 mins No history of migraines Went to Optometrist

17 Left inferior quadrantanopia

18 Visual Field Defects Luu, Lee, Daly Chen Visual field defects after stroke Australian Family Physician July 2010

19 Right Occipital CVA

20 Who needs neuro-imaging? Stereotypical visual aura: always in same location in visual field Increase in frequency or change in pattern to longstanding visual aura Daily = epileptic visual phenomena Sudden alteration in aura characteristics Unexplained visual field defect Subjective persistence of a scotoma following typical visual aura Co-existence of seizures E.g. previous headache, now acephalgic E.g. aura persisting throughout or beyond headache E.g. persistent darkening or dimming of homonymous region of visual field

21 Mrs KO (76yo) c/o sparkly waves BE, worse in LE (amblyopia) x 10 years, no change in nature of symptoms Last 10-15mins (longest 30mins) Symptoms also present with BE closed No headache Increase in frequency of symptoms Previously occasionally Now fortnightly Recently a day 3 episodes lasting 5mins each

22 Mrs KO (76yo) PMH: HT No CVA, IHD POH: Strabismus childhood L Amblyopia Normal ocular examination R 6/9, L CF No RAPD, normal optic discs 0.3 IOP R 16mmHg, L 17mmHg FH: Glaucoma (sister)

23 HVF Not reliable

24 Management? Neuro-imaging? CT and CTA Head: Dec 2012 Normal Feb 2014 Returned for R cataract management Acephalgic migraines less frequent again

25 Ms DC 52yo PC: spinning propeller in R Superotemporal VF, expands, becomes colourful kaleidoscope obscuring VF Resolves > 20mins Originally lasted 1 min, but increased duration and frequency Occurring every other day Sees symptoms with eyes closed No headache 1 episode assoc with nausea and vomiting Between episodes, back to normal, well, no neurological symptoms

26 Ms DC 52yo

27 Ms DC 52yo PMH: Treatment for Breast Cancer Surgery Radiotherapy Chemotherapy Hormone treatment CT scan with contrast 23/6/16 No cause to explain symptoms Presented Aug 2016 Review 4 weeks with HVF If deterioration, MRI 1 day before appointment Found confused, headache, vomiting (didn t turn up at work)

28 Ms DC 52yo

29 Acephalgic migraine vs retinal migraine Usually young, well adults Patchy fading vision over 5 min, then poor vision for 5-60mins +/- headache + No headache Choroidal circulation in spasm No neurologic symptoms Normal eye examination Rx: Ca channel blocker to reduce frequency

30 Patterns of vision loss Monocular or binocular? Patients can mistake monocular for binocular or vice versa Other clinical /neurological signs

31 Patterns of vision loss Monocular Age? >50yo: Amaurosis fugax? (cardiovascular workup) > 50yo & older: GCA? All ages, <50yo E.g. Carotid dissection (trauma, neck pain, Ipsilateral Horner s syndrome, dysgeusia) Exercise or heat: Uhthoff s phenomenon (optic neuritis/ms) Gaze evoked amaurosis: orbital tumour?

32 Patterns of vision loss Transient Binocular Vision Loss Duration? Pattern of recovery? Papilloedema seconds, Transient Visual Obscurations (TVOs) Vertebrobasilar insufficiency onset sudden (seconds), then recovers over seconds to minutes D s: dysarthria, diplopa, dizziness (vertigo), drop attacks, >50yrs, vasculopathic risk factors All symptoms resolve < 1hour TIA - < 15mins Onset within seconds, lasts 1-10mins Visual Aura of Migraine 20 mins (5-60 mins) Retrochiasmal disease < 5 mins (20-30mins)

33 Migraine with visual symptoms Take home messages Who to refer for investigation?

34 Pattern Recognition Typical Migraine Visual Aura Other patterns of vision loss Unilateral Bilateral

35 Diagnostic criteria for typical migraine visual aura Develops gradually over 5mins Duration 5 to 60 mins Headache begins during or follows aura

36 Migraine vs Occipital lesion Red Flags > 40yo, esp no past history of migraine DDx TIA (can be acephalgic) if < 50 yo, Acephalgic (Migraine-like visual aura without headache ) Duration brief (seconds) or < 5 mins (seizure related) Prolonged Symptoms exclusively negative e.g. hemianopia

37 Who needs neuro-imaging? Stereotypical visual aura: always in same location in visual field Increase in frequency (daily = seizure activity?) or change in pattern to longstanding visual aura previous headache, now acephalgic Persisting aura/ persisting scotoma persistent darkening or dimming of homonymous region of visual field Co-existence of seizures

38 Thank you