Uncorrected Vision Problems and Headache
Guest post by Dr. Ingo Anderle, ophthalmic optician
There is a correlation between headaches and migraines and improperly corrected refractive errors and undetected strabismus. This indicates a need to build closer interprofessional relationships between neurology and optometry
This article serves to illustrate the experience I have had with headache patients in my optometric and optical practice, the effects of detecting improper correction of refractive errors, and the detection of hidden strabismus. The correction of these problems results in patients seeing better, having a better life, and having found relief.
To emphasize the need for a closer collaboration between neurology and optometry, I will use two cases I have seen at my practice and treated accordingly.
CASE I
Female patient, 42 years of age, wearing glasses for close to 35 years. Myopic (near-sighted), with astigmatism and anisometropia of 2dpt.
Patient comes in for a check-up to get new glasses. Her history reveals that she has been suffering almost daily from headaches since puberty and increasingly from migraines, which at the time of consultation averaged 3 days per week. Consulting a number of doctors about her migraines and headaches did not provide effective treatment and left her with medication to be taken as required. Patient is working in an office environment, spending about 8 hours on a computer. Hobbies include knitting and other close range activities and the use of a laptop computer at home.
Initial exam reveals her current Rx (2 years old) is over-minussed with 1dpt OS, overall, slight changes in prescribed correction for astigmatism. Fundus eye exam is normal, anterior part doesn’t show any pathologies.
During binocular testing, the patient was shown a split screen red/green image and trial frames fitted accordingly with red and green filter. The patient was asked to describe what she sees and reported that the clarity of image was identical, but that the left hand side green image kept wandering over to the left. This procedure, as well as the way the question was posed, revealed the strabismus and the need of 5pdpt, Base 0º of correction OS. Had the patient only been asked which side was better, rather than to describe her experience, she would have answered they were identical and that would have left the strabismus undiagnosed.
Accomodation is still fine for near vision and only long distance Rx is prescribed.
(New Rx OD: -3.00(cyl -0,50 x5º) / OS: -5,75 (cyl -0,50 x75º) P 5pdpt Base 0º)
Glasses were made at our in-house workshop. Prism is fitted only OS. (Lenses used: Zeiss Clarlet 1.67 Aspheric with Lotutec AR.) Centres are fitted at 3mm below pupil centre and at exactly the same I.P.D. as in the trial frames during the eye exam. After wearing the glasses with the new Rx for only 3 days the patient is reporting a significant improvement in visual acuity and not suffering from headaches as before.
At the annual check-up the patient reported an almost complete cessation of headaches and only occasionally suffering from a migraine (usually weather dependent). Vision Rx is stable and reading glasses with Add 1.00 are prescribed.
At the 2 year check-up the patient is reporting the same as the year before, Rx is stable and reading Add has changed to 1.25.
The patient requested seperate reading glasses. Prism is fitted at 4pdpt and patient is reporting her satisfaction with her new glasses.
CASE II
Female patient, 35 years of age turns up for a new Rx for new glasses. Medical history reveals that the patient is suffering from moderate to severe headaches over a period of 5 years. The average daily medication taken is Ibuprofen 1200mg or equivalent in Paracetamol (acetaminophen). Her current glasses are of the following RX: OD -4.00 (cyl -0,75 x 25º) P 1,5pdpt Base 270 (vertical prism) OS: -2,00 (cyl -1,00 x 5º). The glasses appeared to be very tilted and not in a straight position on the patients face. When mentioned this, she said “I see better that way.”
Over the past 5 years the patient underwent a number of exams and consulted a neurologist numerous times. An MRI and CT scan were performed, both normal. The patient was at the point of giving up trying to find a cure for the headaches and was trying to live with them and not expecting any improvement.
The exam revealed the following RX: OD -3.00 (cyl -0,50 x30º) /OS: -2,00 (cyl-0,75 x 175º), no vertical prism was detected, and again overminussed OD.The vertical prism in her glasses must have been caused by a mistake during the fitting process of the lenses, since no vertical prism was detected during the exam. Her problems with headaches started soon after she had the current pair of glasses made and since then she did not have an eye exam and no new glasses.
The patient did not want to believe that just a new Rx and new glasses would make a significant difference in regard to her headaches. Understandably, after a 5 year ordeal, MRI and CT scans, and consulting neurologists, she did not have any confidence in finding a cure.
However, new glasses were made and after only 2 days she reported back and could not believe that she had not had a headache and that she was generally feeling a lot better. Two weeks later, I called for a follow up and she reported a continued absence of headaches and came in to order a second pair of glasses.
CONCLUSION
As both cases illustrate, there can be a lack of good quality service available when it comes to eye examinations, and there is a shortfall in interprofessional collaboration between neurology and optometry.
Both patients would have benefitted greatly from being referred to an optometrist by their doctors, but both patients also had the unlucky experience with incorrect prescriptions and/or incorrectly made glasses and a lack of experience in binocular testing.
Current practice here in Andalucia (southern Spain) is that a doctor (mostly the GP) refers patients with symptoms such as headaches and blurred vision to consult an optometrist IF they currently do not wear glasses. If a patient is wearing glasses, it is widely assumed that they must be correct (both regarding Rx and correctly fitted) and I hardly ever see a referral to an optometrist.
The relationship between wrongly corrected eyesight or undercorrection and headaches is known and nothing new.
In my opinion it would be good to see more referrals from neurologists to the optometrist, even if it is to exclude wrongly/undercorrected eyesight in the diagnostic process.
POINTERS FOR THE OPTOMETRIC PROFESSION
There is a large shortfall in the quality of eye examinations by ophthalmologists and optometrists, especially in the way they conduct the pre-examination medical history (neither age, nor medications taken, underlying health conditions not explored, workplace and hobbies that give an idea on the demand the patient will have on vision and glasses not identified). Also, during the exam itself, leading questions do not assist in getting the correct picture. If the only question asked is whether one or the other option is better or worse, it does not allow the patients to accurately describe the visual picture they actually see. After all, the issued Rx is a subjective Rx.
Dr. Anderle is an optometrist practicing in southern Spain.
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