2. Case presentation Dr. Sunil Kumar FRCS MS

4. Clinical Challenge Painful red eye with Severe headache

8. Patient came back in morning With agonizing pain in Rt. eye, severe headache, vomiting and watery rhinorrhea

9. Patient was admitted For further evaluation

10. Detailed systemic examination Not rewarding

12. ENT examination was unremarkable

13. Detailed ocular examination during pain-free period was normal except for the conjunctival congestion

14. Normal CT Scan of brain EXCLUDED Intracranial space occupying lesion presenting as headache

23. Diagnosis was revised

24. Patient was thought of suffering from Rectuls headache

25. Treatment was commenced and episode of pain didn’t recur

26. Patient came back again 9 months later with similar complaints Symptom-complex resolved dramatically on same treatment

27. Clinical Challenge Case number 2

33. Detailed systemic examination Was within normal limit

36. ENT examination and x-ray para-nasal sinus view excluded sinusitis

37. She was diagnosed suffering from Painful partial third nerve paresis with diabetes

38. Ophthalmic consultation was advised

39. Attack of cluster headache

41. Diagnosis was revised to Painful third nerve paresis with diabetes with glaucoma

43. Treatment was commenced with Timolol meleate 0.5% eye drops twice per day

44. IOP dropped down to 20 mm Hg But episode of symptom-complex recurred

49. Diagnosis was revised to Rectules headache

50. Treatment was commenced & Episode of pain didn’t recur

51. Final diagnosis Both patient were suffering from CLUSTER HEADACHE Both patient were suffering from CLUSTER HEADACHE

55. Cluster headache as a cause of painful red eye with headache may be missed both by internist as well as ophthalmologist.

60. International Headache Society criteria for diagnosis of cluster headache D. Pain not attributable to any other disorder. C. Attacks occur in a frequency of one every other day to eight per day 6. A sense of restlessness and agitation 5. Ipsilateral ptosis and miosis 4. Ipsilateral forehead and facial sweating 3. Ipsilateral eyelid edema 2. Ipsilateral nasal congestion and/ or rhinorrhea 1. Ipsilateral conjunctival injection and/or lacrimation B. Headache accompanied by at least one of the following: A. Severe or very severe unilateral orbital or supra-orbital and or temporal pain lasting 15-180 minutes if untreated. At least five attacks fulfilling criteria A-C:

66. Exact etio-pathology of cluster headache Still unknown

67. Ipsilateral ventral hypothalamus Seems to play important role.

72. Thank you thank you

73. Fodder for the thought Courtesy: Sunil Kumar FRCS,MS