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Chiara Morini

Erika Poggiali

Vincenzo Murelli

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                                                      Emergency Care Journal 2022; volume 18:10775                                                                      [Emergency Care Journal 2022; 18:10775]                                                     [page 53]Eye and headache: Not always an inseparable associationErika Poggiali,1 Chiara Morini,2 Vincenzo Murelli31Emergency Department, Guglielmo da Saliceto Hospital, Piacenza; 2Ophthalmology Unit, Guglielmo daSaliceto Hospital, Piacenza; 3Radiology Unit, Guglielmo da Saliceto Hospital, Piacenza, ItalyQuestionGiven the patient’s history and CT imaging, what is the most likelydiagnosis?1)    Calcification of the globe2)    Foreign body 3)    Optic disc drusen (ODD)4)    Pseudo papilledemaCorrespondence: Erika Poggiali, Emergency Department, “Guglielmoda Saliceto” Hospital, Via Giuseppe Taverna 49, Piacenza, Italy. Tel.: +39.0523.303044E-mail: E.Poggiali@ausl.pc.itKey words: Chronic headache; calcification of the globe; Optic discdrusen; foreign body; pseudo papilledema.Contributions: EP and CM collected details of the case, cared for thepatient, and drafted the manuscript. VM performed the radiologicalimaging and critically revised the manuscript. All the authors approvedthe final version.Conflicts of interest: EP is member of the editorial board of EmergencyCare Journal. This work was not supported by any grant.Availability of data and materials: All data underlying the findings arefully available upon reasonable request to Erika Poggiali,E.Poggiali@ausl.pc.itEthics approval and consent to participate: As this was a descriptivecase report and data was collected without patient identifiers, ethicsapproval was not required under our hospital’s Institutional ReviewBoard guidelines.Informed consent: The patient provided consent for the access to med-ical records at the time of admission.Received for publication: 4 August 2022.Revision received: 24 August 2022.Accepted for publication: 13 September 2022.This work is licensed under a Creative Commons Attribution 4.0License (by-nc 4.0).©Copyright: the Author(s), 2022Licensee PAGEPress, ItalyEmergency Care Journal 2022; 18:10775doi:10.4081/ecj.2022.10775Publisher's note: All claims expressed in this article are solely those of theauthors and do not necessarily represent those of their affiliated organiza-tions, or those of the publisher, the editors and the reviewers. Any productthat may be evaluated in this article or claim that may be made by its man-ufacturer is not guaranteed or endorsed by the publisher.A 45-year-old man with a history of chronic headache (pulsating,tension-type like and stabbing) with blurring vision since 2016,presented to our emergency department with an acute headache,8/10 in severity, with foreign body sensation in the right eye andsubjective impression of blurred vision. He denied photophobiaand phonophobia. The symptoms were alleviated by NSAIDs.Neurological and full ophthalmological evaluation, includingbilateral acuities, anterior segment, fundoscopy, as well as com-puterized visual fields, resulted normal. Laboratory findings wereunremarkable. Blood pressure was normal. Brain computedtomography (CT) scan showed a small radio-opaque image ofapproximately 3 mm in the anterior part of the right eyeball inthe paramedian area and ruled out masses (including menin-gioma of the optic nerve), signs of bleeding and endocranialhypertension.Non-commercil use onlyAnswerThe final diagnosis is “chronic primary headache and calcifi-cation of the right globe”. Eye calcification can be considered anincidentaloma. Calcification of the globe can have many causes,both benign and malignant.1 Incidental asymptomatic orbital calci-fications are commonly encountered on modern high-resolutionCT images of the brain and orbit.2 CT marked sensitivity to calci-um increases its usefulness in the workup of ocular lesions.3Calcific scleral plaques are usually asymptomatic incidental find-ings, and they usually occur just anterior to the insertion of the hor-izontal (medial and lateral recti muscles), at the level of the lens.The calcified plaques are variable in size, can be single or multiple,involve one or both eyes, and are very common in elderly patients.4Corneal and conjunctival calcification is the main extravascularsite for calcification among patients with end-stage renal diseaseon maintenance haemodialysis.5 Calcifications of the trochlea arecommon findings on CT scan of the orbit6 and should be consid-ered in the differential diagnosis of hyperintense densities in thesuperomedial orbit, especially in cases of trauma where it can beconfused with a foreign body. Axial CT can also show calcificationin the substance of the optic nerve head, consistent with the diag-nosis of ODD. ODD are acellular deposits located in the opticnerve head of up to 2.4% of the population.7 On CT, drusenappears as a discrete, rounded high density confined to the opticdisc surface. CT scans are so sensitive that they may detect drusenwhen the ophthalmoscopic examination is apparently normal.2 Themajority of patients with ODD have visual field defects, most oftendue to anterior ischaemic optic neuropathy. Our patient reported a history of head trauma that had occurred3 years earlier in a car accident. We believe such ocular calcifica-tion might be the result of previous trauma, and long-term ophthal-mological monitoring could be worthy. A calcification in that spe-cific position of the eyewall is unlikely to cause any foreign bodysensation, which has indeed resolved in our patient with the simpleuse of lubricants. Neither was that calcific plaque the origin of thedrop in vision, which has spontaneously come back to normalalong with the resolution of headache without any further care.References1. Gaillard F, Baba Y. Calcification of the globe (differential).Reference article, Radiopaedia.org. Accessed on 01 Aug 2022.Available from: https://doi.org/10.53347/rID-10432. Murray JL, Hayman LA, Tang RA, Schiffman JS. Incidentalasymptomatic orbital calcifications. J Neuro-ophthalmol1995;15:203–8.3. Gordon RN, Slamovits TL, Rosenbaum PS, Bello J. Calcifiedscleral plaques imaged on orbital computed tomography. Am JOphthalmol 1999;127:461–3.4. Alorainy I. Senile scleral plaques: CT. Neuroradiology2000;42:145–8.5. Pessoa MBCN, Santo RM, De Deus AA, et al. Corneal andconjunctival calcification in a dialysis patient reversed byparathyroidectomy. Blood Purif 2021;50:254–6.6. Sobel RK, Goldstein SM. Trochlear calcification: a commonentity. Orbit 2012;31:94–6.7. Hamann S, Malmqvist L, Costello F. Optic disc drusen: under-standing an old problem from a new perspective. ActaOphthalmologica 2018;96:673–84.                             Images in Emergency                                                            [page 54]                                                      [Emergency Care Journal 2022; 18:10775]Non-commercial use only

Eye and headache: Not always an inseparable association

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Eye and headache: Not always an inseparable association

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