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Round table: Experts trade experiences working up common complaints
In this round table, OSN Pediatrics/Strabismus Board Members discuss how to work up common complaints of blinking and headaches, which may or may not have ocular origin.
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Robert S. Gold, MD: Let’s start with discussion of common presentations in your office. A child comes into your office and the mother says, “My child is blinking.” We see this very commonly, so I would like to know, how would you work up this patient?
Blinking
Kenneth P. Cheng, MD: I see at least one child a day who is blinking, and 99.9% of them have a normal exam. In Pittsburgh, we get an allergy season, so in the spring I attribute blinking to allergy. Most times, though, the eyes are white, they are not tearing, they are not itching, and you find nothing on the exam. I usually just reassure the parents and do not do anything else, except a slit lamp exam if I can. I do not do any other workup or evaluation, and I tell the parents that it is likely a mild tic that will probably disappear. I usually do not get called back, but I don’t know whether that is right or not.
Scott E. Olitsky, MD: I do the same. If I do get that phone call, I may suggest that they see a neurologist because sometimes, in a very small minority of children, the question of Tourette’s comes into play with a tic that is persistent. But I cannot think of ever suggesting that at the first visit. It is when I get that phone call that it is not getting better.
Anthony P. Johnson, MD: If the exam is completely normal, I, too, like to reassure the mom. But the one thing that I often ask is, “Is it worse when they’re doing something that requires staring, like playing a video game, or something that requires their intentionally overcoming their blink reflex?” Also, sometimes the child does not really complain about the blinking; it is an observation that we make from across the room that is bothersome to the observer.
Roundtable Participants
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Moderator
- Robert S. Gold
- Kenneth P. Cheng
- Anthony P. Johnson
- Scott E. Olitsky
- Erin D. Stahl
- Rudolph Wagner
- Roberto Warman
- M. Edward Wilson
Another issue is whether or not there is a corneal foreign body and the child is tolerating it. But, as Ken said, do a slit lamp examination, if possible. Often you can actually see the foreign body just with streak retinoscopy, especially in a dilated exam, if you can do streak retinoscopy, as well.
I am reluctant to make a diagnosis of Tourette’s; I would rather rely on the neurologist for that. I am also very unlikely to make that primary referral because most of the time, especially with me living in the allergy capital of the world, I see this blinking a lot, and I am glad to hear some reassurance by other panelists that they concur, that in the face of a normal exam, the blinking is often allergy related.
Gold: A lot of times parents are coming in looking for a therapeutic option. I go through the differential diagnosis — allergy, neurologic issues — and when we know there is no refractive error issue, then I will sometimes tell parents to use a cold compress on their child when they notice the symptoms. I stay away from eye drops unless parents ask for them specifically, and then I just tell them to use an artificial tear. Usually after a week or two of doing that, all the symptoms go away anyway. So, that is a palliative therapy for the parents more than for the child.
Roberto Warman, MD: I don’t bring it up, but when the parents come in asking about Tourette’s, that is a different story. I ask if there are any coughing or unusual noises, guttural noises that they make, or other face movements, and if their answer is “yes” or if I observe them, then that is the patient I send to neurology. Blinking in Tourette’s almost always comes after the other disruptive occurrences and not as the primary occurrence. I am not saying this is common at all; it is extremely rare, and I agree that what is needed is reassurance.
Regarding drops, I do the opposite. When the eyes are white, even if there is a minor allergy component, I purposely do not give drops because what I want to do is not emphasize the process, and it will go away faster.
Cheng: We have a lot of years of examiner experience here, probably on thousands of children who have complained about this. I cannot honestly remember any case of Tourette’s, but I would not necessarily hear about it because the family may have followed up elsewhere. Has anybody heard about real pathology, including Tourette’s, associated with blinking?
Olitsky: I can remember one patient.
M. Edward Wilson, MD: I have. I have seen kids with blinking who have been to several doctors, and I look really carefully and they have a tear quality problem. They have rapid tear breakup time; they have meibomian dysfunction and they are blinking. They feel like cold air is blowing in their face all the time. It is not common, but it is missed oftentimes. It can be treated, and the blinking goes away. I have seen some of that in young children.
Cheng: That is a good point.
Wilson: On careful questioning, you find that they usually have more symptoms in activities or places where you would expect the poor tear quality to be a problem: outdoors and in the cold wind.
Rudolph S. Wagner, MD: Ed is onto something there. Maybe we are not looking as hard for some of the things that could actually be causing blinking, such as dry eyes.
Headache
Gold: A child comes in with a complaint of headaches. What do you do for these children, and when do you consider further intervention or workup?
Erin D. Stahl, MD: First, do the standard exam to rule out refractive error and get a history on the headaches. Sometimes you can qualify the headaches — whether it is a pseudotumor kind of headache, whether it is a chronic daily headache, whether it is a migraine type of headache — and that gives you some idea of what other things to look for in the exam. But with a completely normal eye exam and a headache, I usually refer the patient back to their primary care doctor, and I always tell people, “If you feel like you’re not getting answers and you’re not being well taken care of, then consider seeing a neurologist.” But I do not typically make that referral.
Olitsky: Assuming a normal exam, I do pretty much the same thing. If the history sounds migrainous in nature, I will also usually send them back to the pediatrician or, depending on how debilitating the headaches are, to a neurologist, but I usually will give the parents and/or the child instruction to keep a food diary to determine if foods trigger the headaches. There are lots of triggers, and we talk about some of those. It is helpful for them to have that information at their next appointment.
Warman: For the general readership, there are a couple of questions that are important. Does this headache disrupt the life of the child? Do they have to go home, lie down and sleep? Do they have to stop being active? Do they not go to their favorite activities? Does it wake them up in the middle of the night? It is rare, but when it does, that is a big red flag. Do they wake up with a headache in the morning? Does it come with a lot of vomiting? We see hundreds of patients with headaches. You need to find the things that separate your sending them to a neurologist or doing the workup.
Wagner: Roberto is right to ask about the severity of the headache. I often ask, “Do these headaches occur on Saturdays and Sundays or just during the week?” because in school a lot of kids localize this complaint to whatever else is bothering them, and they will say they have a headache. But I do think that migraine headaches in children do not necessarily present with the aura and other things that typically you see in adults with migraines. A very important question is whether the headache disrupts their routine. For example, do they want to lie down and go to sleep? Very few things will cause a kid to lie down and go to sleep during the day, unless it is severe. If it is a headache like that, I think in the category of migraine. At this point, not surprisingly, parents will often acknowledge that they also get migraines, but they may not necessarily get them with the same symptoms as their child. That is something to keep in mind.
Wilson: Sometimes the pediatricians already have a good handle on this. What they want from us many times is reassurance that the headache is not ocular. Most of the time, it is not ocular. They are very appreciative if we can get the exam done and say, “These are not ocular headaches. There’s not an easy solution right there in the eye exam, so proceed with what you thought was going on, whether it’s atypical migraines or some other type of headache.” That is the most common consultation I get: “Please reassure me that this is a non-ocular headache and I’m not missing papilledema or something like that.”
Cheng: I think we can save patients a lot of time, if they have not already gone the route of neurology, by talking about migraine. I keep a list of migraine triggers in the office. I hand one to the kids whom I think may conceivably have migraine. Migraines are so familial in nature that if there is no family history of migraine, then the child almost assuredly does not have migraine. But when migraine is a possibility, we can counsel them, as was said, about what they are eating. Some of these kids who complain of headaches after school or during school just do not eat properly. They eat a bowl of sugared cereal in the morning and nothing else, or they do not drink anything and then they eat lunch at 1 o’clock in the afternoon. These kids are used to grazing, not having meals, so that may very well give some obvious headaches.
Johnson: The one thing that I worry about missing is swollen optic nerve after shunt malfunction, so I look for that. We all see a large number of patients with hydrocephalus who have been shunted in the past, and they get older and older and sometimes lose follow-up with the neurosurgeon. We also see a fair number with neurofibromatosis, or at least a concern for it. Just recently I had a case that was missed by the pediatric neurologist. This was a child who has been seen by a lot of doctors and has done so well for so long. He had a primary shunt at less than 6 months of age and is now 16 years old. Just suddenly, he had shunt malfunction. That is one thing we have to be watching for.