In a 60‑year‑old man with a 2‑day right periorbital headache, normal head computed tomography, intact neuro‑ophthalmologic examination, no visual changes, and a history of retinal detachment, what is the appropriate diagnostic work‑up and initial management?

Periorbital Headache with History of Retinal Detachment: Diagnostic Work-Up and Management

In this 60-year-old man with periorbital headache, normal CT, and history of retinal detachment, immediate dilated fundus examination with scleral depression by an ophthalmologist is mandatory to exclude retinal pathology, followed by temporal artery evaluation given his age and headache location. 1

Immediate Ophthalmologic Evaluation Required

The history of retinal detachment places this patient at elevated risk for recurrent retinal pathology, and periorbital pain can be an atypical presentation of retinal disease. Any patient with eye trauma history (which includes prior retinal detachment) presenting with new ocular or periorbital symptoms requires immediate dilated fundus examination with scleral depression, as 8-22% will have a retinal tear at initial presentation. 1

Essential Ophthalmologic Examination Components:

• Visual acuity testing to establish baseline 1
• Pupillary assessment for relative afferent pupillary defect 1
• Confrontation visual field testing 1
• Vitreous examination looking specifically for pigmented cells, hemorrhage, and posterior vitreous detachment 1
• Peripheral fundus examination using indirect ophthalmoscopy with scleral depression—this is the mandatory method for detecting peripheral retinal pathology 1

Even though the patient reports no vision changes, symptoms can be subtle or absent initially. Patients with history of retinal pathology require re-examination within 6 weeks if any vitreous pigment, hemorrhage, or vitreoretinal traction is identified, as approximately 2-5% of patients with initially normal examinations will develop retinal breaks in the following weeks. 1

Age-Related Considerations: Giant Cell Arteritis Evaluation

At 60 years old with new periorbital headache, giant cell arteritis (GCA) must be excluded. Up to 15% of patients 65 years and over who present with new-onset headaches may have serious pathology such as stroke, temporal arteritis, neoplasm, and subdural hematoma. 2 While this patient is slightly younger, the periorbital location and his proximity to this age threshold warrant evaluation.

GCA Assessment:

• Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP), recognizing that ESR can be normal in 10-36% of patients with temporal arteritis 2
• Clinical examination for temporal artery tenderness, scalp tenderness, jaw claudication, and visual symptoms 3
• Consider temporal artery biopsy if clinical suspicion is high, noting that false-negative results occur in 5-44% of patients 2

Additional Diagnostic Considerations

Trochlear Pathology:

Primary trochlear headache is a specific cause of periorbital pain that requires examination of the trochlea to be incorporated into clinical practice. 4 Physical examination should include palpation of the trochlear region for tenderness, as this represents a treatable cause of periorbital pain.

Imaging Adequacy:

The normal head CT provides reassurance against space-occupying lesions, hemorrhage, and hydrocephalus. However, CT imaging is typically not indicated specifically for evaluation of optic nerve pathology or subtle retinal conditions. 3 If ophthalmologic examination raises concern for optic nerve or orbital pathology, MRI of the orbits would be the preferred imaging modality. 3

Management Algorithm

1. Immediate ophthalmology referral for dilated fundus examination with scleral depression 1
2. Obtain ESR and CRP to evaluate for GCA 2
3. Perform trochlear examination during physical assessment 4
4. If ophthalmologic examination is normal and inflammatory markers are negative, consider primary headache disorders with appropriate analgesic management 5

Critical Warning Signs for Patient Education

Instruct the patient to return immediately if he develops new or increased floaters, new or persistent light flashes, peripheral visual field loss, or decreased visual acuity. 1 These symptoms indicate potential retinal tear or detachment requiring urgent surgical intervention. 1

Common Pitfalls to Avoid

• Do not assume normal vision equals normal retinal examination—peripheral retinal pathology can exist without central visual symptoms 1, 6
• Do not rely solely on ESR to exclude GCA—clinical suspicion should drive further evaluation even with normal inflammatory markers 2
• Do not defer ophthalmologic examination based on normal CT—CT has limited sensitivity for retinal and optic nerve pathology 3