Headache with migrainous features caused by delayed onset secondary angle closure glaucoma following laser treatment for retinopathy of prematurity

As survival among preterm infants has increased over time, the number of children at risk of complications of prematurity has increased as well. Retinopathy of prematurity (ROP) is a disease of abnormal retinal blood vessel development and is one of the leading causes of preventable blindness in preterm babies.^{1, 2}

We present a former 24-week premature infant who received left laser retinal photocoagulation at 2 months of age for ROP. At 9 years of age, he began experiencing new intermittent headaches behind the left eye that were described as achy and dull. The headaches were associated with light sensitivity, nausea, and vomiting, and they worsened when he moved his head forward. He denied vision changes, waking up from sleep due to headaches, numbness, tingling, or weakness. He had no prior headache history or family history of chronic headaches. His exam was notable for the oblong appearance of the left pupil, but his neurological exam was otherwise nonfocal. His symptoms and exam were thought to be most consistent with migraine headaches.

Due to the positional component of his headaches, further evaluation was pursued, including imaging and consultation with ophthalmology. Brain magnetic resonance imaging revealed no structural explanation for his headaches. Eye exams during this period revealed normal intraocular pressure (IOP) bilaterally and no optic disc edema. There were notable iris abnormalities and iridocorneal adhesions in his left eye consistent with prior history of retinal laser treatment. A lumbar puncture was not pursued due to no other signs or symptoms of increased intracranial pressure aside from the positional features.

Over the next month, several migraine treatments were trialed with inconsistent symptom relief, including acetaminophen in combination with prochlorperazine, diphenhydramine, valproate, and propranolol. Nonsteroidal anti-inflammatory drugs were avoided due to his history of chronic kidney disease. Approximately one month later, his headaches rapidly worsened to throbbing in the left frontal and temporal region. His neurological examination remained stable. However, his left eye pressure was elevated at 34 mmHg (normal ≤ 21 mmHg) during ophthalmologic evaluation. He developed further worsening headaches, blurred vision, nausea, and vomiting one week later. IOP of his left eye had increased to 46 mmHg and did not respond to pharmacologic IOP-lowering therapies. The patient was admitted for urgent Ahmed glaucoma drainage device implantation (New World Medical) in the left eye and experienced immediate headache relief after surgery.

Angle-closure glaucoma can present as early as two weeks after treatment of ROP. However, presentations have been reported anywhere from 12 to 45 years of age.^{3, 4} Angle-closure glaucoma symptoms can first present with intermittent headaches due to periodic elevation of IOP followed by spontaneous normalization.^{5, 6} This likely explains the normal IOP measurements during our patient's initial exams. These headaches are frequently localized to the frontal and temporal regions and can be associated with nausea and vomiting.⁶

More than a year after surgery, the patient's IOP measurements have remained stable. He has experienced occasional headaches, but these have decreased in both frequency and severity postsurgically. The temporal relationship between his worsening headaches and measured increase in IOP with the subsequent improvement of his headaches postsurgically supports angle-closure glaucoma as the primary etiology of his headaches, either as a direct cause or as a trigger for migraine headaches. It is alternatively possible that the patient had concurrent presence of both angle-closure glaucoma and migraine headaches.

Overall, this patient highlights the overlapping symptomatology of migraine headaches and angle-closure glaucoma that may result from laser retinal photocoagulation for ROP. For patients with new headaches and a history of ROP, ocular etiologies should be considered, and early involvement of ophthalmology teams may help establish a diagnosis.

Christina J. Su: Visualization; writing (original draft); writing (review and editing). Carley Gilman: Writing (review and editing). Andrew R. Lee: Conceptualization; writing (review and editing); funding acquisition. Shannon C. Agner: Conceptualization; project administration; supervision; writing (review and editing).

The authors declare no conflicts of interest.