Persistent painful headaches that worsen while reading, refractive questions

[longmeow]

For 2.5 months, my husband(age 41) has experienced persistent painful headaches while reading. Because he programs for a living, he has been unable to work during this time. The headaches worsen while using the computer, where he experiences an "eyes pulling apart" sensation. He does NOT experience blurred or altered vision.

He has visited two ophthalmologists, a muscle specialist, an ear nose and throat doctor, and a nurse at a neurology office, and no one has been able to identify the problem. He has also had a brain and sinus CT scan, both of which were clear, and an EEG that we are waiting on the results for. He is scheduled to see a neuro ophthalmologist and a neurologist in December.

He has an acute astigmatism and is wearing prescription eyeglasses from 2018, so the first thing we scheduled was an optometry visit. At first, he seemed to respond well to the new prescription (though he says he was already starting to feel better at the time, and the new glasses were unrelated), and then after 3 days said they made him feel dizzy and reverted back to the 2018 prescription. His symptoms continued to worsen from there, except once following months of rest, but the symptoms returned again after 2 days of computer use.

The second ophthalmologist ordered him a new prescription that was very similar to his 2018 prescription, but again, he says that it makes him feel dizzy and continues to wear the 2018 prescription. He says that because he even experiences the headaches while sleeping, it can't be a refractive issue, and because the prescription is so similar, he doesn't see the need to switch glasses.

Here is the RX on the two pairs:
2018 glasses:
sphere: +50 cylinder: -2.00 axis: 006
sphere: +2.75 cylinder: -4.50 axis: 168

new glasses:
sphere: +0.75 cylinder: -1.75 axis: 010
sphere: +2.75 cylinder: -4.50 axis: 165

Both glasses were crafted at Lenscrafters and are polycarbonate with scratch resistance/anti reflection/UV blocking. I did notice that on the receipt for the 2018 pair, it says they are "ASPH" but also states they are polycarbonite. "ASPH" is not printed anywhere on the 2021 receipt.

I am wondering if the prescriptions are really that similar, and what else could be causing the headaches. Thank you for reading this, I am at a loss!

[longmeow]

We will look into bifocals, or monofocals for computer use. Thank you very much for the advice!

[longmeow]

One last question, if you don't mind: He thinks a bifocal might be inconvenient for computer-use. What would you recommend for computer use/arm's length magnification?
Thank you again.

[John C Hagan III, MD, FACS, FAAO]

I use no lines for my computer all day. Secret is put screen low and sit high so don't have to tilt head back so far.   They do make "computer glasses" in which the top is focused at the screeen and lower segment on the keyboard.  Works okay for programers and others that do not have to look far away the screen.  Your whole post disturbs me because its something any first year ophthalmology or optometry student would pick up on  "trouble reading at age 41"    You are doing a million dollor work up without trying a hundred dollar cure.

[longmeow]

I return with an unfortunate update. The ophthalmologist he saw in October feared he wouldn't adjust well to progressive lenses, but wrote him a prescription for computer glasses with a +.5 read. The computer glasses only somewhat helped, but he still experiences a splitting head feeling while using the computer. If he covers his weak eye with an eye patch, the split head feeling goes away, but he feels pressure in his forehead.

He saw another ophthalmologist who noted that his eyes are turned inward a bit and referred him to a binocular vision specialist. She noted that the eyes are indeed turned in, but said that she didn't think contact lenses or lasik would be helpful. Because he is out of options, he scheduled an appointment for  contact lenses, regardless.
She recommended vision therapy and blue light blocking, which seems to have conflicting evidence.

We saw yet another ophthalmologist in the area who dilated his eyes before doing a vision test. She was the first to do this.
She said that his prescription was very different from his current glasses, and believes this could be the issue. He asked if he should also update the prescription for his computer glasses, but she seemed to think he wouldn't need them.

The new prescription is as follows:
sphere: +1.00 cylinder: -1.75 axis: 010
sphere: +3.25 cylinder: -4.00 axis: 170

Needless to say, we're feeling hopeless. Thanks for reading.

[John C Hagan III, MD, FACS, FAAO]

Don't feel hopeless. I have said from the beginning I don't think this is a difficult case at all. I find it unbelievable that you have seen so many ophthalmologists and the eyes have not been dilated. Totally unbelievable!  This is really a plain vanilla case.  Your husband's problem is seemingly not difficult to diagnose but treatment may be difficult and time consuming.  From what you have presented the problem likely is a combination of  1. his wildy different refractive errors in each eye (aneisometropia)  2. his age (presbyopia)  3. the eye muscle balance problem.        If we say him in our clinic we would do a glasses test before dilation (manifest refraction) and after dilation (cycloplegic refraction) so we knew the total amount of hyperopia he has. This can only be determined with dilation and a glasses test after dilation.  POSSIBLE SOLUTIONS:   1.  he needs a strong add thatn +0.50   first options would be do a manifest refraction and 'push plus' to see how much of his distance hyperopia he can adjust to then give that with a +1.50 add.  2. If that didn't help then computer glasses WITH PRISM IN RX  The amount and direction of the prism would depend on the amount and direction of the eye muscle imbalance. Your husband probably has difficulty maintaining straight eyes when converging for the computer screen.    3. If still a problem consult a refractive surgeon to discuss options to reduce the difference in the two eyes by laser or surgery.   4. I think the blue blocker and binocular vision specialist are unlikely to help.  5. You might want to make a summary of all your exams and glasses RXs and see a Eye MD eye muscle specialist (strabismologist/pedicatric ophthalmologist).       I have seen patients like your husband before.  This is not a difficult diagnosis but treatment is complex. This problem often runs in families and if you have children and they did not have poblems like this or amlyopia or crossed eyes you are fortunate.

[longmeow]

Thank you for the encouraging words. It seems difficult to find a doctor who will take his problem seriously. We saw a muscle specialist in the past, but he did not examine him thoroughly, and concluded very quickly that my husband's eye muscles looked "fine."

Hopefully we can find someone who is willing to try the things you suggested.

[John C Hagan III, MD, FACS, FAAO]

Best of luck,  look for a MD pediatric/adult strabismus specialist.

[Porick]

I bet the problem is the material the lenses are made out of. I have the same Rx problems and could not use Lens Crafters.  Go to another Optometrist that uses better quality lenses like Trivex.
I also have specific computer glasses that work better with reading as well.

[John C Hagan III, MD, FACS, FAAO]

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[John C Hagan III, MD, FACS, FAAO]

I presented this case to two of my fellow ophthalmologists today. They said exactly the same thing.  This is classic PRESBYOPIA and computer or no line multifocal glasses should be the first thing tried, not the last.

[longmeow]

Thanks for the additional insight. My husband questions the diagnosis of presbyopia, because he doesn't need to move objects further away, and he says that he experiences less pain if he focuses on objects that are closer (for example, he says it is less painful to view his phone than his computer, although viewing the television is also less painful than viewing the computer...so it seems that it's the mid range that is causing the most trouble)

He has another appointment with a new ophthalmologist this month where he will hopefully get a prescription for no line bifocals.

[longmeow]

Correction: I spoke to my husband again, and he thinks though he might have presbyopia, his concern is that the cause may be due to the left eye's weakness. He's concerned that the eye is so weak that there may be nothing that we can do to enable it to see at arm's length. It is much easier for that eye to see close-up.

[John C Hagan III, MD, FACS, FAAO]

His RX is wildly unbalanced and the LE has a RX many times stronger than the RE. Undoubtedly his LE has "amblyopia" and cannot be made to see as well the the RE even with glasses. Ofthen this runs in families. If detected early treated by glasses and patch sometimes contact lens on amblyopic eye or refractive surgery.  I still think this is straight forward presbyopia, with amblyopia LE due to unequal refractive error (aneisometrophia)

[longmeow]

Makes sense. Thank you again!

[John C Hagan III, MD, FACS, FAAO]

If you get a resolution to this down the line please re-post for other having similiar problems.  Good luck