Hrev_master Emergency Care Journal 2022; volume 18:10775 [Emergency Care Journal 2022; 18:10775] [page 53] Eye and headache: Not always an inseparable association Erika Poggiali,1 Chiara Morini,2 Vincenzo Murelli3 1Emergency Department, Guglielmo da Saliceto Hospital, Piacenza; 2Ophthalmology Unit, Guglielmo da Saliceto Hospital, Piacenza; 3Radiology Unit, Guglielmo da Saliceto Hospital, Piacenza, Italy Question Given the patient’s history and CT imaging, what is the most likely diagnosis? 1) Calcification of the globe 2) Foreign body 3) Optic disc drusen (ODD) 4) Pseudo papilledema Correspondence: Erika Poggiali, Emergency Department, “Guglielmo da Saliceto” Hospital, Via Giuseppe Taverna 49, Piacenza, Italy. Tel.: +39.0523.303044 E-mail: E.Poggiali@ausl.pc.it Key words: Chronic headache; calcification of the globe; Optic disc drusen; foreign body; pseudo papilledema. Contributions: EP and CM collected details of the case, cared for the patient, and drafted the manuscript. VM performed the radiological imaging and critically revised the manuscript. All the authors approved the final version. Conflicts of interest: EP is member of the editorial board of Emergency Care Journal. This work was not supported by any grant. Availability of data and materials: All data underlying the findings are fully available upon reasonable request to Erika Poggiali, E.Poggiali@ausl.pc.it Ethics approval and consent to participate: As this was a descriptive case report and data was collected without patient identifiers, ethics approval was not required under our hospital’s Institutional Review Board 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 4.0 License (by-nc 4.0). ©Copyright: the Author(s), 2022 Licensee PAGEPress, Italy Emergency Care Journal 2022; 18:10775 doi:10.4081/ecj.2022.10775 Publisher's note: All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organiza- tions, or those of the publisher, the editors and the reviewers. Any product that 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 and subjective impression of blurred vision. He denied photophobia and phonophobia. The symptoms were alleviated by NSAIDs. Neurological and full ophthalmological evaluation, including bilateral acuities, anterior segment, fundoscopy, as well as com- puterized visual fields, resulted normal. Laboratory findings were unremarkable. Blood pressure was normal. Brain computed tomography (CT) scan showed a small radio-opaque image of approximately 3 mm in the anterior part of the right eyeball in the paramedian area and ruled out masses (including menin- gioma of the optic nerve), signs of bleeding and endocranial hypertension. Non -co mmerc ial us e o nly Answer The final diagnosis is “chronic primary headache and calcifi- cation of the right globe”. Eye calcification can be considered an incidentaloma. Calcification of the globe can have many causes, both benign and malignant.1 Incidental asymptomatic orbital calci- fications are commonly encountered on modern high-resolution CT images of the brain and orbit.2 CT marked sensitivity to calci- um increases its usefulness in the workup of ocular lesions.3 Calcific 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.4 Corneal and conjunctival calcification is the main extravascular site for calcification among patients with end-stage renal disease on maintenance haemodialysis.5 Calcifications of the trochlea are common findings on CT scan of the orbit6 and should be consid- ered in the differential diagnosis of hyperintense densities in the superomedial orbit, especially in cases of trauma where it can be confused with a foreign body. Axial CT can also show calcification in the substance of the optic nerve head, consistent with the diag- nosis of ODD. ODD are acellular deposits located in the optic nerve head of up to 2.4% of the population.7 On CT, drusen appears as a discrete, rounded high density confined to the optic disc surface. CT scans are so sensitive that they may detect drusen when the ophthalmoscopic examination is apparently normal.2 The majority of patients with ODD have visual field defects, most often due to anterior ischaemic optic neuropathy. Our patient reported a history of head trauma that had occurred 3 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 body sensation, which has indeed resolved in our patient with the simple use of lubricants. Neither was that calcific plaque the origin of the drop in vision, which has spontaneously come back to normal along with the resolution of headache without any further care. References 1. 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-1043 2. Murray JL, Hayman LA, Tang RA, Schiffman JS. Incidental asymptomatic orbital calcifications. J Neuro-ophthalmol 1995;15:203–8. 3. Gordon RN, Slamovits TL, Rosenbaum PS, Bello J. Calcified scleral plaques imaged on orbital computed tomography. Am J Ophthalmol 1999;127:461–3. 4. Alorainy I. Senile scleral plaques: CT. Neuroradiology 2000;42:145–8. 5. Pessoa MBCN, Santo RM, De Deus AA, et al. Corneal and conjunctival calcification in a dialysis patient reversed by parathyroidectomy. Blood Purif 2021;50:254–6. 6. Sobel RK, Goldstein SM. Trochlear calcification: a common entity. Orbit 2012;31:94–6. 7. Hamann S, Malmqvist L, Costello F. Optic disc drusen: under- standing an old problem from a new perspective. Acta Ophthalmologica 2018;96:673–84. Images in Emergency [page 54] [Emergency Care Journal 2022; 18:10775] Non -co mmerc ial us e o nly