There are several ocular lesions that are important and treatable as causes of headache, including conjunctivitis, corneal lesions, anterior uveitis, angle closure glaucoma, optic neuritis, metastatic orbital tumors, orbital pseudotumors and the Tolosa-Hunt syndrome. The symptoms of paratrigeminal syndrome, ocular motor nerve paralysis, small vessel disease, carotid cavernous fistulas, and nasopharyngeal carcinomas may all have eye pain as a presenting symptom.Dissection of the internal carotid artery can also present with eye pain (see below). Photophobia is often seen with subarachnoid hemorrhage, meningitis, retrobulbar neuritis and migraine and probably has its basis in central cortical and brainstem reflexes.{203} Carlow{203} notes that the eye and periorbital regions are common points of headache, but that the eye is rarely responsible if ophthalmic signs are not obvious. He also believes that refractive disorders and muscle imbalance are overemphasized as the cause of headache and that correction of these problems seldom provides resolution, the exception being convergence insufficiency. Ocular neurosis is the usual cause of eye strain headache that begins abruptly with use of the eyes in which there is a normal ophthalmologic exam.