Valsalva Retinopathy Clinical Presentation

  • Author: Robert S Duszak, OD, FAAO; Chief Editor: Hampton Roy Sr, MD   more...
 
Updated: Feb 16, 2012
 

History

Individuals with a history of vascular disease, such as diabetes, hypertension, sickle cell disease, anemia, idiopathic thrombocytopenic purpura, or other blood dyscrasias, and those with a history of ocular venous occlusions are at increased risk for retinopathy to occur following a Valsalva maneuver.[8, 9, 10]

  • Patients with Valsalva retinopathy initially present after recently performing a Valsalva maneuver. The severity of the Valsalva maneuver is not directly correlated with the severity of Valsalva retinopathy.
  • Patients present with unilateral or bilateral manifestations, generally within 2 days after onset.
  • Patients may complain of floating spots, cloudy or hazy vision, a reddish tinge over their vision, or a complete loss of vision.
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Physical

  • Overall signs of regurgitation of blood at the capillary level include subconjunctival hemorrhages and skin petechia in the head and neck region.
  • A dilated ocular examination with special attention to visual acuity and pupil testing and a thorough evaluation of the anterior and posterior segments of the eye are recommended.
    • Ocular findings are classically described as preretinal hemorrhages, although vitreous hemorrhages have been reported.
    • Valsalva retinopathy has a predilection for the macula. Often, the ruptured vessels in the perifoveal capillaries cause a sudden and painless loss of central vision.
    • Retinal edema, ranging from barely recognizable localized edema to marked edematous patches, edematous transudates, and superficial intraretinal hemorrhages, is not uncommon.
    • A glistening light reflex reflected from the retina's internal limiting membrane can often be observed overlying the hemorrhage.
    • Hemorrhages are not associated with retinal, choroidal, or systemic disease, but they have a higher incidence in individuals with predisposing risk factors, such as diabetes, hypertension, sickle cell disease, anemia, idiopathic thrombocytopenic purpura, or other blood dyscrasias, and in individuals with previous episodes of ocular venous occlusions.
    • Ocular findings are dependent on both the magnitude of the compressive force and the status of the retinal vessels. Hemorrhages usually vary in size from a punctate spot to one half a disc diameter in size, although a larger hemorrhage encompassing several disc diameters may be observed.
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Causes

Valsalva retinopathy occurs following a Valsalva maneuver. Reported causes of a Valsalva maneuver include straining and physical activities, most commonly during the following: coughing, weight lifting, vomiting, bungee jumping, aerobic exercise, sexual activity, end-stage labor, colonoscopy procedures, fiberoptic gastroenteroscopy, constipation, blowing musical instruments, and compressive injuries.[11, 12, 13, 14, 15, 16, 17, 18, 19] See the image below.

A large preretinal hemorrhage in a 42-year-old manA large preretinal hemorrhage in a 42-year-old man following a Valsalva maneuver. This image was taken 2 days after he underwent heavy straining while lifting weights. This 58-year-old man with uncontrolled diabetes prThis 58-year-old man with uncontrolled diabetes presented with complaints of a spot in his vision following straining during a bowel movement. He had active proliferative diabetic retinopathy, and the hemorrhage shown in this image stems from a broken neovascularized blood vessel secondary to a Valsalva maneuver.
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Contributor Information and Disclosures
Author

Robert S Duszak, OD, FAAO  Attending, Philadelphia Veterans Affairs Medical Center; Consulting Staff, Nemours Health Clinic, Mayfair Eye Associates; Adjunct Clinical Faculty, Eye Institute of the Pennsylvania College of Optometry

Robert S Duszak, OD, FAAO is a member of the following medical societies: American Academy of Optometry, American Geriatrics Society, and American Optometric Association

Disclosure: Nothing to disclose.

Specialty Editor Board

V Al Pakalnis, MD, PhD  Professor of Ophthalmology, University of South Carolina School of Medicine; Chief of Ophthalmology, Dorn Veterans Affairs Medical Center

V Al Pakalnis, MD, PhD is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, and South Carolina Medical Association

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Steve Charles, MD  Director of Charles Retina Institute; Clinical Professor, Department of Ophthalmology, University of Tennessee College of Medicine; Adjunct Professor of Ophthalmology, Columbia College of Physicians and Surgeons; Clinical Professor Ophthalmology, Chinese University of Hong Kong

Steve Charles, MD is a member of the following medical societies: American Academy of Ophthalmology, American Society of Retina Specialists, Club Jules Gonin, Macula Society, and Retina Society

Disclosure: Alcon Laboratories Consulting fee Consulting; OptiMedica Ownership interest Other; Topcon Medical Lasers Consulting fee Consulting

Lance L Brown, OD, MD  Ophthalmologist, Affiliated With Freeman Hospital and St John's Hospital, Regional Eye Center, Joplin, Missouri

Disclosure: Nothing to disclose.

Chief Editor

Hampton Roy Sr, MD  Associate Clinical Professor, Department of Ophthalmology, University of Arkansas for Medical Sciences

Hampton Roy Sr, MD is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, and Pan-American Association of Ophthalmology

Disclosure: Nothing to disclose.

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Initial presentation of a Valsalva retinopathy less than 24 hours following a Valsalva maneuver in an 18-year-old man. Note the large preretinal hemorrhage. Vision was finger counting at 5 feet.
At 4-month follow-up of the same patient as in the image above, most of the large preretinal hemorrhage had cleared with observation alone. Note the wrinkled internal limiting membrane temporal to the macula and the resolving hemorrhage at the edge of the demarcation line of the stretched internal limiting membrane inferiorly. Vision had returned to 20/20.
A large preretinal hemorrhage in a 42-year-old man following a Valsalva maneuver. This image was taken 2 days after he underwent heavy straining while lifting weights.
This 58-year-old man with uncontrolled diabetes presented with complaints of a spot in his vision following straining during a bowel movement. He had active proliferative diabetic retinopathy, and the hemorrhage shown in this image stems from a broken neovascularized blood vessel secondary to a Valsalva maneuver.
 
 
 
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