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Valsalva Retinopathy Treatment & Management

  • Author: Robert S Duszak, OD, FAAO; Chief Editor: Hampton Roy, Sr, MD  more...
 
Updated: Oct 13, 2014
 

Medical Care

Conservative medical treatment is observation. Preretinal hemorrhages secondary to Valsalva retinopathy usually resolve by themselves in a few weeks to a few months. Vitreous hemorrhages may take longer to resolve, possibly up to 6 months.[24]

  • Patients should be instructed to avoid anticoagulant medications and strenuous activities to prevent a rebleed.
  • Patients should be instructed to sleep in a sitting position to promote blood settling, which may improve visual acuity. However, this effect may be transient upon resumption of physical activities.
  • Stool softeners may need to be considered for those with constipation.
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Surgical Care

While there is no widely accepted treatment modality other than observation, in the last few years, Nd:YAG laser membranotomy and Krypton laser membranotomy have been pushed to the forefront for the treatment of large (>3 disc diameters in size) macular subhyaloid hemorrhages of less than 3 weeks' duration. The membranotomy causes immediate drainage of the hemorrhage into the vitreous cavity, which causes the blood to quickly fall with gravity into the inferior vitreous and out of the visual axis, prompting a rapid return of central visual acuity. Pulsed Nd:YAG lasers, krypton lasers, argon lasers, Q-switched Nd:YAG lasers, and frequency doubled Nd:YAG lasers have all been used for disruption of the posterior hyaloid or the internal limiting membrane.[25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36]

  • The location of the membranotomy should be chosen away from the fovea and major blood vessels, at the inferior edge of the hemorrhage, in an area with sufficient underlying hemorrhage present to protect the retina from laser-induced damage. Complications of such maneuvers include the following: retinal tears; hemorrhaging into the choroidal, subretinal and vitreous spaces; retinal detachment; and permanent visual loss. Pressure applied to the eye (with a contact lens, with a Honan balloon, or digitally) may promote clotting in laser-induced hemorrhaging. Referral to a retinal specialist may need to be considered if damage occurs.
  • If underlying retinal disease that requires immediate attention is suspected but cannot be seen secondary to a large preretinal hemorrhage, a membranotomy should be used for a thorough retinal viewing once the blood settles inferiorly in the vitreous cavity.
  • A membranotomy is a particularly useful procedure in those individuals with poor vision in their fellow eye or in patients who require rapid restoration of their vision to continue work.
  • To be effective as well as to avoid a clotted hemorrhage that will not drain into the vitreous and may eventually require a vitrectomy, an Nd:YAG laser membranotomy or a Krypton laser membranotomy must be performed on fresh preretinal blood (ie, within 35 d of bleed).
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Consultations

A consultation with a retinal specialist is not essential but is recommended. If the etiology of the hemorrhage is suspected to arise from neovascularization or if vision loss or a patient's lifestyle requires prompt treatment with an Nd:YAG laser membranotomy or a Krypton laser membranotomy, a retinal specialist should be involved.

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Diet

Diet restrictions are not essential in the management of Valsalva retinopathy. A diet rich in fiber is advisable for those patients with constipation in order to prevent further Valsalva maneuvers that could possibly cause a rebleed.

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Activity

To prevent a rebleed, physical activity should be limited immediately following detection until the retina has sufficiently healed.

Individuals with known proliferative diabetic retinopathy are at increased risk for the development of a vitreous hemorrhage secondary to a Valsalva maneuver; therefore, they should always try to limit activities that cause sudden increases in intrathoracic pressure against a closed glottis.

Patients should be advised to sleep in an upright sitting position to permit gravitation of blood inferiorly out of the visual axis.

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Contributor Information and Disclosures
Author

Robert S Duszak, OD, FAAO Attending Physician, 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 Geriatrics Society, American Academy of Optometry, American Optometric Association

Disclosure: Nothing to disclose.

Specialty Editor Board

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

Disclosure: Received salary from Medscape for employment. for: Medscape.

Steve Charles, MD Director of Charles Retina Institute; Clinical Professor, Department of Ophthalmology, University of Tennessee College of Medicine

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

Disclosure: Received royalty and consulting fees for: Alcon Laboratories.

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, Pan-American Association of Ophthalmology

Disclosure: Nothing to disclose.

Additional Contributors

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, South Carolina Medical Association

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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