Medscape is available in 5 Language Editions – Choose your Edition here.


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.

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).


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.



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.



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.

Contributor Information and Disclosures

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.

  1. Duane TD. Valsalva hemorrhagic retinopathy. Trans Am Ophthalmol Soc. 1972. 70:298-313. [Medline].

  2. Chandra P, Azad R, Pal N. Valsalva and Purtscher's retinopathy with optic neuropathy in compressive thoracic injury. Eye. 2005 Aug. 19(8):914-5. [Medline].

  3. Choi SW, Lee SJ, Rah SH. Valsalva retinopathy associated with fiberoptic gastroenteroscopy. Can J Ophthalmol. 2006 Aug. 41(4):491-3. [Medline].

  4. Lee VY, Liu DT, Chan WM. Valsalva retinopathy as a complication of colonoscopy. J Clin Gastroenterol. 2005 Aug. 39(7):643; author reply 643. [Medline].

  5. Saricaoglu MS, Kalayci D, Guven D, Karakurt A, Hasiripi H. Decompression retinopathy and possible risk factors. Acta Ophthalmol. 2009 Feb. 87(1):94-5. [Medline].

  6. Al-Mujaini AS, Montana CC. Valsalva retinopathy in pregnancy: a case report. J Med Case Reports. 2008 Apr 7. 2:101. [Medline].

  7. Talbert DG. The 'Sutured Skull' and intracranial bleeding in infants. Med Hypotheses. 2006. 66(4):691-4. [Medline].

  8. Androudi S, Ahmed M, Brazitikos P. Valsalva retinopathy: diagnostic challenges in a patient with pars-planitis. Acta Ophthalmol Scand. 2005 Apr. 83(2):256-7. [Medline].

  9. Karagiannis D, Gregor Z. Valsalva retinopathy associated with idiopathic thrombocytopenic purpura and positive antiphospholipid antibodies. Eye. 2006 Mar 10. [Medline].

  10. Mansour AM, Salti HI, Han DP, et al. Ocular findings in aplastic anemia. Ophthalmologica. 2000. 214(6):399-402. [Medline].

  11. Sueke H. Valsalva retinopathy induced by vigorous nightclub dancing. Med J Aust. 2009 Mar 16. 190(6):333. [Medline].

  12. Al-Mujaini AS, Montana CC. Valsalva retinopathy in pregnancy: a case report. J Med Case Reports. 2008 Apr 7. 2:101. [Medline].

  13. Callender D, Beirouty ZA, Saba SN. Valsalva haemorrhagic retinopathy in a pregnant woman. Eye. 1995. 9 (Pt 6):808-9. [Medline].

  14. Friberg TR, Braunstein RA, Bressler NM. Sudden visual loss associated with sexual activity. Arch Ophthalmol. 1995 Jun. 113(6):738-42. [Medline].

  15. Georgiou T, Pearce IA, Taylor RH. Valsalva retinopathy associated with blowing balloons. Eye. 1999 Oct. 13 (Pt 5):686-7. [Medline].

  16. Ioannidis AS, Tranos PG, Harris M. Valsalva retinopathy associated with riding a motorcycle. Eye. 2004 Mar. 18(3):329-31. [Medline].

  17. Oboh AM, Weilke F, Sheindlin J. Valsalva retinopathy as a complication of colonoscopy. J Clin Gastroenterol. 2004 Oct. 38(9):793-4. [Medline].

  18. Roberts DK, MacKay KA. Microhemorrhagic maculopathy associated with aerobic exercise. J Am Optom Assoc. 1987 May. 58(5):415-8. [Medline].

  19. Van Rens E. Traumatic ocular haemorrhage related to bungee jumping. Br J Ophthalmol. 1994 Dec. 78(12):948. [Medline].

  20. Al Rubaie K, Arevalo JF. Valsalva retinopathy associated with sexual activity. Case Rep Med. 2014. 2014:524286. [Medline]. [Full Text].

  21. Weiss KD, Kuriyan AE, Flynn HW Jr. Central retinal vein occlusion after prolonged vomiting and repeated valsalva maneuvers associated with gastroenteritis and dehydration. Ophthalmic Surg Lasers Imaging Retina. 2014 Apr 9. 45 Online:e23-5. [Medline].

  22. Eneh A, Almeida D. Valsalva hemorrhagic retinopathy during labour: a case report and literature review. Can J Ophthalmol. 2013 Dec. 48(6):e145-7. [Medline].

  23. Shukla D, Naresh KB, Kim R. Optical coherence tomography findings in valsalva retinopathy. Am J Ophthalmol. 2005 Jul. 140(1):134-6. [Medline].

  24. Khan MT, Saeed MU, Shehzad MS, Qazi ZA. Nd:YAG laser treatment for Valsalva premacular hemorrhages: 6 month follow up : alternative management options for preretinal premacular hemorrhages in Valsalva retinopathy. Int Ophthalmol. 2008 Oct. 28(5):325-7. [Medline].

  25. Bourne RA, Talks SJ, Richards AB. Treatment of preretinal Valsalva haemorrhages with neodymium:YAG laser. Eye. 1999 Dec. 13 (Pt 6):791-3. [Medline].

  26. Chen YJ, Kou HK. Krypton laser membranotomy for premacular hemorrhage. Ophthalmologica. 2004 Nov-Dec. 218(6):368-71. [Medline].

  27. Chen YJ, Kou HK. Krypton laser membranotomy in the treatment of dense premacular hemorrhage. Can J Ophthalmol. 2004 Dec. 39(7):761-6. [Medline].

  28. Durukan AH, Kerimoglu H, Erdurman C. Long-term results of Nd:YAG laser treatment for premacular subhyaloid haemorrhage owing to Valsalva retinopathy. Eye. 2006 Sep 1. [Medline].

  29. Gabel VP, Birngruber R, Gunther-Koszka H, Puliafito CA. Nd:YAG laser photodisruption of hemorrhagic detachment of the internal limiting membrane. Am J Ophthalmol. 1989 Jan 15. 107(1):33-7. [Medline].

  30. Rennie CA, Newman DK, Snead MP, Flanagan DW. Nd:YAG laser treatment for premacular subhyaloid haemorrhage. Eye. 2001 Aug. 15(Pt 4):519-24. [Medline].

  31. Khan MT, Saeed MU, Shehzad MS, Qazi ZA. Nd:YAG laser treatment for Valsalva premacular hemorrhages: 6 month follow up : alternative management options for preretinal premacular hemorrhages in Valsalva retinopathy. Int Ophthalmol. 2008 Oct. 28(5):325-7. [Medline].

  32. Mumcuoglu T, Durukan AH, Erdurman C, Hurmeric V, Karagul S. Outcomes of Nd:YAG laser treatment for Valsalva retinopathy due to intense military exercise. Ophthalmic Surg Lasers Imaging. 2009 Jan-Feb. 40(1):19-24. [Medline].

  33. Goel N, Kumar V, Seth A, Raina UK, Ghosh B. Spectral-domain optical coherence tomography following Nd:YAG laser membranotomy in valsalva retinopathy. Ophthalmic Surg Lasers Imaging. 2011 May-Jun. 42(3):222-8. [Medline].

  34. Jayaprakasam A, Matthew R, Toma M, Soni M. Valsalva retinopathy in pregnancy: SD-OCT features during and after Nd:YAG laser hyaloidotomy. Ophthalmic Surg Lasers Imaging. 2011 Feb 17. 42 Online:e26-8. [Medline].

  35. Liu Z, Pan X, Bi H. Treatment of Valsalva Retinopathy. Optom Vis Sci. 2014 Oct 2. [Medline].

  36. Kuruvilla O, Munie M, Shah M, Desai U, Miller JA, Ober MD. Nd:YAG membranotomy for preretinal hemorrhage secondary to valsalva retinopathy. Saudi J Ophthalmol. 2014 Apr. 28(2):145-51. [Medline]. [Full Text].

  37. Meyer CH, Mennel S, Rodrigues EB. Persistent premacular cavity after membranotomy in valsalva retinopathy evident by optical coherence tomography. Retina. 2006 Jan. 26(1):116-8. [Medline].

  38. Chapman-Davies A, Lazarevic A. Valsalva maculopathy. Clin Exp Optom. 2002 Jan. 85(1):42-5. [Medline].

  39. Chopdar A. Valsalva hemorrhagic retinopathy. Eye. 1996. 10 (Pt 5):650. [Medline].

  40. de Crecchio G, Pacente L, Alfieri MC, et al. Valsalva retinopathy associated with a congenital retinal macrovessel. Arch Ophthalmol. 2000 Jan. 118(1):146-7. [Medline].

  41. Deane JS, Ziakas N. Valsalva retinopathy in pregnancy. Eye. 1997. 11 (Pt 1):137-8. [Medline].

  42. Duane TD. Valsalva hemorrhagic retinopathy. Am J Ophthalmol. 1973 Apr. 75(4):637-42. [Medline].

  43. Duszak RS, Hardy M, Langford C. Valsalva Retinopathy, A Photo-Journal Case Report (Abstract for Scientific Program presented at American Academy of Optometry, San Diego, 2002). Available at: Optom Vis Sci. 2002 Dec. 79(12):158. [Full Text].

  44. Herr S, Pierce MC, Berger RP. Does valsalva retinopathy occur in infants? An initial investigation in infants with vomiting caused by pyloric stenosis. Pediatrics. 2004 Jun. 113(6):1658-61. [Medline].

  45. Jones WL. Valsalva maneuver induced vitreous hemorrhage. J Am Optom Assoc. 1995 May. 66(5):301-4. [Medline].

  46. Kadrmas EF, Pach JM. Vitreous hemorrhage and retinal vein rupture. Am J Ophthalmol. 1995 Jul. 120(1):114-5. [Medline].

  47. Kassoff A, Catalano RA, Mehu M. Vitreous hemorrhage and the Valsalva maneuver in proliferative diabetic retinopathy. Retina. 1988. 8(3):174-6. [Medline].

  48. Kocak N, Kaynak S, Kaynak T, et al. Unilateral Purtscher-like retinopathy after weight-lifting. Eur J Ophthalmol. 2003 May. 13(4):395-7. [Medline].

  49. Konotey-Ahulu F. Valsalva vitreous haemorrhage and retinopathy in sickle cell haemoglobin C disease. Lancet. 1997 Jun 14. 349(9067):1774. [Medline].

  50. Krepler K, Wedrich A, Schranz R. Intraocular hemorrhage associated with dental implant surgery. Am J Ophthalmol. 1996 Nov. 122(5):745-6. [Medline].

  51. Kwok AK, Lai TY, Chan NR. Epiretinal membrane formation with internal limiting membrane wrinkling after Nd:YAG laser membranotomy in valsalva retinopathy. Am J Ophthalmol. 2003 Oct. 136(4):763-6. [Medline].

  52. Ladjimi A, Zaouali S, Messaoud R, et al. Valsalva retinopathy induced by labour. Eur J Ophthalmol. 2002 Jul-Aug. 12(4):336-8. [Medline].

  53. Lin S, Phillips KS, Wilder MR, Weaver TE. Structural requirements for intracellular transport of pulmonary surfactant protein B (SP-B). Biochim Biophys Acta. 1996 Jul 24. 1312(3):177-85. [Medline].

  54. Mandal AK, Jalali S, Rao VS, et al. Valsalva retinopathy-like hemorrhage associated with combined trabeculotomy-trabeculectomy in a patient with developmental glaucoma. Ophthalmic Surg Lasers. 2001 Jul-Aug. 32(4):330-2. [Medline].

  55. Meyers SM, Foster RE. Choroidal hemorrhage after Valsalva''s maneuver in eyes with a previous scleral buckle. Ophthalmic Surg. 1995 May-Jun. 26(3):216-7. [Medline].

  56. Puthalath S, Chirayath A, Shermila MV, et al. Frequency-doubled Nd:YAG laser treatment for premacular hemorrhage. Ophthalmic Surg Lasers Imaging. 2003 Jul-Aug. 34(4):284-90. [Medline].

  57. Raymond LA. Neodymium:YAG laser treatment for hemorrhages under the internal limiting membrane and posterior hyaloid face in the macula. Ophthalmology. 1995 Mar. 102(3):406-11. [Medline].

  58. Raymond LA, Sacks JG, Choromokos E. Hemorrhagic valsalva retinopathy in Leber's optic neuropathy. Ann Ophthalmol. 1985 Sep. 17(9):553-4. [Medline].

  59. Romano PE. Exhale while lifting or straining to avoid Valsalva retinopathy or bleeding from stressed retinal vessels. Eur J Ophthalmol. 2003 Jan-Feb. 13(1):113. [Medline].

  60. Sahu DK, Namperumalsamy P, Kim R, Ravindran RD. Argon laser treatment for premacular hemorrhage. Retina. 1998. 18(1):79-82. [Medline].

  61. Ulbig MW, Mangouritsas G, Rothbacher HH, et al. Long-term results after drainage of premacular subhyaloid hemorrhage into the vitreous with a pulsed Nd:YAG laser. Arch Ophthalmol. 1998 Nov. 116(11):1465-9. [Medline].

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.
All material on this website is protected by copyright, Copyright © 1994-2016 by WebMD LLC. This website also contains material copyrighted by 3rd parties.