History
Valsalva retinopathy usually manifests as preretinal hemorrhage secondary to rupturing of superficial retinal vessels from physical exertion. The mechanism of Valsalva maneuver is characterized by a sudden rise in intrathoracic or intraabdominal pressure against a closed glottis, which leads to a rapid rise of intravenous pressure within the eye, causing retinal vessels to spontaneously rupture.
Patients with Valsalva retinopathy often present with loss of vision in one eye, but bilateral clinical findings are common. The degree of vision loss depends on the size and location of the preretinal (or, less commonly, subretinal) hemorrhage. Patients usually describe an antecedent Valsalva-like maneuver (eg, coughing, vomiting, heavy lifting, straining in the bathroom, vigorous sexual activity, labor and delivery). The severity of the Valsalva maneuver is not directly correlated with the severity of Valsalva retinopathy.
Some individuals with Valsalva retinopathy may experience spontaneous vision loss without a history of Valsalva maneuver. Without a definitive history of physical exertion, retinal vascular disease should be considered and other systemic conditions investigated. Furthermore, patients receiving anticoagulants may develop a similar clinical picture without a history of unusual exertion.
Patients with Valsalva retinopathy often present with the following symptoms:
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Floaters
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Red-tinged hue to the vision
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Cloudy or hazy vision
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Partial loss of vision
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Complete loss of vision
Ocular Examination and Clinical Features
The clinical signs of suddenly increased systemic venous pressure often include the eye and skin. A subconjunctival hemorrhage may be evident, and skin petechia of the hand and neck may be present.
A comprehensive ocular examination is imperative and should include visual acuity testing, pupil testing, anterior segment examination, and a detailed posterior segment examination.
The "classic" clinical appearance of Valsalva retinopathy on dilated fundus examination is a well-circumscribed preretinal hemorrhage in either the subhyaloid or sub–internal limiting membrane (ILM) space. Interestingly, Valsalva retinopathy has a predilection for the macula region (both premacular and paramacular). Often, the ruptured vessels in the perifoveal vessels can cause a sudden and painless loss of central vision. Uncommonly, subretinal hemorrhage may occur.
Retinal edema in the macular region with associated edematous transudates and superficial intraretinal hemorrhages have been described.
Ocular findings and visual symptoms depend on the severity of the Valsalva force and the underlying status of the retina vasculature. Hemorrhages can vary in size, and, in many cases, a large preretinal hemorrhage encompassing several disc diameters may be observed.
Subhyaloid, sub–internal limiting membrane (ILM) hemorrhage in eye with Valsalva retinopathy. This image was originally published in the ASRS Retina Image Bank. Mitzy E. Torres Soriano, MD. Valsalva Retinopathy. Image Number 18218. © the American Society of Retina Specialists.
Subhyaloid, sub–internal limiting membrane (ILM) hemorrhage showing a fluid level and yellowish color as it settles over time. This image was originally published in the ASRS Retina Image Bank. Kathy Karsten, COT. Subhyaloid Hemorrhage, Right Eye. Number 23763. © the American Society of Retina Specialists.
Causes
The underlying etiology of the Valsalva maneuver most commonly is related to heavy lifting, vomiting, coughing, unusual physical exertion, and straining on the toilet. Other causes, such as sneezing, compressive trauma, labor, vigorous sexual activity, labor, and rollercoaster riding, have been described.
The pathophysiology of Valsalva retinopathy is related to a sudden increase in intraabdominal pressure in a closed glottis.
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.
Patient with history of gastroenteritis and episodes of vomiting followed by loss of central vision.
Patient with sudden loss of vision during labor and seen soon after giving birth.
Physical Examination
Physical examination of the skin may reveal petechiae. See Ocular Examination for clinical features of the eye examination.
Complications
Complications of Valsalva retinopathy may include the following:
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Permanent vision loss
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Hemorrhaging within and under the retina, destroying the cellular structure of the retina
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Slightly reduced visual acuity secondary to either incomplete blood resorption or mild retinal pigment epithelium changes in or around the macula
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Possible toxic damage to the retina due to prolonged contact of retina with hemoglobin and iron, causing irreversible visual impairment
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Bilateral choroidal detachment
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An Nd:YAG laser membranotomy producing epiretinal membrane formation with internal limiting membrane wrinkling as a late postoperative complication (although its frequency has not yet been identified)
The final visual outcome often depends on the location of the hemorrhage and the layer of retina involved (subretinal, intraretinal, preretinal). Specifically, subretinal hemorrhage in the macula most likely causes permanent vision loss.
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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.
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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.
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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.
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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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Subhyaloid, sub–internal limiting membrane (ILM) hemorrhage in eye with Valsalva retinopathy. This image was originally published in the ASRS Retina Image Bank. Mitzy E. Torres Soriano, MD. Valsalva Retinopathy. Image Number 18218. © the American Society of Retina Specialists.
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Subhyaloid, sub–internal limiting membrane (ILM) hemorrhage showing a fluid level and yellowish color as it settles over time. This image was originally published in the ASRS Retina Image Bank. Kathy Karsten, COT. Subhyaloid Hemorrhage, Right Eye. Number 23763. © the American Society of Retina Specialists.
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Patient with history of gastroenteritis and episodes of vomiting followed by loss of central vision.
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Patient with sudden loss of vision during labor and seen soon after giving birth.
