Diagnostic Considerations

With an antecedent history of physical exertion consistent with Valsalva maneuver and clinical features as described in this article, no further diagnostic workup is indicated. If the patient has no history of unusual exertion, investigating potential associated vascular conditions should be considered. The most common systemic conditions that cause retinal findings masquerading as Valsalva retinopathy include diabetes, hypertension, sickle cell disease, anemia, and idiopathic thrombocytopenic purpura (or other blood dyscrasias—acquired or genetic). Referral to a primary care physician and appropriate laboratory and physical examination is thus warranted.

Differential Diagnoses

Anemic Retinopathy
Colonic Polyps
Diabetic Retinopathy
Hemorrhagic Posterior Vitreous Detachment
Hypertensive Retinopathy
Ocular Parasitic Infection
Purtscher Retinopathy and Purtscher-like Retinopathy
Retinal Macroaneurysm
Retinal Vein Occlusion (RVO)
Sickle Cell Retinopathy
Terson Syndrome

Workup

Duane TD. Valsalva hemorrhagic retinopathy. Trans Am Ophthalmol Soc. 1972. 70:298-313. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
Choi SW, Lee SJ, Rah SH. Valsalva retinopathy associated with fiberoptic gastroenteroscopy. Can J Ophthalmol. 2006 Aug. 41(4):491-3. [QxMD MEDLINE Link].
Lee VY, Liu DT, Chan WM. Valsalva retinopathy as a complication of colonoscopy. J Clin Gastroenterol. 2005 Aug. 39(7):643; author reply 643. [QxMD MEDLINE Link].
Saricaoglu MS, Kalayci D, Guven D, Karakurt A, Hasiripi H. Decompression retinopathy and possible risk factors. Acta Ophthalmol. 2009 Feb. 87(1):94-5. [QxMD MEDLINE Link].
Al-Mujaini AS, Montana CC. Valsalva retinopathy in pregnancy: a case report. J Med Case Reports. 2008 Apr 7. 2:101. [QxMD MEDLINE Link].
Talbert DG. The 'Sutured Skull' and intracranial bleeding in infants. Med Hypotheses. 2006. 66(4):691-4. [QxMD MEDLINE Link].
Shukla D, Naresh KB, Kim R. Optical coherence tomography findings in valsalva retinopathy. Am J Ophthalmol. 2005 Jul. 140(1):134-6. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
Bourne RA, Talks SJ, Richards AB. Treatment of preretinal Valsalva haemorrhages with neodymium:YAG laser. Eye. 1999 Dec. 13 (Pt 6):791-3. [QxMD MEDLINE Link].
Chen YJ, Kou HK. Krypton laser membranotomy for premacular hemorrhage. Ophthalmologica. 2004 Nov-Dec. 218(6):368-71. [QxMD MEDLINE Link].
Chen YJ, Kou HK. Krypton laser membranotomy in the treatment of dense premacular hemorrhage. Can J Ophthalmol. 2004 Dec. 39(7):761-6. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
Rennie CA, Newman DK, Snead MP, Flanagan DW. Nd:YAG laser treatment for premacular subhyaloid haemorrhage. Eye. 2001 Aug. 15(Pt 4):519-24. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
Liu Z, Pan X, Bi H. Treatment of Valsalva Retinopathy. Optom Vis Sci. 2014 Oct 2. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link]. [Full Text].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
Karagiannis D, Gregor Z. Valsalva retinopathy associated with idiopathic thrombocytopenic purpura and positive antiphospholipid antibodies. Eye. 2006 Mar 10. [QxMD MEDLINE Link].
Mansour AM, Salti HI, Han DP, et al. Ocular findings in aplastic anemia. Ophthalmologica. 2000. 214(6):399-402. [QxMD MEDLINE Link].
Sueke H. Valsalva retinopathy induced by vigorous nightclub dancing. Med J Aust. 2009 Mar 16. 190(6):333. [QxMD MEDLINE Link].
Al-Mujaini AS, Montana CC. Valsalva retinopathy in pregnancy: a case report. J Med Case Reports. 2008 Apr 7. 2:101. [QxMD MEDLINE Link].
Callender D, Beirouty ZA, Saba SN. Valsalva haemorrhagic retinopathy in a pregnant woman. Eye. 1995. 9 (Pt 6):808-9. [QxMD MEDLINE Link].
Friberg TR, Braunstein RA, Bressler NM. Sudden visual loss associated with sexual activity. Arch Ophthalmol. 1995 Jun. 113(6):738-42. [QxMD MEDLINE Link].
Georgiou T, Pearce IA, Taylor RH. Valsalva retinopathy associated with blowing balloons. Eye. 1999 Oct. 13 (Pt 5):686-7. [QxMD MEDLINE Link].
Ioannidis AS, Tranos PG, Harris M. Valsalva retinopathy associated with riding a motorcycle. Eye. 2004 Mar. 18(3):329-31. [QxMD MEDLINE Link].
Oboh AM, Weilke F, Sheindlin J. Valsalva retinopathy as a complication of colonoscopy. J Clin Gastroenterol. 2004 Oct. 38(9):793-4. [QxMD MEDLINE Link].
Roberts DK, MacKay KA. Microhemorrhagic maculopathy associated with aerobic exercise. J Am Optom Assoc. 1987 May. 58(5):415-8. [QxMD MEDLINE Link].
Van Rens E. Traumatic ocular haemorrhage related to bungee jumping. Br J Ophthalmol. 1994 Dec. 78(12):948. [QxMD MEDLINE Link].
Al Rubaie K, Arevalo JF. Valsalva retinopathy associated with sexual activity. Case Rep Med. 2014. 2014:524286. [QxMD MEDLINE Link]. [Full Text].
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. [QxMD MEDLINE Link].
Eneh A, Almeida D. Valsalva hemorrhagic retinopathy during labour: a case report and literature review. Can J Ophthalmol. 2013 Dec. 48(6):e145-7. [QxMD MEDLINE Link].
Chapman-Davies A, Lazarevic A. Valsalva maculopathy. Clin Exp Optom. 2002 Jan. 85(1):42-5. [QxMD MEDLINE Link].
Chopdar A. Valsalva hemorrhagic retinopathy. Eye. 1996. 10 (Pt 5):650. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
Deane JS, Ziakas N. Valsalva retinopathy in pregnancy. Eye. 1997. 11 (Pt 1):137-8. [QxMD MEDLINE Link].
Duane TD. Valsalva hemorrhagic retinopathy. Am J Ophthalmol. 1973 Apr. 75(4):637-42. [QxMD MEDLINE Link].
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: http://www.aaopt.org/meetings/meeting3/index.asp. Optom Vis Sci. 2002 Dec. 79(12):158. [Full Text].
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. [QxMD MEDLINE Link].
Jones WL. Valsalva maneuver induced vitreous hemorrhage. J Am Optom Assoc. 1995 May. 66(5):301-4. [QxMD MEDLINE Link].
Kadrmas EF, Pach JM. Vitreous hemorrhage and retinal vein rupture. Am J Ophthalmol. 1995 Jul. 120(1):114-5. [QxMD MEDLINE Link].
Kassoff A, Catalano RA, Mehu M. Vitreous hemorrhage and the Valsalva maneuver in proliferative diabetic retinopathy. Retina. 1988. 8(3):174-6. [QxMD MEDLINE Link].
Kocak N, Kaynak S, Kaynak T, et al. Unilateral Purtscher-like retinopathy after weight-lifting. Eur J Ophthalmol. 2003 May. 13(4):395-7. [QxMD MEDLINE Link].
Konotey-Ahulu F. Valsalva vitreous haemorrhage and retinopathy in sickle cell haemoglobin C disease. Lancet. 1997 Jun 14. 349(9067):1774. [QxMD MEDLINE Link].
Krepler K, Wedrich A, Schranz R. Intraocular hemorrhage associated with dental implant surgery. Am J Ophthalmol. 1996 Nov. 122(5):745-6. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
Ladjimi A, Zaouali S, Messaoud R, et al. Valsalva retinopathy induced by labour. Eur J Ophthalmol. 2002 Jul-Aug. 12(4):336-8. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
Raymond LA, Sacks JG, Choromokos E. Hemorrhagic valsalva retinopathy in Leber's optic neuropathy. Ann Ophthalmol. 1985 Sep. 17(9):553-4. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
Sahu DK, Namperumalsamy P, Kim R, Ravindran RD. Argon laser treatment for premacular hemorrhage. Retina. 1998. 18(1):79-82. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
J. Donald M. Gass. Stereoscopic Atlas of Macular Diseases: Diagnosis and Treatment. 4th ed. St. Louis: Mosby; 1997.

Media Gallery

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.
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.
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.

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Valsalva Retinopathy Differential Diagnoses

Diagnostic Considerations

Differential Diagnoses

References

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