Valsalva Retinopathy

Updated: Aug 22, 2016
  • Author: Charles W Eifrig, MD; Chief Editor: Hampton Roy, Sr, MD  more...
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Overview

Background

Valsalva retinopathy was first described in 1972 by Thomas Duane as "a particular form of retinopathy, pre-retinal and hemorrhagic in nature, secondary to a sudden increase in intrathoracic pressure." [1] It was used to describe retinal hemorrhages in association with heavy lifting, coughing, straining at stool, or vomiting. The Valsalva maneuver was named after the Italian anatomist Antonio Maria Valsalva, who defined the Valsalva ligaments and anatomy related to the forcible exhalation effort against a closed glottis.

Valsalva retinopathy classically manifests as preretinal hemorrhage secondary to rupturing of superficial retinal vessels caused by physical exertion. The mechanism of a 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 capillaries to spontaneously rupture.

Prognosis is usually good, with spontaneous resolution occurring within months after onset, but depends on location of the hemorrhage and the layer of retina involved.

See the images below.

Initial presentation of a Valsalva retinopathy les 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 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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Pathophysiology

Increasing intrathoracic pressure against a closed glottis diminishes venous return to the heart, decreasing stroke volume and subsequently increasing the venous system pressure. [2, 3, 4, 5, 6]

The process occurs in 4 separate and distinct phases. First, a sudden increase in intrathoracic pressure decreases venous return to the right side of the heart. Second, diminished cardiac filling lowers the mean arterial pressure, slowing the pulse, leading to reflex tachycardia and peripheral vasoconstriction. Third, release of the strain causes a prompt reduction in the intrathoracic pressure, further lowering the blood pressure and simultaneously increasing the cardiac pressure. Finally, an abrupt increase in blood pressure occurs as venous blood surges back to the heart, inducing reflex bradycardia.

During a Valsalva maneuver, blood pressure in the peripheral portions of the body increases rapidly. As the sudden rise in intraocular venous pressure occurs, a spontaneous rupture of retinal capillaries ensues.

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Epidemiology

Frequency

The frequency of Valsalva retinopathy is difficult to ascertain considering the rare nature of the condition.

United States

The incidence of Valsalva retinopathy in the United States has not been reported.

International

The worldwide incidence of Valsalva retinopathy has not been reported.

Mortality/Morbidity

Decreased vision occurs in the affected eye or eyes, ranging from complaints of floaters to complete loss of central vision. Vision often improves over weeks to months, depending on the severity of the retinal findings.

Race

No racial predilection exists.

Sex

No sexual predilection exists.

Age

Persons of any age can be affected. [7]

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Prognosis

Prognosis is generally good, as complete recovery of vision usually occurs; however, this depends on location of the hemorrhage and the layer of retina involved.

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Patient Education

There is no definitive way to prevent Valsalva retinopathy, but refraining from "holding your breath" during lifting, sneezing, and coughing may reduce the risk. Furthermore, breathing freely and openly helps decrease the chance of a Valsalva maneuver.

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