Medical Care
Conservative medical treatment is observation. Preretinal hemorrhage (sub–internal limiting membrane and subhyaloid) due to Valsalva retinopathy usually resolves within a few weeks or months. Vitreous hemorrhage may take longer to resolve, depending on the density of the hemorrhage, possibly up to 6 months. [9]
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 described 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 settle 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. [10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21]
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.
If there is a concomitant or underlying retinal disease that requires immediate attention, a membranectomy can be considered to allow thorough evaluation of the underlying retina.
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.
If a dense vitreous hemorrhage or significant premacular hemorrhaging is present (and no improvement with initial observation), pars plana vitrectomy may be required.
Consultations
A consultation with a retinal specialist is recommended to better diagnose and treat the underlying problem and to evaluate any other concomitant retinal pathology contributing to the disease process.
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.
Activity
To reduce the risk of a rebleed, physical activity should be limited immediately following the clinical diagnosis and until the retina has sufficiently healed.
Individuals with known proliferative diabetic retinopathy (or other retinal vascular diseases) 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 promote settling of the blood inferiorly out of the visual axis.
Prevention
Avoid Valsalva-like maneuvers, if possible.
To prevent a rebleed, physical activity should be limited immediately following detection until the retina has healed.
A medical workup, as suggested by the individual's history and physical examination, to look for predisposing factors, may be helpful in detecting underlying diseases or contributing causes that are preventable or treatable.
Long-Term Monitoring
Depending on the magnitude of the retinopathy, various follow-up schedules may be used accordingly.
Typically, for those patients who are being observed, follow-up care is at 1 week, 1 month, and 3 months following the initial incident. Wide variations in the timing and the frequency of follow-up care, depending on the location, the severity, and the underlying cause of the hemorrhage, are not uncommon.
For those patients who have undergone a laser membranotomy, follow-up care is usually arranged at 24 hours, 1 week, 1 month, 3 months, 6 months, 12 months, and 18 months. This schedule may vary depending on individual circumstances.
If the patient requires a pars plana vitrectomy, standard postoperative care is instituted.
Further Inpatient Care
Inpatient care may be required if indicated by the medical workup. [22]
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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.
