AUTHOR AND EDITOR INFORMATION

Section 1 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

INTRODUCTION

Section 2 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

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."

Immediately following a Valsalva maneuver, a sudden rise in intraocular venous pressure causes retinal capillaries to spontaneously rupture. The prognosis for Valsalva retinopathy is generally good, with newer treatment modalities speeding recovery time.

Pathophysiology

Increasing intrathoracic pressure against a closed glottis diminishes venous return to the heart, decreasing stroke volume and subsequently increasing the venous system pressure.

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.

Frequency

United States

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

International

Worldwide incidence has not been reported.

Mortality/Morbidity

Unilateral manifestations are most commonly seen, but bilateral findings have been reported.

Decreased vision occurs in the affected eyes, ranging from complaints of floating spots 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

Any age can be affected.

CLINICAL

Section 3 of 11  

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• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
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History

Individuals with a history of vascular disease, such as diabetes, hypertension, sickle cell disease, anemia, idiopathic thrombocytopenic purpura, or other blood dyscrasias, and those with a history of ocular venous occlusions are at increased risk for retinopathy to occur following a Valsalva maneuver.

• Patients with Valsalva retinopathy initially present after recently performing a Valsalva maneuver. The severity of the Valsalva maneuver is not directly correlated with the severity of Valsalva retinopathy.
• Patients present with unilateral or bilateral manifestations, generally within 2 days after onset.
• Patients may complain of floating spots, cloudy or hazy vision, a reddish tinge over their vision, or a complete loss of vision.

Physical

• Overall signs of regurgitation of blood at the capillary level include subconjunctival hemorrhages and skin petechia in the head and neck region.
• A dilated ocular examination with special attention to visual acuity and pupil testing and a thorough evaluation of the anterior and posterior segments of the eye are recommended.
• • Ocular findings are classically described as preretinal hemorrhages, although vitreous hemorrhages have been reported.
  • Valsalva retinopathy has a predilection for the macula. Often, the ruptured vessels in the perifoveal capillaries cause a sudden and painless loss of central vision.
  • Retinal edema, ranging from barely recognizable localized edema to marked edematous patches, edematous transudates, and superficial intraretinal hemorrhages, is not uncommon.
  • A glistening light reflex reflected from the retina's internal limiting membrane can often be observed overlying the hemorrhage.
  • Hemorrhages are not associated with retinal, choroidal, or systemic disease, but they have a higher incidence in individuals with predisposing risk factors, such as diabetes, hypertension, sickle cell disease, anemia, idiopathic thrombocytopenic purpura, or other blood dyscrasias, and in individuals with previous episodes of ocular venous occlusions.
  • Ocular findings are dependent on both the magnitude of the compressive force and the status of the retinal vessels. Hemorrhages usually vary in size from a punctate spot to one half a disc diameter in size, although a larger hemorrhage encompassing several disc diameters may be observed.

Causes

Valsalva retinopathy occurs following a Valsalva maneuver. Reported causes of a Valsalva maneuver include straining and physical activities, most commonly during the following: coughing, weight lifting, vomiting, bungee jumping, aerobic exercise, sexual activity, end-stage labor, colonoscopy procedures, fiberoptic gastroenteroscopy, constipation, blowing musical instruments, and compressive injuries.

DIFFERENTIALS

Section 4 of 11  

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• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
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Other Problems to be Considered

Blunt trauma
Retinopathy, hypertensive
Retinopathy, radiation
Posterior vitreous detachment
Shaken baby syndrome
Vitreous hemorrhage

WORKUP

Section 5 of 11  

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• Workup
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• Follow-up
• Miscellaneous
• Multimedia
• References

Lab Studies

• Lab studies can be used to rule out predisposing risk factors, including diabetes, sickle cell disease, anemia, idiopathic thrombocytopenic purpura, and other blood dyscrasias. Important tests include the following:
• • Complete blood count
  • Fasting blood sugar, glucose tolerance test
  • Prothrombin time, activated partial thromboplastin time
  • Sickle-cell preparation, hemoglobin electrophoresis, antiphospholipid antibodies
  • Urinalysis

Imaging Studies

• Retinal photographs can be useful to monitor the progression and the resolution of retinal hemorrhages over time.
• Retinal fluorescein angiography can be used to determine the location of active leakage if neovascularization is suspected secondary to an underlying medical problem.
• If blood in the vitreous is obstructing the view of the retina, B-scan ultrasonography can be used to screen for a retinal break or detachment.
• Optical coherence tomography (OCT) has been used to view the exact location of a premacular hemorrhage (under the internal limiting membrane).

Other Tests

• Blood pressure measurement is an essential ancillary test to rule out hypertension as a predisposing risk factor.

Histologic Findings

Preretinal hemorrhages lie just under the internal limiting membrane and in front of the nerve fiber layer. They arise from the superficial capillary bed. As the hemorrhage resolves over time, the blood typically settles at the bottom of the internal limiting membrane of the retina in a D-shaped pattern. Very specific color changes are associated with resolution: red to yellow and yellow to white. Upon complete resolution of the hemorrhage, retinal function is typically unaffected.

Valsalva retinopathy has a predilection for the macula. The perifoveal capillary bed is presumably targeted because of its detailed structural architecture.

TREATMENT

Section 6 of 11  

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• Follow-up
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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.

• 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.

• 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).

Consultations

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

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 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.

MEDICATION

Section 7 of 11  

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No proven beneficial medical therapy for this condition is available. The underlying risk factors contributing to disease development should be treated.

FOLLOW-UP

Section 8 of 11  

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• Follow-up
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• Multimedia
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Further Inpatient Care

• Inpatient care may be required if indicated by the medical workup.

Further Outpatient Care

• 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.

Deterrence/Prevention

• 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 precipitating factors may be helpful in detecting underlying diseases or contributing causes that are preventable or treatable.

Complications

• Although most patients who are managed with observation alone heal without complications, slightly reduced visual acuities secondary to either incomplete blood resorption or mild retinal pigment epithelium changes in or around the macula have been reported.
• A slowly resolving subhyaloid hemorrhage prolongs contact of the retina with hemoglobin and iron, possibly causing toxic damage to the retina and reducing visual function, which may be irreversible.
• One incidence has been reported of a bilateral choroidal detachment occurring after a Valsalva maneuver.
• An Nd:YAG laser membranotomy has produced epiretinal membrane formation with internal limiting membrane wrinkling as a late postoperative complication, although its frequency has not yet been identified.

Prognosis

• The prognosis for patients with pure Valsalva retinopathy is generally good with observation alone. Vision usually returns to normal over a short period of time, from weeks to months.

Patient Education

• While lifting heavy objects, patients should be advised not to hold their breath for extended periods of time and to take multiple breaths between bearing-down phases. Exhaling while lifting or straining prevents a Valsalva maneuver because one cannot exhale against a closed glottis. Straining during bowel movements should be avoided.
• For excellent patient education resources, visit eMedicine's Eye and Vision Center. Also, see eMedicine's patient education article Subconjunctival Hemorrhage (Bleeding in Eye).

MISCELLANEOUS

Section 9 of 11  

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• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

Medical/Legal Pitfalls

• Always be aware of potential medicolegal pitfalls, especially those pertaining to Valsalva retinopathy. If a patient presents after recently performing a Valsalva maneuver with a small amount of retinopathy, resulting medicolegal pitfalls do not frequently occur. However, if a patient presents with a larger hemorrhage and if a history or a workup suggests an underlying medical condition (eg, diabetes, sickle cell disease), the patient must be monitored with extreme care to rule out other potential mitigating factors (eg, neovascularization) that may require prompt attention and treatment. A failure to diagnose such conditions could result in legal action.
• Valsalva retinopathy seen in an infant is a red flag for shaken baby syndrome and, if suspected, should be reported immediately to the appropriate authorities. A failure to do so could result in legal action.
• Individuals suspected of having a known risk factor for Valsalva retinopathy must be carefully screened following such an incident (ie, Valsalva maneuver). A failure to do so could result in legal action.
• If an Nd:YAG laser membranotomy or a Krypton laser membranotomy is considered, the patient must be aware of all potential complications, as well as viable therapeutic alternatives depending upon the circumstances of the case. A failure to obtain informed consent (or if the patient feels insufficiently informed) could result in legal action.

MULTIMEDIA

Section 10 of 11  

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• Introduction
• Clinical
• Differentials
• Workup
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• Follow-up
• Miscellaneous
• Multimedia
• References

Media file 1:  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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Media file 2:  At 4-month follow-up of same patient as in Image 1, 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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Media type:  Image

Media file 3:  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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Media type:  Image

Media file 4:  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.
	View Full Size Image
Media type:  Image

REFERENCES

Section 11 of 11

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

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Article Last Updated: Nov 1, 2006