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 Table of Contents  
CASE REPORT
Year : 2021  |  Volume : 1  |  Issue : 2  |  Page : 332-334

Clinical and spectral-domain optical coherence tomography findings in Valsalva retinopathy


Vitreo-Retinal Services, Suraj Eye Institute, Nagpur, Maharashtra, India

Date of Submission23-Aug-2020
Date of Acceptance06-Oct-2020
Date of Web Publication01-Apr-2021

Correspondence Address:
Dr. Sarang P Lambat
Suraj Eye Institute, 559, New Colony, Near Byramji Town, Sadar, Nagpur - 440 001, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijo.IJO_2746_20

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  Abstract 


Valsalva retinopathy is a prominent cause of premacular hemorrhage in young patients. We report the case of a young male patient with premacular hemorrhage due to Valsalva retinopathy who underwent Neodymium-doped Yttrium Aluminum Garnet (Nd: YAG) laser evacuation of the blood. Within 5 minutes, there was a significant clearance of the blood from the macular area. A week later we could demonstrate a vascular sign on fluorescein angiography. It is known that the source of blood in Valsalva retinopathy is the rupture of perifoveal capillaries. Based on the findings on fluorescein angiography we could postulate that the bleeding in our case could have been due to the rupture of a larger retinal venule.

Keywords: Nd: YAG laser hyaloidotomy, source of hemorrhage, Valsalva retinopathy


How to cite this article:
Lambat SP, Nangia VB, Nangia PV, Mishra SD, Jaiswal SJ. Clinical and spectral-domain optical coherence tomography findings in Valsalva retinopathy. Indian J Ophthalmol Case Rep 2021;1:332-4

How to cite this URL:
Lambat SP, Nangia VB, Nangia PV, Mishra SD, Jaiswal SJ. Clinical and spectral-domain optical coherence tomography findings in Valsalva retinopathy. Indian J Ophthalmol Case Rep [serial online] 2021 [cited 2021 Jul 29];1:332-4. Available from: https://www.ijoreports.in/text.asp?2021/1/2/332/312395



Valsalva retinopathy was first reported by Duane in 1973.[1] It typically presents as a sudden visual loss in an otherwise healthy individual, caused by a premacular haemorrhage secondary to a Valsalva manoeuvre. The most frequently reported causes of Valsalva manoeuvre include vomiting, coughing, straining and physical activities.[2],[3],[4] A sudden increase in pressure in the intraocular veins, secondary to an increased intrathoracic pressure, causes spontaneous rupture of perifoveal capillaries. Predilection to the macula is explained by the absence of firm attachments of the internal limiting membrane (ILM) to the retina in this area.[5]


  Case Report Top


A male, 32 years of age, came to us with the sudden loss of vision in his left eye during a heavy bout of exercise. He did not have any systemic illness and any other significant ocular history. On examination, his best-corrected visual acuity (BCVA) in the right eye was 6/6 and counting fingers at 1 meter in the left eye. Anterior segment examination was normal in both eyes. The left eye showed a large premacular sub-ILM hemorrhage with no other detectable vascular abnormality [Figure 1]a. On spectral-domain optical coherence tomography (SDOCT), the blood was seen as a hyper-reflective dome-like elevation under the ILM and the hyaloid was seen as a separate membrane [Figure 1]b. We performed Nd: YAG LASER posterior hyaloidotomy and the puncture of the ILM which released the preretinal blood instantly in the vitreous and the macular area was almost clear from the blood within 5 minutes with immediate improvement in vision by 11 lines to 6/9 [Figure 1]c. With SDOCT the defect in the posterior hyaloid and the ILM created by the Nd: YAG LASER application was well delineated [Figure 1]d.
Figure 1: The fundus photo shows the presence of premacular blood. (a) Spectral-domain optical coherence tomography (SDOCT) showing the location to be sub internal limiting membrane (ILM), the red arrow shows the hyaloid. (b) The fundus photo was taken 5 min after doing laser hyaloidotomy. (c) OCT shows the opening in the ILM created by the laser (red arrow). (d) The fundus photograph shows complete clearance of blood from the macular area a week after the laser. (e) Fluorescein angiography done shows the presence of some hyperfluorescence along the superior arcade vessel (f and g). The red arrow shows premacular empty cavity (h)

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One week later his vision had improved further by one line to 6/6 and there was a complete evacuation of the sub ILM hemorrhage [Figure 1]e. A fluorescein angiogram revealed abnormal hyperfluorescence along the superotemporal arcade vessel [Figure 1]f and [Figure 1]g. SD-OCT image revealed the presence of a premacular empty cavity [Figure 1]h.


  Discussion Top


Sub-ILM hemorrhages have been associated with various causes, the most common being Valsalva retinopathy and Terson's syndrome.[6],[7] The hemorrhage due to Valsalva usually resolves spontaneously and rarely causes visual loss in the absence of underlying ocular pathology such as proliferative diabetic retinopathy.[6] However, spontaneous resolution of the hemorrhage may take up to 6 months.[8] Prolonged contact of the retina with hemoglobin and its catabolites can possibly cause toxic retinal damage, which may be irreversible.[7]

This case has three distinct features that we wish to highlight. First, the posterior hyaloid could be clearly seen on OCT and it indicated that the hemorrhage was sub-ILM which has been demonstrated previously in studies.[9] However, these studies were based on time-domain OCT and the data on SDOCT is lacking. The location of blood whether sub ILM or subhyloid has been a matter of debate. This finding helps us in understanding the morphology of this condition.

Secondly, there was a significant evacuation of the blood within a short span of a few minutes from the premacular area with Nd: YAG LASER resulting in rapid improvement in vision. The fact that the intervention was performed within a few hours may have led to immediate response. Kroll and Busse had recommended this treatment within the first 3–4 days after the occurrence of hemorrhage.[8] In such cases of premacular hemorrhages due to Valsalva retinopathy, early intervention can lead to rapid resolution of hemorrhage. Young economically active patients with higher visual requirements often expect a rapid recovery of vision. It is advisable to make judicial use of LASER energy as it is associated with complications including epiretinal membrane formation with ILM wrinkling, persistent non-clearing vitreous opacities, macular hole formation, and retinal detachment.[8],[10]

Third, there was hyperfluorescence on fluorescein angiography along the border of the superior arcade vessel probably pointing towards possible healing of the ruptured vein. To the best of our knowledge, this is a new finding which would add to the source of blood in cases of Valsalva retinopathy.


  Conclusion Top


It could possibly be concluded that if the amount of premacular blood is less we can presume that the source of blood could be due to rupture of smaller retinal capillaries and if the amount of blood collection is significant, involving the entire macular area then it could be due to rupture of a retinal venule.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Duane TD. Valsalva hemorrhagic retinopathy. Trans Am Ophthalmol Soc 1972;70:298-313.  Back to cited text no. 1
    
2.
T G, Ia P, Rh T. Valsalva retinopathy associated with blowing balloons. Eye Lond Engl 1999;13:686-7.  Back to cited text no. 2
    
3.
Herr S, Pierce MC, Berger RP, Ford H, Pitetti RD. Does valsalva retinopathy occur in infants? An initial investigation in infants with vomiting caused by pyloric stenosis. Pediatrics 2004;113:1658-61.  Back to cited text no. 3
    
4.
Ladjimi A, Zaouali S, Messaoud R, Ben Yahia S, Attia S, Jenzri S, et al. Valsalva retinopathy induced by labour. Eur J Ophthalmol 2002;12:336-8.  Back to cited text no. 4
    
5.
Foos RY. Vitreoretinal juncture; topographical variations. Invest Ophthalmol 1972;11:801-8.  Back to cited text no. 5
    
6.
Celebi S, Kükner AS. Photodisruptive Nd: YAG laser in the management of premacular subhyaloid hemorrhage. Eur J Ophthalmol 2001;11:281-6.  Back to cited text no. 6
    
7.
Ulbig MW, Mangouritsas G, Rothbacher HH, Hamilton AM, McHugh JD. Long-term results after drainage of premacular subhyaloid hemorrhage into the vitreous with a pulsed Nd: YAG laser. Arch Ophthalmol 1998;116:1465-9.  Back to cited text no. 7
    
8.
Kroll P, Busse H. Therapy of preretinal macular hemorrhages. Klin Monbl fur Augenheilkd 1986;188:610-2.  Back to cited text no. 8
    
9.
Mennel S. Subhyaloidal and macular haemorrhage: Localisation and treatment strategies. Br J Ophthalmol 2007;91:850-2.  Back to cited text no. 9
    
10.
Kwok AKH, Lai TYY, Chan NR. Epiretinal membrane formation with internal limiting membrane wrinkling after Nd: YAG laser membranotomy in valsalva retinopathy. Am J Ophthalmol 2003;136:763-6.  Back to cited text no. 10
    


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