Valsalva Retinopathy

Back

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.



View Image

Initial presentation of a Valsalva retinopathy less than 24 hours following a Valsalva maneuver in an 18-year-old man. Note the large preretinal hemor....



View Image

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 w....

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.

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]

Prognosis

Prognosis is generally good, as complete recovery of vision (with observation) usually occurs within weeks to months following onset. However, visual prognosis depends on the location of the hemorrhaging and specifically the layer of retina involved.

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.

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 eMedicineHealth's Eye and Vision Center. Also, see eMedicineHealth's patient education article Subconjunctival Hemorrhage (Bleeding in Eye).

History

Valsalva retinopathy usually manifests as preretinal hemorrhage secondary to rupturing of superficial retinal vessels from physical exertion. The mechanism of 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 vessels to spontaneously rupture.

Patients with Valsalva retinopathy often present with loss of vision in one eye, but bilateral clinical findings are common. The degree of vision loss depends on the size and location of the preretinal (or, less commonly, subretinal) hemorrhage. Patients usually describe an antecedent Valsalva-like maneuver (eg, coughing, vomiting, heavy lifting, straining in the bathroom, vigorous sexual activity, labor and delivery). The severity of the Valsalva maneuver is not directly correlated with the severity of Valsalva retinopathy.

Some individuals with Valsalva retinopathy may experience spontaneous vision loss without a history of Valsalva maneuver. Without a definitive history of physical exertion, retinal vascular disease should be considered and other systemic conditions investigated. Furthermore, patients receiving anticoagulants may develop a similar clinic picture without a history of unusual exertion.

Patients with Valsalva retinopathy often present with the following symptoms:

Ocular Examination and Clinical Features

The clinical signs of suddenly increased systemic venous pressure often include the eye and skin. A subconjunctival hemorrhage may be evident, and skin petechia of the hand and neck may be present.

A comprehensive ocular examination is imperative and should include visual acuity testing, pupil testing, anterior segment examination, and a detailed posterior segment examination.

The "classic" clinical appearance of Valsalva retinopathy on dilated fundus examination is a well-circumscribed preretinal hemorrhage in either the subhyaloid or sub–internal limiting membrane (ILM) space. Interestingly, Valsalva retinopathy has a predilection for the macula region (both premacular and paramacular). Often, the ruptured vessels in the perifoveal vessels can cause a sudden and painless loss of central vision. Uncommonly, subretinal hemorrhage may occur.

Retinal edema in the macular region with associated edematous transudates and superficial intraretinal hemorrhages have been described.

Ocular findings and visual symptoms depend on the severity of the Valsalva force and the underlying status of the retina vasculature. Hemorrhages can vary in size, and, in many cases, a large preretinal hemorrhage encompassing several disc diameters may be observed.



View Image

Subhyaloid, sub–internal limiting membrane (ILM) hemorrhage in eye with Valsalva retinopathy. This image was originally published in the ASRS Retina I....



View Image

Subhyaloid, sub–internal limiting membrane (ILM) hemorrhage showing a fluid level and yellowish color as it settles over time. This image was original....

Causes

The underlying etiology of the Valsalva maneuver is most commonly related to heavy lifting, vomiting, coughing, unusual physical exertion, and straining on the toilet. Other causes, such as sneezing, compressive trauma, labor, vigorous sexual activity, labor, and rollercoaster riding, have been described.

The pathophysiology of Valsalva retinopathy is related to a sudden increase in intraabdominal pressure in a closed glottis.

 See the image below.



View Image

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....



View Image

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 ....



View Image

Patient with history of gastroenteritis and episodes of vomiting followed by loss of central vision.



View Image

Patient with sudden loss of vision during labor and seen soon after giving birth.

Physical Examination

Physical examination of the skin may reveal petechia. See Ocular Examination for clinical features of the eye examination.

Complications

Complications of Valsalva retinopathy may include the following:

The final visual outcome often depends on the location of the hemorrhage and the layer of retina involved (subretinal, intraretinal, preretinal). Specifically, subretinal hemorrhage in the macula most likely causes permanent vision loss.

Laboratory Studies

Laboratory 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:

Imaging Studies

Serial retinal photography can be used to monitor the progression and the resolution of retinal hemorrhages over time.

Retinal fluorescein angiography (FA) can be used to rule out choroidal or retinal neovascularization. Fluorescein angiography can also help identify retinal ischemia or other vasculopathic conditions not associated with Valsalva retinopathy. Finally, angiography can help localize the hemorrhage.

If blood in the vitreous is obstructing the view of the retina, B-scan ultrasonography can be used to rule out a retinal break, tumor, or retinal detachment as cause of the vitreous hemorrhage.

Optical coherence tomography (OCT) can be used to better localize the perimacular or premacular hemorrhage (eg, subhyaloid, sub–internal limiting membrane).[8]

Other Tests

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

Histologic Findings

Preretinal hemorrhages are often located just under the internal limiting membrane and on the surface of the nerve fiber layer. Vitreous hemorrhage and subhyaloid hemorrhage can be seen in this condition. The hemorrhage tends to arise from the superficial capillary bed. As the hemorrhage resolves over time, the blood typically settles at the inferior aspect of the internal limiting membrane 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.

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]

Medication Summary

No proven medical therapy is available for Valsalva retinopathy. The underlying risk factors contributing to the disease development should be treated.

Author

Charles W Eifrig, MD, Vitreoretinal Surgeon, Retina Associates of Orange County

Disclosure: Nothing to disclose.

Coauthor(s)

Judy H Jun, Sackler School of Medicine, Israel

Disclosure: Nothing to disclose.

Specialty Editors

Francisco Talavera, PharmD, PhD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Steve Charles, MD, Founder and CEO of Charles Retina Institute; Clinical Professor, Department of Ophthalmology, University of Tennessee College of Medicine

Disclosure: Received royalty and consulting fees for: Alcon Laboratories.

Chief Editor

Hampton Roy, Sr, MD, Associate Clinical Professor, Department of Ophthalmology, University of Arkansas for Medical Sciences

Disclosure: Nothing to disclose.

Additional Contributors

Robert S Duszak, OD, FAAO, Attending Physician, Philadelphia Veterans Affairs Medical Center; Consulting Staff, Nemours Health Clinic, Mayfair Eye Associates; Adjunct Clinical Faculty, Eye Institute of the Pennsylvania College of Optometry

Disclosure: Nothing to disclose.

V Al Pakalnis, MD, PhD, Professor of Ophthalmology, University of South Carolina School of Medicine; Chief of Ophthalmology, Dorn Veterans Affairs Medical Center

Disclosure: Nothing to disclose.

References

  1. Duane TD. Valsalva hemorrhagic retinopathy. Trans Am Ophthalmol Soc. 1972. 70:298-313. [View Abstract]
  2. 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. [View Abstract]
  3. Choi SW, Lee SJ, Rah SH. Valsalva retinopathy associated with fiberoptic gastroenteroscopy. Can J Ophthalmol. 2006 Aug. 41(4):491-3. [View Abstract]
  4. Lee VY, Liu DT, Chan WM. Valsalva retinopathy as a complication of colonoscopy. J Clin Gastroenterol. 2005 Aug. 39(7):643; author reply 643. [View Abstract]
  5. Saricaoglu MS, Kalayci D, Guven D, Karakurt A, Hasiripi H. Decompression retinopathy and possible risk factors. Acta Ophthalmol. 2009 Feb. 87(1):94-5. [View Abstract]
  6. Al-Mujaini AS, Montana CC. Valsalva retinopathy in pregnancy: a case report. J Med Case Reports. 2008 Apr 7. 2:101. [View Abstract]
  7. Talbert DG. The 'Sutured Skull' and intracranial bleeding in infants. Med Hypotheses. 2006. 66(4):691-4. [View Abstract]
  8. Shukla D, Naresh KB, Kim R. Optical coherence tomography findings in valsalva retinopathy. Am J Ophthalmol. 2005 Jul. 140(1):134-6. [View Abstract]
  9. 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. [View Abstract]
  10. Bourne RA, Talks SJ, Richards AB. Treatment of preretinal Valsalva haemorrhages with neodymium:YAG laser. Eye. 1999 Dec. 13 (Pt 6):791-3. [View Abstract]
  11. Chen YJ, Kou HK. Krypton laser membranotomy for premacular hemorrhage. Ophthalmologica. 2004 Nov-Dec. 218(6):368-71. [View Abstract]
  12. Chen YJ, Kou HK. Krypton laser membranotomy in the treatment of dense premacular hemorrhage. Can J Ophthalmol. 2004 Dec. 39(7):761-6. [View Abstract]
  13. 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. [View Abstract]
  14. 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. [View Abstract]
  15. Rennie CA, Newman DK, Snead MP, Flanagan DW. Nd:YAG laser treatment for premacular subhyaloid haemorrhage. Eye. 2001 Aug. 15(Pt 4):519-24. [View Abstract]
  16. 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. [View Abstract]
  17. 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. [View Abstract]
  18. 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. [View Abstract]
  19. 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. [View Abstract]
  20. Liu Z, Pan X, Bi H. Treatment of Valsalva Retinopathy. Optom Vis Sci. 2014 Oct 2. [View Abstract]
  21. 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. [View Abstract]
  22. 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. [View Abstract]
  23. 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. [View Abstract]
  24. Karagiannis D, Gregor Z. Valsalva retinopathy associated with idiopathic thrombocytopenic purpura and positive antiphospholipid antibodies. Eye. 2006 Mar 10. [View Abstract]
  25. Mansour AM, Salti HI, Han DP, et al. Ocular findings in aplastic anemia. Ophthalmologica. 2000. 214(6):399-402. [View Abstract]
  26. Sueke H. Valsalva retinopathy induced by vigorous nightclub dancing. Med J Aust. 2009 Mar 16. 190(6):333. [View Abstract]
  27. Al-Mujaini AS, Montana CC. Valsalva retinopathy in pregnancy: a case report. J Med Case Reports. 2008 Apr 7. 2:101. [View Abstract]
  28. Callender D, Beirouty ZA, Saba SN. Valsalva haemorrhagic retinopathy in a pregnant woman. Eye. 1995. 9 (Pt 6):808-9. [View Abstract]
  29. Friberg TR, Braunstein RA, Bressler NM. Sudden visual loss associated with sexual activity. Arch Ophthalmol. 1995 Jun. 113(6):738-42. [View Abstract]
  30. Georgiou T, Pearce IA, Taylor RH. Valsalva retinopathy associated with blowing balloons. Eye. 1999 Oct. 13 (Pt 5):686-7. [View Abstract]
  31. Ioannidis AS, Tranos PG, Harris M. Valsalva retinopathy associated with riding a motorcycle. Eye. 2004 Mar. 18(3):329-31. [View Abstract]
  32. Oboh AM, Weilke F, Sheindlin J. Valsalva retinopathy as a complication of colonoscopy. J Clin Gastroenterol. 2004 Oct. 38(9):793-4. [View Abstract]
  33. Roberts DK, MacKay KA. Microhemorrhagic maculopathy associated with aerobic exercise. J Am Optom Assoc. 1987 May. 58(5):415-8. [View Abstract]
  34. Van Rens E. Traumatic ocular haemorrhage related to bungee jumping. Br J Ophthalmol. 1994 Dec. 78(12):948. [View Abstract]
  35. Al Rubaie K, Arevalo JF. Valsalva retinopathy associated with sexual activity. Case Rep Med. 2014. 2014:524286. [View Abstract]
  36. 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. [View Abstract]
  37. Eneh A, Almeida D. Valsalva hemorrhagic retinopathy during labour: a case report and literature review. Can J Ophthalmol. 2013 Dec. 48(6):e145-7. [View Abstract]
  38. Chapman-Davies A, Lazarevic A. Valsalva maculopathy. Clin Exp Optom. 2002 Jan. 85(1):42-5. [View Abstract]
  39. Chopdar A. Valsalva hemorrhagic retinopathy. Eye. 1996. 10 (Pt 5):650. [View Abstract]
  40. 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. [View Abstract]
  41. Deane JS, Ziakas N. Valsalva retinopathy in pregnancy. Eye. 1997. 11 (Pt 1):137-8. [View Abstract]
  42. Duane TD. Valsalva hemorrhagic retinopathy. Am J Ophthalmol. 1973 Apr. 75(4):637-42. [View Abstract]
  43. 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.
  44. 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. [View Abstract]
  45. Jones WL. Valsalva maneuver induced vitreous hemorrhage. J Am Optom Assoc. 1995 May. 66(5):301-4. [View Abstract]
  46. Kadrmas EF, Pach JM. Vitreous hemorrhage and retinal vein rupture. Am J Ophthalmol. 1995 Jul. 120(1):114-5. [View Abstract]
  47. Kassoff A, Catalano RA, Mehu M. Vitreous hemorrhage and the Valsalva maneuver in proliferative diabetic retinopathy. Retina. 1988. 8(3):174-6. [View Abstract]
  48. Kocak N, Kaynak S, Kaynak T, et al. Unilateral Purtscher-like retinopathy after weight-lifting. Eur J Ophthalmol. 2003 May. 13(4):395-7. [View Abstract]
  49. Konotey-Ahulu F. Valsalva vitreous haemorrhage and retinopathy in sickle cell haemoglobin C disease. Lancet. 1997 Jun 14. 349(9067):1774. [View Abstract]
  50. Krepler K, Wedrich A, Schranz R. Intraocular hemorrhage associated with dental implant surgery. Am J Ophthalmol. 1996 Nov. 122(5):745-6. [View Abstract]
  51. 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. [View Abstract]
  52. Ladjimi A, Zaouali S, Messaoud R, et al. Valsalva retinopathy induced by labour. Eur J Ophthalmol. 2002 Jul-Aug. 12(4):336-8. [View Abstract]
  53. 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. [View Abstract]
  54. 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. [View Abstract]
  55. 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. [View Abstract]
  56. 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. [View Abstract]
  57. 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. [View Abstract]
  58. Raymond LA, Sacks JG, Choromokos E. Hemorrhagic valsalva retinopathy in Leber's optic neuropathy. Ann Ophthalmol. 1985 Sep. 17(9):553-4. [View Abstract]
  59. 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. [View Abstract]
  60. Sahu DK, Namperumalsamy P, Kim R, Ravindran RD. Argon laser treatment for premacular hemorrhage. Retina. 1998. 18(1):79-82. [View Abstract]
  61. 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. [View Abstract]
  62. J. Donald M. Gass. Stereoscopic Atlas of Macular Diseases: Diagnosis and Treatment. 4th ed. St. Louis: Mosby; 1997.

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.

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.

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.

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.

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.