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06-14-2012, 06:22 PM
Valsalva Retinopathy:

Vision loss after asthma attack

Matthew Rauen, MD, Thomas A. Oetting, MS, MD, and Thomas A. Weingeist, PhD, MD
July 10, 2007
Chief Complaint: 32 year-old female patient presented with a "black spot" in the vision of her left eye.
History of Present Illness: The patient awoke the morning of presentation with a black spot inferotemporal to fixation. This was accompanied by blurry vision in the left eye. The patient had poorly controlled asthma the day prior to the onset of her visual symptoms associated with an intense coughing episode. She had no complaints regarding the right eye.
Past Ocular History: Unremarkable for surgery or trauma. She is myopic and wears -4.50 sphere spectacle correction in both eyes.
Medical History: History of asthma and migraine headaches.
Medications: Oral contraceptive pill daily. Albuterol inhaler and sumatriptan both as needed.
Family History: No history of coagulopathy.
Social History: Noncontributory.
Ocular Examination:


Visual Acuity, with correction: Right eye (OD)-- 20/20; Left eye (OS)--20/40
Extraocular motility: Full, both eyes (OU)
Pupils: No relative afferent pupillary defect (RAPD)
Intra-ocular pressure: OD-- 18 mm Hg; OS -- 17 mmHg
External and anterior segment examination: Normal
Amsler Grid Testing: OD-- Normal; OS--Inferotemporal Scotoma (see Figure 1)
Dilated fundus exam: OD-- Normal; OS--A large preretinal hemorrhage was evident in the paripapillary region and nasal macula (see Figure 2)
Figures 1 and 2Figure 1: Amsler grid, OS. Amsler grid testing can be used to evaluate the central 10 degrees of the visual field. The patient described a scotoma inferotemporal to fixation in the left eye, as depicted here. Figure 2: Fudus photograph, OS. A large preretinal hemorrhage is visagle around the upper margin of the disc and extending into the macula.
http://webeye.ophth.uiowa.edu/eyeforum/cases-i/case67/Valsalva-Retinopathy-vision-loss-asthma_1.jpghttp://webeye.ophth.uiowa.edu/eyeforum/cases-i/case67/Valsalva-Retinopathy-vision-loss-asthma_2.jpg
Course: Blood pressure measured 124/73. Complete blood count was normal, with a hemoglobin of 14.2 and platelet count of 300. The patient was seen by the Retina Service at the University of Iowa and the decision was made to observe the hemorrhage and improve control of her asthma symptoms with her Primary Care Physician. Two weeks later, the preretinal hemorrhage had diminished in size, but the patient continued to report blurry vision (VA 20/40) with the left eye (see Figure 3). She was seen again two months later and the hemorrhage had largely resolved. Her vision had recovered to baseline (VA 20/20) (see Figure 4).
Figures 3 & 4Figure 3: Fundus photo, OS, 2 weeks after initial presentation. Figure 4: Fundus photo, OS, 2 months after initial presentation showing near complete resolution of hemorrhage.
http://webeye.ophth.uiowa.edu/eyeforum/cases-i/case67/Valsalva-Retinopathy-vision-loss-asthma_3.jpghttp://webeye.ophth.uiowa.edu/eyeforum/cases-i/case67/Valsalva-Retinopathy-vision-loss-asthma_4.jpg
Discussion: Valsalva Retinopathy is a rare cause of preretinal hemorrhage (1). Typically, patients present with acute painless loss of vision after performing a Valsalva-type maneuver. Mechanistically, it is thought that an acute rise in intrathoracic/intraabdominal pressure from closure of the glotis leads to an intraoclular venous pressure increase and capillary rupture. The patient in this case provided a classic history of straining prior to the onset of symptoms (i.e. coughing during asthma attack). Valsalva retinopathy has also been described following weight lifting, vomiting, sexual activity, end stage labor, blowing musical instruments, and compressive injuries (2-6).
Some debate exists as to where the hemorrhage is actually located. Some have localized the hemorrhage to a sub-internal limiting membrane (ILM) location (7-9), while others have provided convincing data to support a subhyaloid position (10). While not utilized in this case, OCT can assist in identifying the exact location of such hemorrhages.
This patient was observed and the hemorrhage cleared relatively quickly. This is often the case, but occasionally the hemorrhage can be slow to resolve. Since the late 1980s, several authors have advocated the use of Nd:YAG hyaloidotomy / membranotomy to assist in visual recovery. A large hemorrhage that obscures the macula may prompt such an approach as these patients may have dramatically reduced vision. Results in the literature have been quite impressive with this treatment (11,12).
Diagnosis: Valsalva Retinopathy

EPIDEMIOLOGY


Frequently unilateral, but may be bilateral
Occurs infrequently with straining maneuvers
Usually in otherwise healthy eyes
Equal prevelance in males and females
No race predilection
SIGNS


Preretinal hemorrhage, frequently involving the macula
Otherwise normal fundus
Optical Coherence Tomography (OCT) can be used to localize the homorrhage to the subhyaloid or sub-internal limiting membrane (ILM) space
SYMPTOMS


Acute painless loss of vision occurring shortly after straining
Patients frequently complain of central or paracentral visual field defect
TREATMENT

Can rule out other etiologies predisposing to preretinal hemorrhage:

Blood pressure for hypertension
Blood sugar to evaluate for diabetes
CBC for blood dyscrasias
PT/PTT/INR to evaluate coagulopathy
Observation: hemorrhage resolves in weeks to months
Patient shoud be instructed to avoid straining activites in the acute phase
Avoid anticoagulation if possible
Nd:YAG laser for non-clearing hemorrhage or if rapid improvement in vision is sought (monocular patient)

Differential Diagnoses:


Hypertensive Retinopathy
Diabetic Retinopathy
Purtscher's Retinopathy
Posterior Vitreous Detachment
References


Duane TD. Valsalva hemorrhagic retinopathy. Trans Am Ophthalmol Soc. 1972;70:298-313.
Friberg TR, Braunstein RA, Bressler NM. Sudden visual loss associated with sexual activity. Arch Ophthalmol. 1995;113:738-742.
Georgiou T, Pearce IA, Taylor RH. Valsalva retinopathy associated with blowing balloons. Eye. 1999;13 ( Pt 5):686-687.
Oboh AM, Weilke F, Sheindlin J. Valsalva retinopathy as a complication of colonoscopy. J Clin Gastroenterol. 2004;38:793-794.
Callender D, Beirouty ZA, Saba SN. Valsalva haemorrhagic retinopathy in a pregnant female. Eye. 1995;9 ( Pt 6):808-809.
Wickremasinghe SS, Tranos PG, Davey C. Valsalva haemorrhagic retinopathy in a pregnant female: implications for delivery. Acta Ophthalmol Scand. 2003;81:420-422.
Gass J. Traumatic retinopathy. In: Stereoscopic atlas of macular diseases:diagnosis and tretment.. St Louis: Mosby; 1997:737-774.
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;136:763-766.
Shukla D, Naresh KB, Kim R. Optical coherence tomography findings in valsalva retinopathy. Am J Ophthalmol. 2005;140:134-136.
Schuman JS PC, Fujimoto JG. Optical coherence tomography of ocular diseases. Thorofare: Slack; 2004:1-698.
Durukan AH, Kerimoglu H, Erdurman C, Demirel A, Karagul S. Long-term results of Nd:YAG laser treatment for premacular subhyaloid haemorrhage owing to Valsalva retinopathy. Eye. 2006.
Aralikatti AK, Haridas AS, Smith JM. Delayed Nd:YAG laser membranotomy for traumatic premacular hemorrhage. Arch Ophthalmol. 2006;124:1503.