The Valsalva That Wasn’t

Case History:

A 28 year old male presents to the emergency room with a 6-day history of vision loss in his left eye. The patient also complains of mild photophobia and pain. Symptoms occurred suddenly while the patient was watching a movie at home. He denies any past ocular history or trauma.

Past medical history is positive for head trauma with loss of consciousness ten months prior to presentation. The patient is not on any medications. Family history is non-contributory. The patient is employed as a computer technician and denies using alcohol, tobacco, or recreational drugs. Review of systems is negative.

On clinical examination, the patient is healthy, alert, and oriented. His visual acuity is 20/20 OD and HM OS. The patient has a diffuse visual field deficit to confrontation OS. IOP is normal. Pupils are equal, round, and reactive to light without APD. Anterior segment exam is normal. The funduscopic exam reveals a normal OD and a four disk-diameter, layered, pre-retinal hemorrhage overlying the inferior macula OS (see photo). There is intra-retinal hemorrhage along the inferior border of this lesion, as well as in two other foci within the posterior pole.

Fluorescein angiography reveals blocking from pre-retinal hemorrhage with no obvious leakage. Spectral-Domain OCT demonstrates layered sub-ILM hemorrhage over the macula (see photo). Laboratory exam reveals a normal CBC, PT, and PTT.

Diagnosis: Valsalva Retinopathy

The cause for visual loss in this patient is pre-retinal hemorrhage caused by valsalva retinopathy. This likely occurred during a moment of increased intra-thoracic pressure leading to reflux into the retinal venules and bleeding into the sub-ILM space. Despite extensive questioning, an obvious valsalva event (i.e. weight lifting, constipation, sneezing) could not be elicited from the patient.

In our case, Spectral-Domain OCT technology was used to image the pre-retinal hemorrhage with high resolution. This new technology is superior to the Stratus OCT for several reasons, including:

• B-scan images in SD-OCT are created from 4,096 sequential A-scans, compared to 200 A-scans with Stratus OCT, leading to significantly higher resolution.
• SD-OCT uses a raster pattern instead of radial, which allows for 3-dimensional imaging and volumetric measurements of the retina
• Images from a SD-OCT can be registered to fundus photography and fluorescein angiography for precise and reproducible localization of pathology
• The SD-OCT gives operators wide-angle exposure, allowing for imaging of peripheral retinal pathology

In this case, notice the SD-OCT’s ability to resolve individual RBC’s floating sub-ILM above the fovea. Also notice the clear demarcation of the outer-retinal anatomy, including the inner-segment, outer-segment junction. This level of resolution is only possible with SD-OCT.

Treatment for valsalva retinopathy is conservative. Almost all patients will recover full visual acuity over the span of months as the hemorrhage clears. Several studies have investigated the use of YAG laser pulses to disrupt the ILM and drain pre-retinal blood into the vitreous. This may be advantageous for patients with poor vision in their fellow eye or in cases where immediate binocularity is necessary. However, cases of macular hole, ERM, and tractional RD after YAG ILM-otomy have been reported in the literature.

Our patient was managed with observation. He experienced improvement of his vision from HM to 20/50 OS at the 3-month follow-up visit. The patient’s vision is expected to continue to improve as pre-retinal hemorrhage clears with time.

Figure 1

Figure 2

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