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Valsalva retinopathy
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Valsalva retinopathy

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Contributors: Sid Schechet MD, D. Chimene Richa MD
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Synopsis

First described by Duane in 1972, Valsalva retinopathy is the occurrence of pre-retinal hemorrhages caused by a sudden increase in intrathoracic pressure. It usually occurs in an otherwise healthy eye and generally spontaneously resolves.

A sudden forced exhalation with a closed glottis, known as the Valsalva maneuver, causes a sudden increase in intrathoracic and intraabdominal pressure. This causes the systemic venous pressure to rise, and simultaneously the intraocular venous pressure rises as well. Subsequently, the small, superficial retinal capillaries rupture and form pre-retinal hemorrhages under the internal limiting membrane (ILM) or under the posterior hyaloid face (known as subhyaloid). Occasionally, these pre-retinal hemorrhages may break through the ILM or posterior hyaloid face into the vitreous, becoming a vitreous hemorrhage. The hemorrhages typically occur in the macular area and appear as one or more well-circumscribed, red hemorrhages. If the blood spread through the ILM, then there may be a "boat-shaped" subhyaloid hemorrhage or more diffuse vitreous hemorrhage.

Activities that induce the Valsalva maneuver and thus can cause Valsalva retinopathy include coughing, vomiting, straining during a bowel movement, strenuous exertion, exercise, sexual intercourse, labor, blowing musical instruments, and general anesthesia.

Valsalva retinopathy usually occurs in healthy eyes, but more at-risk patients include those with prior vascular disease such as diabetic or hypertensive retinopathy, retinal telangiectasias, or retinal macroaneurysms. Also, anticoagulated patients or those with a bleeding diathesis are more susceptible to Valsalva retinopathy. This can occur at any age with no predilection for gender, ethnicity, or region.

Patients report experiencing a sudden, painless loss of vision or may note a new scotoma or red-tinged floaters. They may report an antecedent Valsalva-like maneuver. This may occur in one eye or both with an asymmetric appearance. Visual acuity may be normal or impaired if the hemorrhages involve the foveal region. The severity of the retinopathy is not correlated with the severity of the Valsalva maneuver.

Valsalva retinopathy generally spontaneously resolves over the course of weeks to months. The prognosis is very good with visual acuity usually returning to baseline as the hemorrhage clears.

Codes

ICD10CM:
H35.00 – Unspecified background retinopathy

SNOMEDCT:
232031001 – Valsalva retinopathy

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Diagnostic Pearls

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Differential Diagnosis & Pitfalls

  • Diabetic retinopathy – may see hard exudates and neovascularization
  • Hemorrhagic posterior vitreous detachment
  • Hypertensive retinopathy – would see other signs such as vascular attenuation and arteriovenous nicking
  • Macroaneurysm – would also commonly have intraretinal hemorrhages
  • Sickle cell retinopathy – would see other signs such as "salmon patches" and "sea fan" neovascularization
  • Purtscher retinopathy – would see cotton-wool spots and retinal whitening
  • Terson syndrome – associated with subarachnoid hemorrhage
  • Blood dyscrasia
  • Radiation retinopathy – would have history of radiation therapy
  • Anemic retinopathy – would see many intraretinal hemorrhages

Best Tests

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Management Pearls

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Therapy

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References

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Last Reviewed: 12/15/2016
Last Updated: 12/14/2016
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Valsalva retinopathy
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Valsalva retinopathy : Retinal hemorrhage, Vigorous exercise
Copyright © 2019 VisualDx®. All rights reserved.