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A sharp rise in intrathoracic or intra-abdominal pressure can cause sudden and profound visual loss from retinal haemorrhage—Valsalva haemorrhagic retinopathy.
A woman of 23 attended the accident and emergency department after feeling unwell and acutely short of breath for one day. She used salmeterol, beclomethasone and salbutamol inhalers for asthma; otherwise there was no medical history of note. On examination she was tachypnoeic, tachycardic and unable to complete full sentences. Temperature was normal. There were widespread wheezes in the chest. When she was breathing 7 L/min oxygen, pO2 was 16.92 kPa and pCO2 7.59 kPa. An acute exacerbation of asthma was diagnosed and she was started on treatment with nebulized salbutamol and ipratropium together with intravenous steroids. After thirty minutes the chest symptoms were much improved and she was able to complete full sentences; on 4 L/min oxygen arterial blood pO2 was 11.04 kPa and pCO2 5.13 kPa. However, she complained of loss of central vision in her right eye since admission. On ophthalmic examination, visual acuities were of hand movement on the right and 6/6 on the left, and fundoscopy revealed a large, well-circumscribed premacular haemorrhage with a fluid level in the right eye (Figure 1). Valsalva haemorrhagic retinopathy was diagnosed. Laboratory investigations including sickle screen, coagulation screen, full blood count, erythrocyte sedimentation rate and blood glucose all gave normal results. Her vision improved over the next few weeks to 6/6 in each eye as the premacular haemorrhage resolved spontaneously.
Valsalva haemorrhagic retinopathy was first described in 1973 as macular haemorrhage resulting from a sudden rise in intrathoracic or intra-abdominal pressure against a closed glottis1. This pressure, transmitted to the eye, causes rupture of superficial retinal capillaries. It has been associated with vomiting, constipation, continuous positivepressure ventilation and transrectal surgery2,3. Certain seemingly harmless activities have also been reported to cause Valsalva retinopathy, including aerobic exercise4, inflation of party balloons5 and weight-lifting6.
In Valsalva haemorrhagic retinopathy, the haemorrhage is typically dome-shaped and beneath the internal limiting membrane of the retina. A fluid level may become visible as the blood settles inferiorly. Vision may also be reduced by an accompanying vitreous haemorrhage. The internal limiting membrane may become detached but spontaneous reattachment is usual, sometimes with reduplication. A history of straining is helpful in establishing the diagnosis since a similar clinical picture can be seen in diabetic retinopathy and retinal artery macroaneurysm. Fluorescein angiography is helpful in identifying underlying retinopathy.
In many reported cases of Valsalva retinopathy, vision has spontaneously returned to normal2,3. However, rapid visual recovery can be obtained by use of Nd.YAG laser to puncture the internal limiting membrane and drain the haemorrhage6. Complications of laser treatment, though uncommon, include choroidal haemorrhage, retinal hole formation and vitreous haemorrhage6.