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BMJ Case Rep. 2010; 2010: bcr08.2008.0760.
Published online Feb 22, 2010. doi:  10.1136/bcr.08.2008.0760
PMCID: PMC3029068
Rare disease
Maculopathy: a rare association of the Valsalva manoeuvre (Valsalva maculopathy)
Sajjad Ahmed Sheikh,1 Reyaz Ahmed Untoo,2 Imtiaz Ahmed Lone,3 and Nusrat Shaheen4
1SKIMS Medical College, Ophthalmology, Bemina, Srinagar, 190017, India
2SKIMS Medical College, Ophthalmology, Bemina, Srinagar, Jammu and Kashmir, 190017, India
3SKIMS Medical College, Bemina, Srinagar, Jammu and Kashmir, 190017, India
4SKIMS Medical College, Bemina, Srinagar, Jammu and Kashmir, 190017, India
Correspondence to Sajjad Ahmed Sheikh, sjjd_sheikh/at/yahoo.co.in
A 22-year-old man complained of sudden, painless loss of vision (vague scotoma in central vision) in his right eye. The patient became symptomatic following a session of weight training at a gymnasium the previous day. There was no history trauma. Medical, ocular and familial history were unremarkable. The inferior and temporal aspect of the haemorrhage was darker due to gravitation, but the rest of the fundus was normal. The appearance of the right fundus, combined with an associated unequivocal history of physical exertion, was consistent with a diagnosis of Valsalva maculopathy (holding breath while bench pressing). Systemic examination and all relevant blood tests were normal. Fluorescein angiography (FFA) was done which confirmed the diagnosis. The patient recovered a vision of 6/6 in his right eye after 2 months. FFA was again done, which showed no sequelae of the problem.
Background
We present this case to increase awareness of the possible complication of maculopathy occurring in individuals undertaking stressful exercise, especially during the Valsalva manoeuvre (holding breath while bench pressing).
A 22-year-old man complained of sudden, painless loss of vision (vague scotoma in central vision) in his right eye. The patient became symptomatic following a session of weight training at a gymnasium the previous day. There was no history of trauma. Medical, ocular and familial history were unremarkable. The inferior and temporal aspect of the haemorrhage was darker due to gravitation, but the rest of the fundus was normal. The appearance of the right fundus, combined with an associated unequivocal history of physical exertion, was consistent with a diagnosis of Valsalva maculopathy (holding breath while bench pressing). The systemic examination and all relevant blood tests were normal, and there was no other relevant social history. Fluorescein angiography (FFA) (fig 1) was done which confirmed the diagnosis.
Figure 1
Figure 1
Patient at the time of presentation (pre-treatment).
Treatment
The patient was put on ketorolac eye drops four times daily for 2 months, with a tablet of calcium dobesilate twice daily for 3 weeks.
Outcome and follow-up
The patient recovered a vision of 6/6 in his right eye after 2 months. FFA was again done (fig 2), which showed no sequelae of the problem. His vision continues to remain normal to date.
Figure 2
Figure 2
Patient post-treatment.
Duane coined the term Valsalva haemorrhagic retinopathy in 1972 in a report on three cases,1 followed by a fourth case in 1973.2 Pitta and colleagues presented nine cases,3 in whom absorption of the haemorrhage varied from 1 week to 6 months. Pruett et al reported 20 cases whose recovery of vision varied from 1–7 months.4
Valsalva maculopathy has been reported following aerobic exercise,5 vigorous sexual activity,6 inflating balloons,7 prostate8 and dental surgery,9 episodes of constipation, vomiting and lifting in pregnant women,10,11 and in acute Leber’s optic neuropathy.12
Pulsed ND:YAG lasers, krypton lasers, argon lasers, and Q-switched ND-YAG lasers have been used for disruption of the posterior hyaloid or internal limiting membrane, for enhancing recovery.13,14
Learning points
  • Patients should be educated about the inherent dangers of breath holding while exercising, especially with high risk factors such as PDR, sickle cell retinopathies, and blood dyscrasias.
  • Exhaling while lifting or straining presents a Valsalva against a closed glottis.
  • The prognosis for Valsalva maculopathy is extremely favourable, and patients should be reassured accordingly.
Footnotes
Competing interests: None.
Patient consent: Patient/guardian consent was obtained for publication.
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3. Pitta CG, Steiner RF, Gragoudas ES, et al. small unilateral foveal hemorrhages in young adults. Am J Ophthalmol 1980; 89: 96–102. [PubMed]
4. Pruett RC, Carvallho AC, Trempe CL. Microhaemorrhagic maculopathy. Arch Ophthalmol 1981; 99: 425–32. [PubMed]
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10. Callender D, Beirouty ZA, Saba SN. Valsalva heamorrhage retinopathy in a pregnant woman. Eye 1995; 9: 808–9. [PubMed]
11. Deane JS, Ziakas N. Valsalva retinopathy in pregnancy. Eye 1997; 11: 137–8. [PubMed]
12. Raymond LA, Sacks JG, Choromokos E. Hemorrhagic Valsalva retinopathy in Leber’s optic neuropathy. Ann Ophthalmol 1985; 17: 553–4. [PubMed]
13. Zaman F, Irwin R, Godley BF. ND: YAG laser treatment for macular preretinal hemorrhage. Arch Ophthalmol 1999; 117: 694–695. [PubMed]
14. Stefer U, Gerke E. Nd: YAG laser treatment for a premacular Valsalva hemorrhage under the posterior hyaloid face. Deutsche ophthalmologische Gesellschaft 95th Annual Meeting September 1997 [cited 29 May 2001]. http:/www.dog.org/engl/abstract97/P564.html.
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