Valsalva Retinopathy After Yoga in a Patient With No Clear Predisposing Condition.

Purpose: To present a case of Valsalva retinopathy occurring after yoga in a patient without a clear predisposing condition. Methods: A retrospective chart review was performed. Results: A 36-year-old woman presented with a 2-day history of a "blob," hazy vision, and floaters in her left eye. She was performing a backbend during yoga but denied being in a headstand position. The visual acuity (VA) was 20/20-2 OS. Ophthalmoscopy showed a retinal hemorrhage inferior to the optic disc in the left eye, which was confirmed on imaging. One month later, ophthalmoscopy and imaging showed almost complete resolution of the hemorrhage with a VA of 20/20+2 OS. Conclusions: This case of Valsalva retinopathy did not involve a predisposing condition, headstand positioning, or breathing exercises. Therefore, when clinicians encounter young, healthy patients with Valsalva retinopathy, they should consider exposures to activities such as yoga as potential risk factors.

Intravitreal Anti-vascular Endothelial Growth Factor (Anti-VEGF) Therapy for Valsalva Related Sub-internal Limiting Membrane (Sub-ILM) Macular Haemorrhage: A Case Report.

Valsalva retinopathy is an uncommon type of retinopathy that manifests as a rapid and painless vision decline, typically observed in young individuals without prior medical conditions. This condition arises from an elevated pressure within the veins of the eye, causing preretinal haemorrhage with a notable tendency to impact the macula. We describe here a case of valsalva-related sub-internal limiting membrane (sub-ILM) macular haemorrhage which was successfully treated with anti-vascular endothelial growth factor (anti-VEGF). A 27-year-old woman presented with a clinical presentation of a large sub-ILM macular haemorrhage resulting from a valsalva maneuver following a prolonged severe cough. The sub-ILM macular haemorrhage was completely resolved after being treated with three injections of intravitreal ranibizumab with a visual recovery of vision from counting fingers to 20/20 on three month follow-up.

Valsalva Retinopathy Associated With COVID-19: Diagnosis and Surgical Management.

Purpose: To report a case of severe Valsalva retinopathy secondary to intense coughing and vomiting as symptoms of COVID-19 and describe the presentation, diagnosis, and surgical management. Methods: The patient's subjective findings, examination, fundus photography, optical coherence tomography (OCT) examinations, and laboratory results were used to diagnose the patient. Results: Surgical management was required to remove a vitreous hemorrhage (VH) and a sub-internal limiting membrane (sub-ILM) hemorrhage. Another foveal hemorrhage was determined to be intraretinal with intraoperative OCT. The patient's visual acuity improved from hand motions to 20/20 OD at postoperative week 6. Conclusions: The related COVID-19 symptoms of severe coughing and vomiting led to the Valsalva retinopathy. The VH and sub-ILM hemorrhage were successfully removed surgically. On intraoperative OCT, a foveal hemorrhage was determined to be intraretinal; thus, the decision was made to monitor it and allow it to resolve over time.

Vitreous hemorrhage - Causes, diagnosis, and management.

Vitreous hemorrhage is associated with a myriad of conditions such as proliferative diabetic retinopathy, proliferative retinopathy following vascular occlusion and vasculitis, trauma, retinal breaks, and posterior vitreous detachment without retinal break. Multiple pathological mechanisms are associated with development of vitreous hemorrhage such as disruption of abnormal vessels, normal vessels, and extension of blood from an adjacent source. The diagnosis of vitreous hemorrhage requires a thorough history taking and clinical examination including investigations such as ultra-sonography, which help decide the appropriate time for intervention. The prognosis of vitreous hemorrhage depends on the underlying cause. Treatment options include observation, laser photo-coagulation, cryotherapy, intravitreal injections of anti-vascular endothelial growth factor, and surgery. Pars plana vitrectomy remains the cornerstone of management. Complications of vitreous hemorrhage include glaucoma (ghost cell glaucoma, hemosiderotic glaucoma), proliferative vitreoretinopathy, and hemosiderosis bulbi.

When the Party Goes Wrong: A Case Report of Recurrent Valsalva Retinopathy Treated With Pars Plana Vitrectomy.

Valsalva retinopathy is a preretinal hemorrhage caused by a sudden increase in intrathoracic or intra-abdominal pressure, which generally happens after sudden and intense physical effort. This case report describes a case of Valsalva preretinal hemorrhage first treated with laser membranotomy, which subsequently recurred and was retreated with a pars plana vitrectomy. An 18-year-old male was admitted due to complaints of decreased visual acuity in his right eye for three days. He had been practicing strength training in the gymnasium before the complaints started but denied trauma or other precipitating factors. Fundoscopy revealed a central preretinal hemorrhage, and he underwent laser membranotomy, which successfully released the blood from the sub-hyaloid space into the vitreous cavity. However, the following night, he went to a nightclub party and then returned with the same initial symptoms of decreased visual acuity in his right eye. Fundoscopy revealed a relapse of the hemorrhage, which was now too central for membranotomy. He was proposed for a pars plana vitrectomy, with an aspiration of the blood, which was found to be under the inner limiting membrane. The patient achieved complete functional recovery after two weeks, with visual acuities of 20/20 on his right eye. Valsalva retinopathy may be treated with a conservative non-interventional approach, but laser membranotomy and surgery may be beneficial in selected cases, promoting faster visual rehabilitation and avoiding potential long-term toxicity effects of the prolonged presence of preretinal blood. Compliance with the postoperative rest period is essential after a laser membranotomy is performed, and failure to do it may result in the recurrence of the hemorrhage.

Postcoital visual loss due to valsalva retinopathy: A case report.

Valsalva retinopathy is a rare pathology presenting as a sudden and painless loss of vision affecting young subjects with no medical history. It is the result of an increase of intraocular venous pressure, leading to retrohyaloid haemorrhage. We describe here the clinical presentation of a retrohyaloid hemorrhage resulting from a valsalva mechanism following a sexual activity, in a 28-year-old patient treated by Neodymium:yttrium-aluminum-garnet (Nd:YAG) laser hyaloidotomy with a visual recovery of 20/20 on 3 weeks follow-up. Valsalva retinopathy is a rare and an easy-to-diagnose pathology that is safely handled by Nd:YAG laser hyaloidotomy for a quick visual acuity recovery.

Role of Neodymium Double Frequency Laser Posterior Hyaloidotomy in Delayed Presentation of Sub-hyaloid Haemorrhage.

Laser hyaloidotomy with Nd: YAG or green argon laser is a non-invasive, out-patient procedure in which the posterior hyaloid face is punctured and the opening enables the drainage of sub-hyaloid haemorrhage into the vitreous. The blood is absorbed gradually and vision is improved within days with gradual clearance of the macular area. Researchers recommend laser treatment in recent haemorrhages (<2 weeks) while for delayed cases invasive surgeries are advised. We report a case of delayed presentation of sub-hyaloid haemorrhage (>3 weeks) treated successfully with laser hyaloidotomy.

Achoo - God bless you!

BACKGROUND: : "Achoo" is the sound that is correlated with sneezing. A sneeze, in rare occasions, it can cause Valsalva retinopathy. Usually, small bleeding gets absorbed with time. But if the haemorrhage stays for a longer period of time, it can lead to de-hemoglobinization of blood which can cause damage to the photoreceptors. If such a damage occurs over the macula, it can cause irreversible visual loss. Hence, prompt and meticulous treatment is indicated in such cases. One such case is described here where a lady suffered from a sudden bout of sneezing and presented to us after a month later. A large sub-internal limiting membrane (ILM) bleed was noted over the macula. Hence a vitrectomy with ILM peeling with drainage of blood was advised. She recovered 20/40 visual acuity one month following surgery. PURPOSE: This video emphasizes on diagnosis of sub-ILM hemorrhage and the technique in which the sub-ILM bleed can be drained in the modern era of microincision vitreoretinal surgeries. SYNPOSIS: A key aspect in such cases is to distinguish sub-ILM from sub-hyaloid bleed. Subtle differentiating points on imaging are described in the video. In cases of sub-ILM hemorrhage, the most important surgical step after performing a core vitrectomy is a good posterior vitreous detachment (PVD) induction. After that, ILM peeling is carried out with the help of finesse loop and ILM peeling forceps. Using proportional vacuum and aspiration alternatively from the cutter, the hemorrhage is displaced and drained. This step can prevent damage to the underlying retinal tissue. After the macula hemorrhage is completely cleared, an air-fluid exchange is done. HIGHLIGHTS: Teaching points include: 1. Diagnostic markers for sub-ILM hemorrhage; 2.The method of PVD induction in cases of Sub ILM hemorrhage; and 3.Technique of drainage of sub-ILM hemorrhage using proportional vacuum and aspiration function of the cutter. VIDEO LINK: https://youtu.be/hBhfLDy9o-Y.

Valsalva Retinopathy after a Vomiting Episode.

This case presents a minimal invasive alternative for the treatment of subhyaloid hemorrhages. Young, female, 32 years old, with no regular medication and with no personal or ophthalmological history, reports a sudden and profound decrease in visual acuity after an episode of vomiting, with 2 days of evolution. After funduscopic observation and complementary diagnostic tests, subhyaloid hemorrhage was detected and laser hyaloidotomy was performed, with restoration of visual acuity after 1 week. Nd:YAG laser treatment made it possible to quickly restore the visual acuity of the patient after following diagnostic procedures, avoiding other types of treatments, such as pars plana vitrectomy. This case reports a Valsalva retinopathy with clinical presentation in the form of subhyaloid hemorrhage after an episode of self-limited vomiting, effectively treated with Nd: YAG laser.

Sub-internal limiting membrane hemorrhage as an unusual presentation of polypoidal choroidal vasculopathy.

We report the two cases who presented with sudden decreased vision and sub-internal limiting membrane (ILM) hemorrhage without a history of Valsalva maneuver, trauma, or hematological disorders. Multimodal imaging revealed the features suggestive of polypoidal choroidal vasculopathy (PCV) in addition to the sub-ILM hemorrhage. A provisional diagnosis of sub-ILM hemorrhage secondary to PCV was made and was treated with intravitreal Bevacizumab injection. Treatment resulted in the improved visual acuity along with the resolution of the sub-ILM hemorrhage. These cases highlight the possibility of isolated sub-ILM hemorrhage as a presenting fundus finding in PCV, which is previously unreported. This report also highlights the importance of multimodal imaging in diagnosing chorioretinal disorders with unusual presentation.

A Unique Case of Valsalva Retinopathy: Preretinal Hemorrhage Identified on Bedside Ultrasound.

BACKGROUND: Emergency physicians frequently evaluate patients with vision changes. The differential for this chief symptom is broad. We present a unique cause of a fixed scotoma that started while the patient was running sprints. CASE REPORT: The patient described a bright central scotoma that later became a dark oblique line across her central vision. This painless defect moved predictably with eye movements. Ocular ultrasonography was performed and revealed a well-demarcated hyperechoic lesion in the posterior segment of the right eye. There was no similar lesion found in her left eye. In consultation with ophthalmology, the patient's history and examination were consistent with valsalva retinopathy. To our knowledge, this is only the second published case of valsalva retinopathy/premacular hemorrhage identified on ocular ultrasonography in emergency medicine literature. In this article, we further expand on management and provide correlating fundoscopic images. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Emergency physicians frequently evaluate patients with visual changes. Valsalva retinopathy is a rare cause of a visual scotoma that can be diagnosed through history and ultrasound. It often resolves over weeks to months without intervention. However, it does require urgent ophthalmologic evaluation to rule out peripheral retinal tears, which may require laser retinopexy or surgical management.

[Combined retinal vascular occlusion after overexertion in sport at a young age : An unusual case as interdisciplinary challenge]. / Kombinierter Netzhautgefäßverschluss nach sportlicher Überanstrengung im jungen Alter : Ein ungewöhnlicher Fall als interdisziplinäre Herausforderung.

This case report presents a unilateral visual impairment after overexertion in sport at a young age. A combined central retinal vein occlusion with a cilioretinal arterial branch occlusion was diagnosed. This clinical picture has been described in case series and does not usually have an embolic etiology. In the cardiovascular clarification a patent foramen ovale was found, which was surgically closed.

Valsalva retinopathy: Long-term results and management strategies.

PURPOSE: To investigate the long-term results and efficacy of the treatment modalities for preretinal hemorrhage due to valsalva retinopathy. METHODS: Retrospective review was conducted on 24 eyes of 24 patients with valsalva retinopathy who were treated between 2004 and 2019. These patients were treated with Nd:YAG laser, argon laser and vitrectomy or were only observed. Nd:YAG laser hyaloidotomy was performed in 10 eyes, argon laser was applied to two of those following failed Nd:YAG laser, and vitrectomy was performed in one eye. A conservative approach was adopted in 13 eyes. RESULTS: There were 15 females and nine males with mean age of 41.08 ± 12.72 (21-65) years. Mean follow-up period was 42.83 ± 23.78 (range: 12-116) months. Patients with hemorrhage size smaller than or equal to 4-disc diameter were observed for spontaneous resorption and achieved 20/20 visual acuity within 6 months. Visual acuity of all patients treated with Nd:YAG and/or argon laser, increased within the first week after the treatment. Vitrectomy was performed in only one patient with hemorrhage located away from macula. The good visual outcomes were achieved in all treatment modalities. CONCLUSIONS: Observation, Nd:YAG laser and argon laser seem to be safe and effective approaches for eyes with valsalva retinopathy. The size, volume and duration of hemorrhage are the most crucial factors for treatment choice, success and complications.

Mode of Delivery in the Setting of Repeated Vitreous Hemorrhages in Proliferative Diabetic Retinopathy: A Case Report and Review of the Literature.

The state of pregnancy affects all organ systems including the eyes. Progression of diabetic retinopathy (DR) is a known association. In proliferative DR, there is an increased risk of vitreous hemorrhage (VH) during spontaneous vaginal delivery (SVD) due to the Valsalva maneuver. A 30-year-old female with poorly controlled type I diabetes and hypothyroidism on treatment was following up with the antenatal services at our hospital. This was her second pregnancy having had a previous miscarriage. Three months into her pregnancy, our Ophthalmology service was consulted to assess her and give our advice regarding the safest mode of delivery for her. Questioning revealed that she was following regularly elsewhere for proliferate DR with previous interventions and history of multiple and repeated VHs. When she was seen in our Ophthalmology clinic, she was anxious about the mode of delivery that was best suited for her with regard to her ocular condition. On examination, her visual acuity (VA) without correction was 20/40 in both eyes, improving to 20/20 in the right eye and 20/30 in the left eye after refraction. Her intra-ocular pressure was normal. A dilated fundus examination (DFE) showed changes of high-risk proliferative DR in both eyes and a VH in the right eye. Subsequent follow-up did not reveal any new complaints or concerns. She required one session of pan-retinal photocoagulation (PRP) in her first-trimester visit. DFE showed improvement in VH when compared to her initial examination. After discussing her condition with her obstetrician, it was decided to offer the patient a cesarean section (C/S) delivery, as her risk of developing VH during SVD was greater than normal. At 38 weeks of gestation, she delivered a healthy boy following an uneventful elective C/S. There were no visual complaints throughout her admission for the procedure or thereafter. During the reproductive age, DR is a leading cause of decreased vision. Pregnancy is an independent risk factor for progression of DR, with the stage of DR prior to conception being another. If not managed well, proliferative DR can result in VH, with the risk also existing in relation to SVD due to recurrent Valsalva maneuvers during labor. Our patient who initially presented with proliferative DR in both eyes and a VH in the right eye received one session of PRP to both eyes in the first trimester and was closely followed up throughout her pregnancy thereafter. When her due date neared, it was decided that the safest and most suitable mode of delivery was an elective C/S due to her increased risk of VH related to Valsalva maneuvers during SVD, especially since this was to be her first delivery.

Valsalva retinopathy induced by handstand: a case report.

BACKGROUND: Valsalva retinopathy is known to occur as a sudden preretinal or sub-internal limiting membrane hemorrhage induced by a rapid rise in venous pressure following increased intrathoracic or intraabdominal pressure. Here we report a case of Valsalva retinopathy that was probably induced by straining that occurred due to following a handstand. CASE PRESENTATION: A 15-year-old boy became aware of decreased visual acuity in his left eye immediately after doing a handstand for approximately 10 s during physical education class, and subsequently visited a local clinic on the same day. Upon examination, a vitreous hemorrhage (VH) in the posterior pole of the fundus was found in his left eye, and he was subsequently referred to our department 7 days later. Upon examination, the VH around the optic nerve head of the left eye appeared to be resolved, and an oval-shaped sub-internal limiting membrane (sub-ILM) hemorrhage was found in the superonasal side of the optic nerve head. No abnormalities were observed in the macular area. Four months later, the sub-ILM hemorrhage was found to have spontaneously resolved. Subsequent fluorescein angiography examinations revealed no abnormal findings at the lesion site. CONCLUSIONS: In this patient, we hypothesize that the Valsalva retinopathy was induced by straining that occurred due to a handstand, and that the resultant sub-ILM hemorrhage progressed to VH.

Atypical Valsalva retinopathy from habitual ear popping.

PURPOSE: To report a unique case of Valsalva retinopathy associated with ear popping behavior. OBSERVATIONS: A 57-year-old woman with a history of well-controlled hypertension presented with episodes of seeing "spots" in her left eye for many years. Her most recent episode failed to resolve spontaneously. Fundus examination revealed scattered retinal hemorrhages in the left eye, and optical coherence tomography demonstrated sub-internal limiting membrane location of these hemorrhages. Fluorescein angiography did not reveal any vascular abnormalities. Based on these findings and an in-depth review of systems, a diagnosis of Valsalva retinopathy was made associated with patient's ear popping habit. CONCLUSIONS AND IMPORTANCE: Habitual ear popping can be a potential etiology of symptomatic Valsalva retinopathy. This under-appreciated association may be clinically relevant for patients with a history of suspected Eustachian tube narrowing or dysfunction.

Demographic profile, clinical features, and outcome of peripapillary subretinal hemorrhage: an observational study.

BACKGROUND: To evaluate the etiology, demographic profile, clinical features, and outcomes in patients with peripapillary subretinal hemorrhage (PSH). METHODS: Thirty-eight eyes of 37 consecutive patients with PSH were enrolled in this prospective observational study over 4 years; all were followed for 2 years. The main outcome measures were demographic profile, possible etiology, clinical features, outcome, and prognosis. RESULTS: Sixty-eight percent (26/38) of eyes were in female patients; the mean patient age was 20 years. Only 1 patient (1/37) showed bilateral involvement. All patients experienced acute onset of PSH. All eyes were myopic and their best-corrected visual acuities ranged from 20/1000 to 20/12.5. The fundus features of affected eyes were classified into 3 groups: (1) PSH alone (4/38 eyes, 10.5%); (2) PSH with intrapapillary hemorrhage (17/38 eyes, 44.7%); (3) PSH with intrapapillary and vitreous hemorrhage (17/38 eyes, 44.7%). PSH occurred in nasal edges of optic discs with a crescent shape and dull-red color. All affected optic discs were small and crowded, exhibiting variable degrees of tilting. The cup of affected optic discs was narrower and deeper than that of normal control discs. Other ancillary tests provided no additional value. After a mean follow-up of 2.85 months, the hemorrhages resolved spontaneously without sequelae. Recurrence of disease was not observed in any patients. CONCLUSIONS: PSH is common in myopic eyes with tilted optic discs. We suspect that these hemorrhages occurred as a result of abrupt movement acting on a morphologically vulnerable optic disc.

Dissociated optic nerve fiber layer in a case of Terson syndrome.

PURPOSE: To report a case of Terson syndrome who developed dissociated optic nerve fiber layer appearance after pars plana vitrectomy. CASE REPORT: The author reports a young male patient with Terson syndrome who developed bilateral vitreous hemorrhage and sub-internal limiting membrane hemorrhage after road traffic accident. He underwent pars plana vitrectomy and removal of the already detached internal limiting membrane and the sub-internal limiting membrane hemorrhage in both eyes. In both eyes, dissociated optic nerve fiber layer was appreciated and left eye had a peculiar resemblance to the appearance of cystoid macular edema. CONCLUSIONS: Dissociated optic nerve fiber layer appearance may be noted following vitrectomy and removal of detached internal limiting membrane in patients with vitreous hemorrhage and sub-internal limiting membrane bleed due to Terson syndrome.

Histopathological Changes and Clinical Outcomes following Intervention for Sub-Internal Limiting Membrane Haemorrhage.

INTRODUCTION: Haemorrhage confined to the sub-internal limiting membrane (ILM) space can be associated with good visual recovery. There is controversy as to the best management of purely sub-ILM haemorrhage, which ranges from observation to immediate surgical intervention. METHODS: We studied a retrospective case series of patients with sub-ILM haemorrhage who underwent vitrectomy with subsequent histological analysis of the removed ILM. RESULTS: Sixteen patients underwent vitrectomy for sub-ILM haemorrhage. Five patients had underlying Terson syndrome, 6 had ruptured macro-aneurysms, and 5 had Valsalva retinopathy. Seven patients demonstrated cellular proliferation on the retinal surface of the ILM with staining for glial fibrillary acidic protein and cytokeratin 7, as well as CD68pg and Prussian blue. All but 1 of these cases were isolated from patients undergoing surgery >4 weeks following initial symptoms, the other presented at >2 weeks. Serial optical coherence tomography (OCT) was available in 8 patients; serial OCT in patients with delayed intervention demonstrated persistent inner retinal layer hyper-reflectance. Fourteen of 15 patients demonstrated symptomatic recovery and showed visual improvement with acuity ranging from -0.1 to 1.8 (mean 0.43) within 3 months of intervention (1 was lost to follow-up). The post-operative vision was 0.11 logMAR (mean; range -0.1 to 0.4) at 3 months in the group with intervention within 2 weeks of symptoms, and 0.9 logMAR (mean; range 0.0 to HM) in the group with delayed surgery. CONCLUSIONS: Early surgical intervention for sub-ILM haemorrhage resulted in good visual outcomes; delayed surgery may lead to proliferative vitreoretinopathy-like changes on the inner retinal surface of the ILM, and untreated cases may demonstrate persistent inner retinal changes potentially limiting visual prognosis despite subsequent surgical intervention.