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 sex, 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.
H35.00 – Unspecified background retinopathy
232031001 – Valsalva retinopathy
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