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• W2024887557 abstract "Sir, Valsalva retinopathy is caused by a sudden increase in intrathoracic or abdominal pressure against a closed glottis (Valsalva manoeuvre). The rapid rise in venous pressure may lead to the rupture of normal and abnormal superficial retinal capillaries, resulting in haemorrhagic detachment of the internal limiting membrane and, possibly, vitreous haemorrhage (Callender et al. 1995). Visual loss can be profound if haemorrhage occurs in the premacular region. Most cases of Valsalva retinopathy resolve spontaneously over several months, with vision returning to pre-haemorrhage levels. When Valsalva haemorrhage occurs during pregnancy, there may be difficulty in determining the optimal method for delivery in order to prevent progression and recurrence. We report a 38-year-old Afro-Caribbean woman, who presented to the Eye Services Department 35 weeks into her third pregnancy. Her previous pregnancies had been uneventful and the current pregnancy had been without incident until presentation. After a violent bout of vomiting, the subject noticed that vision had deteriorated in her left eye, without accompanying photopsia or visual field loss. She had no significant medical or ocular history and, in particular, no history of coagulation defects, sickle cell disease or diabetes. Examination revealed best corrected visual acuity (VA) of 6/5 in the right eye and 6/24 in the left eye. Her anterior segments were normal in appearance. The left eye had evidence of subhyaloid haemorrhage superior to the disc (Fig. 1), accompanied by vitreous haemorrhage inferiorly and nasally (not visible), with no evidence of a retinal tear or vascular anomaly. There was no sign of neovascularization of the disc or elsewhere. Systemic examination revealed a blood pressure of 123/70. A diagnosis of Valsalva retinopathy was made, with the mild vitreous haemorrhage accounting for the decrease in VA. Fundus photograph of the left eye, showing a dense round retinal haemorrhage (upper arrow), a boat-shaped subhyaloid haemorrhage (middle arrow) close to the optic disc and a few nerve fibre layer haemorrhages nasal to the disc (lower arrow). Management consisted of rest and avoidance of non-steroidal anti-inflammatory medications. The remainder of the pregnancy passed without further incident and 4 weeks later the subject spontaneously delivered a healthy 3.39 kg male after 2 hours, 19 mins of labour. Four months after delivery, the patient's VA had improved to 6/9 and the preretinal haemorrhage had largely resolved (Fig. 2). Fundus photograph of the same eye 4 months after spontaneous delivery, showing substantial resolution of the haemorrhages. Some residual preretinal haemorrhages are still present (arrow). The Valsalva haemorrhage in this case most likely occurred as a result of the violent bout of vomiting experienced by the patient. The sudden associated elevation of intra-abdominal pressure probably led to a systemic increase in venous pressure and subsequent transmission to and rupture of the superficial retinal capillaries within the left eye. Although the haemorrhage was extra-macular, VA was reduced as a result of the accompanying vitreous haemorrhage. Breaches within the internal limiting membrane account for the spread of the blood from the retina to the vitreous cavity. Although most cases of Valsalva retinopathy resolve spontaneously within a few months, recovery may be complicated by pigmentary changes at the macula, which preclude VA returning to normal. (Deane & Ziakas 1997). Labour is associated with a significant elevation in venous pressure secondary to increased intra-abdominal pressure against a closed glottis. There is debate as to whether spontaneous vaginal delivery is liable to exacerbate the haemorrhage. Potential interventions include elective caesarean section under epidural/general anaesthesia to prevent progression by limiting such Valsalva increases in venous pressure. In this case, as in other cases where spontaneous vaginal delivery was chosen, without epidural or other intervention (Duane 1972; Deane & Ziakas 1997), no recurrence of the haemorrhage was noted on examination post partum. Anaesthesia is required for delivery by elective caesarean section. Several cases of retinal haemorrhage have been described in association with both general and epidural anaesthesia (Bolder & Norton 1984; Ling et al. 1993). General anaesthesia may cause hypoxia and hypercarbia, both of which cause vasodilatation and an increase in retinal venous pressure. Moreover, extubation may lead to significant rises in venous pressure secondary to coughing (Chidley et al. 1998). Epidural anaesthesia has also been associated with retinal haemorrhage, possibly as a result of increases in the cerebrospinal fluid pressure (secondary to volume effects within the epidural space) leading to elevated retinal venous pressure and subsequent haemorrhage (Chidley et al. 1998). As Valsalva haemorrhage is self-limiting and is usually associated with spontaneous recovery of vision (albeit after several months), the available evidence suggests that additional obstetric or anaesthetic intervention in cases of Valsalva haemorrhage during pregnancy is unnecessary to prevent recurrence and occasionally may be harmful. Additionally, in the unlikely event of progression to the macular region after normal delivery, neodymium-YAG laser photodisruption of the internal limiting membrane overlying the subhyaloid haemorrhage may be performed to allow dispersal of the blood into the vitreous cavity and consequently improve acuity (Ladjimi et al. 2002). Ultimately, patients should be counselled about the possible risks of each method of delivery and their wishes should be carefully considered when making a final decision." @default.
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• W2024887557 date "2003-07-11" @default.
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• W2024887557 title "Valsalva haemorrhagic retinopathy in a pregnant woman: implications for delivery" @default.
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