This 29YO pregnant female presented with sudden vision loss in her left eye immediately following a bout of severe vomiting. Vision was 20/20 in her normal OD and counting fingers OS.
Optos color RG imaging shows a large sub-internal limiting membrane (ILM) hemorrhage extending throughout the macula. Blood immediately drained into the subhyaloid and vitreous spaces following the YAG laser. One week later, the macular blood completely resolved. The margins of the prior elevated ILM are still visible, and some far inferior vitreous blood is noted. Vision was 20/20.
Learning Points:
Valsalva retinopathy is characterized by usually unilateral retinal and preretinal blood caused by rupture of the superficial retinal capillaries from suddenly raised intrathoracic or intra-abdominal pressure. Various causes include coughing, heavy lifting, and vomiting. These hemorrhages virtually always resolve without sequelae, although the preretinal blood in severe cases can be drained into the inferior vitreous by creating a small ILM opening using either a thermal or Nd:YAG laser (Durukan et al, Eye 2008;22:214-218).
The site chosen for laser delivery is ideally at the inferior margin of thick blood, well away from the fovea to avoid underlying retinal damage. For the Nd:YAG, the laser energy should begin at 4 mJ and be gradually titrated upward until an opening is created that allows the blood to drain inferiorly into the vitreous.
