Valsalva Retinopathy - Causes, Symptoms, Diagnosis, and Treatment

What Is Valsalva Retinopathy?

Thomas Duane used this term in 1972. He referred to Valsalva retinopathy as the bleeding in the eyes that may be secondary to increased intrathoracic pressure. This may be caused due to any activity that increases the intra- thoracic pressure, such as lifting heavy weights, coughing, or vomiting. It is similar to the Valsalva maneuver. The Valsalva maneuver involves putting pressure against the closed glottis by the Valsalva tendons. The classical case of Valsalva retinopathy is when the thin blood vessels of the eye break as a reaction to the increased intrathoracic pressure. A sudden rise in the intra-abdominal or intrathoracic pressure causes the intravenous pressure to increase, causing the small blood vessels of the eye to rupture. This condition is mostly resolved on its own, giving a good prognosis to this condition. However, the course of the treatment should be decided based on the location of the bleeding.

How Common Is Valsalva Retinopathy?

This condition occurs very rarely. Even when it occurs, its severity varies. This condition has no age, sex, or racial predilection and can occur in anyone.

What Are the Symptoms of Valsalva Retinopathy?

Before the symptoms, the patient may be asked for the history of any physical exertion that could have possibly caused this condition. Some of the symptoms of Valsalva retinopathy include:

1. Loss of Vision: Due to the bleeding within the eye, the person may experience a loss of vision. It may be in one or both of the eyes. The degree of vision loss depends on the amount of bleeding within the eye. If the bleeding is less, then the loss of vision may be only partial.

2. Floaters: The person may see floaters in the vision. This may be transient or may be present throughout.

3. Reddish Hue in the Eyes: Due to bleeding within the eyes, there may be a reddish hue on the eyes. This may vary according to the bleeding in the eyes.

4. Cloudy Vision: The vision may be cloudy due to the rupturing of the eyes' blood vessels.

What Are the Causes of Valsalva Retinopathy?

• Any cause of increased pressure in the abdomen or thorax can lead to valsalva retinopathy, more so in individuals who already have underlying systemic diseases like Diabetes, Hypertension, or who are on anticoagulants or have bleeding disorders.

Other causes of valsalva retinopathy include:

• Bouts of cough or sneezing.

• Playing musical instruments that involve blowing wind.

• Constipation.

• Trauma such as RTA (road traffic accidents).

• Lifting heavt weight.

• Vigorous sexual activity.

• Vigorous rollercoaster rides.

What Are the Complications of Valsalva Retinopathy?

Although Valsalva retinopathy resolves on its own, it may still give rise to some complications. Some of the complications of Valsalva retinopathy include:

1. Loss of vision that may be temporary or permanent. Permanent vision loss may be caused due to detachment of the retina from its underlying tissues.

2. Bleeding inside and underneath the retina, destruction of the cellular structure of the retina.

3. Slightly decreased visual acuity may be caused due to either incomplete blood resorption or slight retinal pigment epithelium changes in or across the macula.

4. There could be damage to the retina. When there is bleeding within the eyes, the retina stays in contact with blood pigments such as hemoglobin and iron for a long time. This could possibly cause permanent damage to the retina due to various chemical changes. This damage can also lead to permanent blindness.

5. There could be a detachment of the choroidal tissues in both eyes.

However, the extent of damage to the eyes largely depends on the amount and place of bleeding within the eyes.

How to Diagnose Valsalva Retinopathy?

Valsalva retinopathy diagnosis depends on patient history, lab diagnosis, and imaging. A conclusion should be made depending on all of these factors. The various steps in the diagnosis of Valsalva retinopathy include:

1. Laboratory Studies: Laboratory studies can be used to rule out the chances of predisposing blood conditions. Some of these conditions may be associated with spontaneous ruptures of vessels, such as sickle cell anemia, diabetes, thrombocytopenic purpura, and other bleeding and clotting disorders. The various tests that can be done to rule out these are:

• Complete blood count (estimates red and white blood cell levels).

• Blood glucose levels (estimates the blood glucose levels before and after food).

• Prothrombin levels (helps to assess if the patient has clotting issues).

• Activated partial prothrombin time.

• Tests to rule out sickle cell anemia (sickle cell anemia may cause ischemia).

• Routine urine analysis (helps to analyze the proteins and salts in the urine).

2. Imaging Studies: Various imaging studies can be used to diagnose Valsalva retinopathy. These imaging studies help to localize the clot and check its resolution. The various imaging studies include:

• A Series of retinal pictures can be used to check the resolution of retinal clots and bleeding.

• Retinal angiography may be done to check for any ischemia of blood vessels that may be associated with Valsalva retinopathy. It may also be useful in localizing the vessels that ruptured, leading to internal hemorrhage.

• If a complete or partial vision loss may have occurred after Valsalva retinopathy, B-scan ultrasonography can be performed. This aids in the diagnosis of any possible retinal detachment. This retinal tear or detachment could have caused bleeding in the vitreous medium, which could have led to a loss of vision.

• An optical coherence tomography (OCT) can be performed to accurately locate the region of bleeding.

3. Other Assessments: The blood pressure has to be definitely monitored. Increased hypertension could lead to rupture of intraocular blood vessels as it could directly lead to increased intraocular pressure.

How to Treat Valsalva Retinopathy?

Valsalva retinopathy may demand a combination of various methods for its treatment. This may include:

1. Conservative Approach: A conservative approach to Valsalva retinopathy will be to wait and watch. If the bleeding has not caused any loss of vision or does not affect any major structure, the doctor may suggest letting the hemorrhage resolve on its own. However, necessary imaging studies will be done, and the resolution of the clot will be monitored periodically. The patient may be put on certain medications for a quick recovery. Various dos and don'ts may be advised to the patients.

2. Surgical Approach: While the conservative approach is the most preferred approach, surgery may be preferred in some cases where there may be any hindrance to the vision. Lasers may be used to dissolve the clot.

How Can Valsalva Retinopathy Be Prevented?

Valsalva retinopathy cannot be prevented directly. Since its occurrence is directly related to lifting heavy objects, certain precautions can be taken to prevent this. One should consciously avoid holding his breath while performing activities like lifting heavy objects, sneezing, or coughing to prevent Valsalva retinopathy. While performing activities like weight lifting, periodic exhalations should be performed.

Conclusion:

Valsalva retinopathy is a condition that may occur to anybody at any point in time. If someone is at greater risk of getting this condition, such as a person who lifts heavy weights or a patient with a bleeding disorder, it is necessary to take adequate precautions. Although this condition resolves on its own, it is necessary to get medical attention at the earliest.