Double ring sign at the macula in a patient with Valsalva retinopathy.

A 52-year-old woman with hypertension presented with a sudden, painless and profound loss of vision in the left eye while doing farm work. Visual acuity was 0.08 only in the affected eye. Ophthalmoscopic examination revealed a large dome-shaped subinternal limiting membrane (sub-ILM) haemorrhage and a subhyaloid haemorrhage located anterior to the sub-ILM haemorrhage. The latter also showed a niveau formation. This finding is known as a ‘double ring’ sign with the ‘inner ring’ caused by the sub-ILM bleed (Figure 1a, solid white arrows) and the ‘outer ring’ caused by the subhyaloid bleed (Figure 1a, solid yellow arrows). The above findings were confirmed by optical coherence tomography (OCT) examination. These rings may represent the demarcation line between the detached and the adherent ILM (Figure 1b, hollow white arrows) and the posterior hyaloid (Figure 1b, hollow yellow arrows), respectively. OCT also clearly showed shadowing due to concentrated blood cells. Therefore, the patient was diagnosed as having Valsalva retinopathy. The patient was followed without any treatment. Three months later, the haemorrhages showed almost complete resolution