Valsalva retinopathy in pregnancy: a case report

Introduction: Valsalva retinopathy is a unilateral or bilateral condition that occurs when increased intra-thoracic or intra-abdominal pressure transmitted to the eye causes a sharp rise in the intraocular venous pressure, and rupture of superficial retinal capillaries. The patient often gives a history of a recent strenuous physical act, which could have increased the intra-thoracic pressure. Pregnancy is known to be a risk factor for Valsalva retinopathy. Case presentation: A 23-year-old woman in her seventh month of pregnancy presented with a history of decreased vision in her left eye of one-week duration. Examination of the affected eye showed best corrected visual acuity of 20/50, and fundus examination revealed a pre-retinal hemorrhage located in the macula. Based on clinical findings, the diagnosis of Valsalva retinopathy was made. Conclusion: Retinal hemorrhages can be generated by Valsalva maneuvers. Pregnancy is a known risk factor for Valsalva retinopathy; however, the diagnosis should be made only after excluding other causes of retinal hemorrhages. It is a self-limited event. We report a case of Valsalva retinopathy complicating normal pregnancy and confirm that, to date, there is no evidence to indicate that there is a risk of recurrence following spontaneous vaginal delivery. Introduction Valsalva retinopathy is a unilateral or bilateral condition that occurs when increased intra-thoracic or intra-abdominal pressure transmitted to the eye causes a sharp rise in the intra-ocular venous pressure, and rupture of superficial retinal capillaries [1]. The patient often gives a history of a recent strenuous physical act, which could have increased the intra-thoracic pressure. Pregnancy is known to be a risk factor for Valsalva retinopathy [2]. We hereby report a case of Valsalva retinopathy in a woman in her seventh month of pregnancy. Case presentation A 23-year-old woman in her seventh month of pregnancy presented with a history of decreased vision in her left eye of one week duration. Her previous medical history was unremarkable but for constipation. She was not on medications. Ophthalmic examination showed best corrected visual acuity of 20/20 in the right eye (OD) and 20/50 in the left eye (OS). The anterior segment was unremarkable and intra-ocular pressure was 10 mm Hg in both eyes. Fundus examination was normal OD, and revealed a preretinal hemorrhage located in the macula OS (Figure 1). Since the patient was pregnant, fluorescein angiography was not performed. Blood pressure, full blood count, Published: 7 April 2008 Journal of Medical Case Reports 2008, 2:101 doi:10.1186/1752-1947-2-101 Received: 4 November 2007 Accepted: 7 April 2008 This article is available from: http://www.jmedicalcasereports.com/content/2/1/101 © 2008 Al-Mujaini and Montana; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Page 1 of 3 (page number not for citation purposes) Journal of Medical Case Reports 2008, 2:101 http://www.jmedicalcasereports.com/content/2/1/101 coagulation profile, fasting blood sugar and sickle cell tests were within normal limits. Additional tests for a hypercoagulable state and autoimmune diseases were negative. A clinical diagnosis of Valsalva retinopathy was made and it was decided to observe the patient. Follow-up one month later revealed improvement in the best corrected visual acuity to 20/20 OS, with complete resolution of the macular hemorrhage (Figure 2). The patient had a spontaneous vaginal delivery, was seen immediately after the delivery, with no recurrence of the retinal hemorrhage. Discussion Pregnancy exerts multiple hormonal, metabolic, hematological and immunological alterations in the mother that represent risk factors for Valsalva retinopathy. Elevation of intra-abdominal pressure during pregnancy, with a further increase during labor, leads to a considerable elevation in intravenous pressure, which increases the potential for retinal hemorrhages following a Valsalva maneuver. Hematological changes during pregnancy such as thrombocytopenia add to the risk of Valsalva retinopathy in pregnancy. It is important to rule out all systemic diseases that may result in retinal hemorrhages, such as diabetes, hypertension, sickle cell disease, anemia, coagulopathy, blood dyscrasias and previous ocular vein occlusions. Whether vaginal delivery poses a risk of recurrence or exacerbation of the hemorrhage is unclear [2]. A review of the literature showed no recurrence of retinopathy following spontaneous vaginal delivery [2,3]. Valsalva maneuvers typically result in sub-internal limiting membrane hemorrhages with a predilection for the macula, but sub-retinal, retinal or intravitreal hemorrhages can occur. The prognosis in general is good and the condition in most patients resolves spontaneously over several months. Some patients may have a poor visual outcome, which has been attributed to retinal pigmentary changes at the macula [3]. In most cases, conservative management is indicated with periodic observation. A YAG laser has been employed in selective cases to disperse the pre-retinal hemorrhages and speed up resolution [4]. Conclusion Retinal hemorrhages can be generated by Valsalva maneuvers. Pregnancy is a known risk factor for Valsalva retinopathy; however, the diagnosis should be made only after excluding other causes of retinal hemorrhages. It is a selflimited event. We have reported a case of Valsalva retinopathy complicating normal pregnancy and confirm that, to date, there is no evidence to indicate that there is a risk of recurrence following spontaneous vaginal delivery. Competing interests The author(s) declare that they have no competing interests. Authors' contributions All authors participated in the design of the manuscript. AM was involved in drafting the manuscript for important intellectual content. All authors read and approved the final manuscript. Consent Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal. Fundus photograph of the left eye a month later igure 2 Fundus photograph of the left eye a month later. Fundus photograph of the left eye at presentation igure 1 Fundus photograph of the left eye at presentation. Page 2 of 3 (page number not for citation purposes) Journal of Medical Case Reports 2008, 2:101 http://www.jmedicalcasereports.com/content/2/1/101 Publish with BioMed Central and every scientist can read your work free of charge "BioMed Central will be the most significant development for disseminating the results of biomedical research in our lifetime." Sir Paul Nurse, Cancer Research UK Your research papers will be: available free of charge to the entire biomedical community peer reviewed and published immediately upon acceptance cited in PubMed and archived on PubMed Central yours — you keep the copyright Submit your manuscript here:http://www.biomedcentral.com/info/publishing_adv.aspBioMedcentralReferences1. Chapman-Davies A, Lazarevic A: Valsalva maculopathy. Clin ExpOptom 2002, 85:42-45.2. Deane JS, Ziakas N: Valsalva retinopathy in pregnancy. Eye1997, 11:137.3. Wickremasinghe SS, Tranos PG, Davey C: Valsalva hemorrhagicretinopathy in a pregnant woman: implications for delivery.Acta Ophthalmol Scand 2003, 81:420-422.4. Bourne RA, Talks SJ, Richards AB: Treatment of preretinal Val-salva hemorrhages with neodymium: YAG laser. Eye 1999,13:791-793. Page 3 of 3(page number not for citation purposes)