Sudden visual loss in asthma.

A woman of 23 attended the accident and emergency department after feeling unwell and acutely short of breath for one day. She used salmeterol, beclomethasone and salbutamol inhalers for asthma; otherwise there was no medical history of note. On examination she was tachypnoeic, tachycardic and unable to complete full sentences. Temperature was normal. There were widespread wheezes in the chest. When she was breathing 7 L/min oxygen, pO2 was 16.92 kPa and pCO2 7.59 kPa. An acute exacerbation of asthma was diagnosed and she was started on treatment with nebulized salbutamol and ipratropium together with intravenous steroids. After thirty minutes the chest symptoms were much improved and she was able to complete full sentences; on 4 L/min oxygen arterial blood pO2 was 11.04 kPa and pCO2 5.13 kPa. However, she complained of loss of central vision in her right eye since admission. On ophthalmic examination, visual acuities were of hand movement on the right and 6/6 on the left, and fundoscopy revealed a large, wellcircumscribed premacular haemorrhage with a fluid level in the right eye (Figure 1). Valsalva haemorrhagic retinopathy was diagnosed. Laboratory investigations including sickle screen, coagulation screen, full blood count, erythrocyte sedimentation rate and blood glucose all gave normal results. Her vision improved over the next few weeks to 6/6 in each eye as the premacular haemorrhage resolved spontaneously.