From the Ophthalmology Department, Vitreo-Retinal Services, Queen Elizabeth II Hospital, Welwyn Garden City, Hertfordshire, United Kingdom.
The authors have no financial or proprietary interest in the materials presented herein.
The authors thank Simon Watman, RMIP, BIPP, Ophthalmic Photography Department, Queen Elizabeth Hospital, for his contribution in taking the fundus photographs and OCT scans demonstrated in this article.
Address correspondence to Malhar Soni, DO, MS, DNB, FRCS, Ophthalmology Department, Queen Elizabeth II Hospital, Howlands, Welwyn Garden City, Hertfordshire, AL7 4HQ, UK.
Valsalva retinopathy is a hemorrhagic retinopathy, which is often premacular in location. A sudden rise in intra-thoracic or intra-abdominal pressure, predisposed to by certain conditions such as pregnancy, causes an increase in intraocular venous pressure and subsequent retinal capillary rupture.1 The blood is subhyaloid or found under the inner limiting membrane.2–5
Recently Nd:YAG,6 argon, and krypton laser hyaloidotomy have all been used in treating large (> 3 disc diameters) macular subhyaloid hemorrhages of less than 3 weeks’ duration. Hyaloid puncture away from the fovea and inferiorly allows dispersion of blood into the inferior vitreous (with gravity), rapidly clearing the visual axis. This simple, non-invasive procedure is a safe alternative to conservative management or vitrectomy.
Our case report demonstrates lesion features we believe made laser hyaloidotomy successful, even after 3 weeks from onset. Serial optical coherence tomography (OCT) visualized pre-treatment and post-treatment structural features including treatment site.
A 35-year-old woman at 24 weeks’ gestation presented with a 3-day history of sudden, painless central visual loss in her right eye. Visual acuity was counting fingers in the right eye and 6/4 in the left eye. Examination of the right eye revealed a healthy disc appearance and a large premacular subhyaloid hemorrhage measuring 5 disc diameters in size (Fig. 1A). Blood pressure measurement and blood tests were performed to exclude vascular etiologies for the lesion, including full blood count, fasting glucose, coagulation screen, inflammatory markers, and autoimmune screen, all of which yielded normal results.
Figure 1. Fundus Photographs Showing the Right Eye Premacular Subhyaloid Hemorrhage Immediately After Nd:YAG Laser Hyaloidotomy (A) and Complete Resolution of the Hemorrhage 1 Week After Treatment (B).
The patient was reviewed in casualty at 1 week and had her first vitreoretinal clinic appointment more than 3 weeks after presentation. At this visit, the patient’s lesion had not reduced in size, but a fluid level was present. This suggested that the hemorrhage was still fluid in nature and would respond to laser treatment.
Using the Q-switched Nd:YAG laser and the area centralis high magnification laser lens, one shot of laser (4.7 mJ) was applied to the posterior hyaloid membrane, aiming at the inferior hemorrhagic border and away from the fovea, allowing the subhyaloid hemorrhage to resolve completely (Fig. 1B). Spectral-domain OCT (SD-OCT) imaging using the 3D OCT-1000 (Topcon Inc., Paramus, NJ) recorded the lesion at the time of treatment, and at 2 minutes, 1 week (Fig. 2A), and 11 weeks (Fig. 2B) after treatment.
Figure 2. The B-Scan Spectral-Domain Optical Coherence Tomography Image (A), Taken at 1 Week After Treatment. This Shows Discontinuity of the Posterior Hyaloid Membrane Next to the White Line, Suggestive of the Laser Hyaloidotomy Site (with Red Blood Cells Seen Anterior to It). (B) Healing of the Laser Site at 11 Weeks After Treatment. The Pin-Point Registration Technology Helps to Confirm the Exact Location on Sequential Spectral-Domain Optical Coherence Tomography Scans.
Visual acuity improved from counting fingers pre-treatment to 6/24 at 2 minutes, 6/6 at 1 week, and 6/4 at 11 weeks after treatment. Figure 2 shows that despite dispersion of blood from the subhyaloid cavity, the cavity walls remained unchanged at 2 minutes, 1 week, and 11 weeks after treatment. Figure 2 also demonstrates SD-OCT images with the laser site visible (white arrow, Fig. 2A) 1 week after treatment and its disappearance (white arrow, Fig. 2B) by 11 weeks. At 1 week, a 6 × 6 mm macular cube scan allowed detailed examination demonstrating discontinuity in the posterior hyaloid face associated with the B-scan OCT image defect. Using this detailed evaluation and pin-point registration technology, there was no discontinuity at 11 weeks, suggesting hyaloidotomy site healing.
Valsalva retinopathy can cause either subhyaloid hemorrhage or hemorrhagic detachment of the inner limiting membrane2–5 resulting in sudden vision loss. Three main treatment modalities exist for Valsalva retinopathy. These include observation, laser hyaloidotomy (Nd:YAG laser/argon laser/krypton laser), and vitrectomy. Observation, with obviously the least risk of iatrogenic complication, appears to have a risk of visual complications as a result of epiretinal membrane formation7 and macular pigmentary changes. Resolution of hemorrhage and improvement of vision can take months to achieve.
Laser, such as Nd:YAG laser, does lead to a rapid resolution of clinical features, improvement of vision, and potentially reduced visual complications. However, it should be noted that there have not been any studies comparing the effects of observation and laser hyaloidotomy and studies exist showing that, despite treatment with YAG hyaloidotomy, complications such as epiretinal membrane formation may still occur.8 Another study showed that no functional abnormalities persisted after conservative management (observation) of premacular hemorrhages.9 Although a straight-forward procedure with low reported risks, it should be noted that caution should be exercised to direct the laser treatment to the lower border of the hemorrhage and well away from the fovea. Care must be taken to focus on the hyaloid anterior to the hemorrhage so that macular burn does not occur, which carries a risk of iatrogenic scotoma or loss of vision secondary to foveal burn. Vitrectomy is possible, but the risks should be considered before undertaking such a procedure.
Our case confirms the rapidity of resolution of visual function after the procedure of Nd:YAG laser hyaloidotomy in a case of pregnancy-induced Valsalva retinopathy. In addition, imaging of the procedure by SD-OCT can demonstrate great detail in terms of the structural features of the lesion at the time of laser and subsequent to the treatment.
Using SD-OCT, we were able to visually demonstrate the site of puncture of the hyaloid membrane, the flow of blood from the subhyaloid cavity into the vitreous, and the position of the posterior hyaloid face. The SD-OCT documentation of the presence of a persistent premacular cavity after laser treatment has rarely been described in case reports of Valsalva retinopathy with sub-inner limiting membrane hemorrhage2,3,10 and has not previously been reported with SD-OCT in treated subhyaloid Valsalva retinopathy. In one case, subsequent resolution of the cavity was documented.4 Tatlipinar et al.2 suggested that the posterior vitreous may provide a scaffold for retinal glial cells to proliferate and form the pre-retinal cavity membrane.
SD-OCT was able to demonstrate the site of the laser treatment and was still seen at 1 week after treatment; however, this defect in the posterior hyaloid face had disappeared and presumably healed by 11 weeks after treatment. This was evaluated by using the pin-point registration technology, detailed examination of the 6 × 6 mm macular cube scan, and careful examination of all relevant images on the OCT scan. We acknowledge that pin-point registration technology alone is not 100% reliable in exact subsequent localization.
To our knowledge, this visualization of the treatment site by SD-OCT and its subsequent closure has not previously been published in the literature. It has been suggested that laser should be performed within 3 weeks following onset of the maculopathy.11 Our patient underwent treatment after 3 weeks of onset of the Valsalva retinopathy. At this time, the hemorrhage was still fluid as demonstrated by the red color, the blood level, and the D-shape of the subhyaloid hemorrhage. We suggest that a visible fluid level in subhyaloid hemorrhage is an important sign and indication for successful Nd:YAG laser posterior hyaloidotomy. We also suggest that interesting features about the structural changes that occur as a result of the lesion and the site of treatment can be elucidated in detail by SD-OCT. The structural changes that remain despite resolution of vision and clinical appearance require further study of a large number of cases. What is also interesting is that the laser point was visible 1 week after the treatment, but appeared to have healed at the clinic visit at 11 weeks. In fact, there is currently little knowledge about the nature of vitreoretinal interface, and using SD-OCT to evaluate pathologies such as subhyaloid hemorrhage may help us to elucidate and understand the structure of this critical ocular interface to a greater extent.
- Deane JS, Ziakas N. Valsalva retinopathy in pregnancy. Eye. 1997;11:137–138.
- Tatlipinar S, Shah SM, Nguyen QD. Optical coherence tomography features of sub-internal limiting membrane haemorrhage and preretinal membrane in valsalva retinopathy. Can J Ophthalmol. 2007;42:129–130.
- Shukla D, Naresh KB, Kim R. Optical coherence tomography findings in valsalva retinopathy. Am J Ophthalmol. 2005;140:134–136. doi:10.1016/j.ajo.2004.12.026 [CrossRef]
- Pérez-Rico C, Montes-Mollón A, Castro-Rebollo M, Pareja-Esteban J, Benítez-Herreros J. Optical coherence tomography features of sub-internal limiting membrane hemorrhage and temporary premacular cavity following Nd-YAG laser membranotomy in valsalva retinopathy. Jpn J Ophthalmol. 2008;52:513–515. doi:10.1007/s10384-008-0592-0 [CrossRef]
- Errera MH, Barale PO, Danan-Husson A, et al. Optical coherence tomography: a reliable tool for localisation of macular hemorrhage: two case reports [article in French]. J Fr Ophtalmol. 2008;31:e20.
- Puthalath S, Chirayath A, Shermila MV, et al. Frequency-doubled Nd:YAG laser treatment for premacular hemorrhage. Ophthalmic Surg Lasers Imaging. 2003;34:284–290.
- García-Arumí J, Corcostegui B, Tallada N, Salvador F. Epiretinal membranes in Terson’s syndrome: a clinicopathologic study. Retina. 1994;14:351–355. doi:10.1097/00006982-199414040-00011 [CrossRef]
- Kwok AK, Lai TY, Chan NR. Epiretinal membrane formation with internal limiting membrane wrinkling after Nd:YAG laser membranotomy in valsalva retinopathy. Am J Ophthalmol. 2003;136:763–766. doi:10.1016/S0002-9394(03)00442-2 [CrossRef]
- Maár N, Tittl M, Ergun E, Stur M. Results of fundus perimetry after resorbed premacular hemorrhages under the internal limiting membrane in 10 patients [article in German]. Monbl Augenheilkd. 2000;217:269–273. doi:10.1055/s-2000-10366 [CrossRef]
- Meyer CH, Mennel S, Rodrigues EB, Schmidt JC. Persistent premacular cavity after membranotomy in valsalva retinopathy evident by optical coherence tomography. Retina. 2006;26:116–118. doi:10.1097/00006982-200601000-00024 [CrossRef]
- Duszak RS. Retinopathy, valsalva: treatment & medication. emedicine Web site. http://emedicine.medscape.com/article/1228106-treatment. Updated November 1, 2006. Accessed September 9, 2009.