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Valsalva hemorrhagic retinopathy during labour: a case report and literature review

      Valsalva retinopathy and vision loss can occur most commonly after heavy lifting, straining during stooling, coughing, and vomiting. The increase in intra-abdominal or intrathoracic pressure against a closed glottis and the ensuing sudden rise in venous pressure can rupture superficial retinal capillaries and lead to retinal hemorrhage. The bleeding may either be contained within the retina, or a breach in the internal limiting membrane may result in a vitreous hemorrhage. Valsalva retinopathy was first described by Duane in 1972.
      • Duane T.D.
      Valsalva Hemorrhagic Retinopathy.
      This article describes the case of Valsalva hemorrhagic retinopathy occurring without vision loss during spontaneous vaginal delivery.
      Our patient is a 36-year-old white female who presented a day after the spontaneous vaginal delivery of her second child. She noticed a black spot in the visual field of her left eye immediately after labour. She denied any other visual complaints. She was otherwise healthy with no significant ocular history and no history of sickle cell disease, diabetes, or bleeding disorders. Her first pregnancy and labour had been unremarkable, and the present pregnancy had also been uncomplicated until presentation.
      On examination, blood pressure was 107/59 and heart rate was 87. Uncorrected visual acuity at distance was 20/20 bilaterally. Intraocular pressures were within normal limits, and the remainder of the anterior segment examination was noncontributory. Dilated fundus examination of the left eye revealed a large subinternal limiting membrane bleed inferotemporal to the optic disc but sparing the fovea (Fig. 1). There was no evidence of vitreous hemorrhage. The opposite fundus was unremarkable.
      Figure thumbnail gr1
      Fig. 1Fundus photograph of the left eye showing a large retinal hemorrhage inferotemporal to the optic disc, partially within the inferior vascular arcades but sparing the fovea.
      A diagnosis of Valsalva retinopathy was made, and she was discharged home with conservative measures. At the 10-week follow up appointment, her vision remained 20/20, and the hemorrhage had resolved leaving some residual fluid and fibrosis (Fig. 2).
      Figure thumbnail gr2
      Fig. 2Fundus photograph of the left eye 10 weeks later showing full resolution of the hemorrhage but residual fluid and mild fibrosis.
      We found 9 reported cases of Valsalva retinopathy in pregnant females in the global scientific literature. Four cases occurred because of vomiting during the antenatal period,
      • Callender D.
      • Beirouty Z.A.Y.
      • Saba S.N.
      Valsalva haemorrhagic retinopathy in a pregnant woman.
      • Wikremasinghe S.S.
      • Tranos P.G.
      • Davey C.
      Valsalva haemorrhagic retinopathy in a pregnant woman: implications for delivery.
      • Al-Mujaini A.S.
      • Montana C.C.
      Valsalva retinopathy in pregnancy: a case report.
      • Ramskold L.A.H.
      Valsalva retinopathy secondary to hyperemesis gravidarum.
      and one occurred while stooling.
      • Chidley K.E.
      • Law R.
      • Vanner R.G.
      Caesarean section following a recent retinal haemorrhage.
      Two had a history of constipation,
      • Al-Mujaini A.S.
      • Montana C.C.
      Valsalva retinopathy in pregnancy: a case report.
      • Deane J.S.
      • Zaikas N.
      Letter to the Editor.
      and one had a history of heavy lifting.
      • Deane J.S.
      • Zaikas N.
      Letter to the Editor.
      One occurred during labour.
      • Ladjimi A.
      • Zaouali S.
      • Messaoud R.
      • Ben Yahia S.
      • Attia S.
      • Jenzri S.
      • Khairallah M.
      Valsalva retinopathy induced by labour.
      Initial visual acuities ranged from 20/80 to counting fingers, and final acuities ranged from 20/20 to 20/60. All patients except one subsequently underwent spontaneous vaginal delivery with no ophthalmic complications. One patient underwent an elective cesarean section to avoid a recurrence of the hemorrhage during the extreme Valsalva manoeuvres involved in vaginal labour.
      • Chidley K.E.
      • Law R.
      • Vanner R.G.
      Caesarean section following a recent retinal haemorrhage.
      Two authors reported treating their patients with Nd:YAG laser hyaloidotomy with successful resolution of the hemorrhage and return to 20/20 vision.
      • Ladjimi A.
      • Zaouali S.
      • Messaoud R.
      • Ben Yahia S.
      • Attia S.
      • Jenzri S.
      • Khairallah M.
      Valsalva retinopathy induced by labour.
      • Jayaprakasam A.
      • Matthew R.
      • Toma M.
      • Soni M.
      Valsalva retinopathy in pregnancy: SD-OCT features during and after Nd:YAG laser hyaloidotomy.
      All other patients were treated conservatively.
      There is some discussion in the literature about the role of elective cesarean section in pregnant women with Valsalva hemorrhagic retinopathy. Despite the theoretical risk for worsening the retinopathy during a vaginal delivery, to date there are no case reports to support this. Moreover, general and epidural anaesthetics have themselves been reported to cause retinal hemorrhage via a number of mechanisms.
      • Ling C.
      • Atkinson P.L.
      • Munton C.G.F.
      Bilateral retinal haemorrhages following epidural injection.
      • Bolder P.M.
      • Norton M.L.
      Retinal Hemorrhage following anaesthesia.
      • Victory R.A.
      • Hassett P.
      • Morrison G.
      Transient Blindness following epidural analgesia.
      First, injecting fluid into the epidural cavity can raise cerebrospinal fluid pressure. This, in turn, can raise intraocular venous pressure.
      • Ling C.
      • Atkinson P.L.
      • Munton C.G.F.
      Bilateral retinal haemorrhages following epidural injection.
      • Victory R.A.
      • Hassett P.
      • Morrison G.
      Transient Blindness following epidural analgesia.
      Second, hypoxia or hypercarbia can induce increases in intracranial pressure, as well as retinal vasodilation, leading to an increase in retinal venous pressure.
      • Chidley K.E.
      • Law R.
      • Vanner R.G.
      Caesarean section following a recent retinal haemorrhage.
      Third, the coughing and straining that may be associated with extubation can also cause an increase in retinal venous pressure.
      • Chidley K.E.
      • Law R.
      • Vanner R.G.
      Caesarean section following a recent retinal haemorrhage.
      We report the second case of Valsalva hemorrhagic retinopathy in the scientific literature in which symptoms began intrapartum, presumably as a result of the strain of vaginal labour. Moreover, our case is unique in that there was no decrease in visual acuity at initial presentation. It is possible that patients whose retinopathy does not affect visual acuity may not report their symptoms at all. In addition, because of the significant demands of caring for a neonate, patients may also not notice their symptoms if it includes only a small scotoma. It is likely that instances of labour-induced Valsalva retinopathy are under-reported in the literature. Our case report shows that in patients with minimal symptoms, conservative observation is reasonable. Furthermore, the prognosis appears to be promising. These patients can expect an excellent recovery with full return to baseline vision within months.

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