Young Male with Vision Loss

A healthy 30-year-old man presented to the emergency department with blurred vision and floaters described as “cobwebs” in the left eye, occurring acutely while he lifted weights 4 days before. Visual acuity was normal in the right eye and 20/40 in the left eye. The remainder of the physical examination was unremarkable, aside from a lower visual field deficit in the left eye. Bedside ocular ultrasonography was performed (Figure 1). Given the vision loss, ophthalmology was consulted for further evaluation. Valsalva retinopathy. Bedside ocular ultrasonography revealed elevation of the retina and a thin, hypoechoic fluid collection temporal to the optic nerve, concerning for pre- versus intraretinal bleeding. Dilated funduscopic examination confirmed a superficial, intraretinal hemorrhage superotemporal to the optic nerve, as well as overlying vitreous hemorrhage. No retinal detachments were identified. In Valsalva retinopathy, the sudden increase in venous blood pressure from Valsalva maneuvers leads to an acute increase in intraocular venous pressure, resulting in hemorrhagic detachment of the internal retinal layers bordering the vitreous humor.1Duane T.D. Valsalva hemorrhagic retinopathy.Trans Am Ophthalmol Soc. 1972; 70: 298-313PubMed Google Scholar, 2Garcia Fernandez M. Navarro J.C. Castano C.G. Long-term evolution of Valsalva retinopathy: a case series.J Med Case Rep. 2012; 6: 346Crossref PubMed Scopus (36) Google Scholar, 3Simakurthy S. Tripathy K. Valsalva retinopathy.in: StatPearls. StatPearls Publishing, Treasure Island, FL2020Google Scholar The hallmark of this pathology is that the hemorrhage is intraretinal, distinct from vitreous hemorrhage and retinal detachment. Treatment aims to reduce straining (ie, stool softeners and avoidance of strenuous exercise) and avoiding anticoagulating medications.3Simakurthy S. Tripathy K. Valsalva retinopathy.in: StatPearls. StatPearls Publishing, Treasure Island, FL2020Google Scholar Most patients achieve complete return of vision when hemorrhage spontaneously clears, often within weeks to months; however, management may vary, depending on the location of the bleeding.3Simakurthy S. Tripathy K. Valsalva retinopathy.in: StatPearls. StatPearls Publishing, Treasure Island, FL2020Google Scholar4Chen Y.J. Kou H.K. Krypton laser membranotomy in the treatment of dense premacular hemorrhage.Can J Ophthalmol. 2004; 39: 761-766Abstract Full Text PDF PubMed Scopus (7) Google Scholar Funduscopic examination 1 week later demonstrated resolving hemorrhage (Figure 2). The patient followed up 2 months later and reported significant improvement in his vision.