Valsalva retinopathy (VR) is a disease in which a sudden increase in intrathoracic or intra-abdominal pressure causes elevated intraocular venous pressure, rupturing superficial capillaries in the macula. This results in preretinal (mainly under the internal limiting membrane) hemorrhage and sudden vision loss.
It was first reported in 1972 by Duane as “hemorrhagic retinopathy of Valsalva.” It can occur in healthy eyes, and the hemorrhage is typically absorbed naturally over time.
It is most common in young to middle-aged adults, usually unilateral, and bilateral cases are rare. 6)
It can occur in healthy young to middle-aged individuals without specific diseases. Any activity that rapidly increases intrathoracic or intra-abdominal pressure, such as weightlifting, coughing, vomiting, or childbirth, can be a trigger. In conditions with abnormal retinal vessels, such as diabetic retinopathy or hypertensive retinopathy, hemorrhage may occur with even lower pressure increases.
The impact on vision varies depending on the location, size, and extent of the hemorrhage, ranging from minor scotomas to hand motion vision. 6)
Findings vary depending on the site of blood accumulation. The most common is subinternal limiting membrane hemorrhage, but hemorrhage can also occur in the subhyaloid (posterior hyaloid) space, within the retina, or into the vitreous cavity. Rarely, subretinal hemorrhage may occur. 4)
Subinternal Limiting Membrane Hemorrhage
Shape: A well-demarcated round or dumbbell-shaped red elevation.
Fluid level: In the sitting position, blood settles, and the upper part of the hemorrhage appears transparent.
Vascular obscuration: Retinal vessels are completely invisible within the hemorrhage area (because it lies anterior to the retinal nerve fiber layer).
Color change: Over days, dehemoglobinization progresses, changing to a yellowish-white color. 7)
Subhyaloid hemorrhage
Boat-shaped appearance: Blood settles inferiorly, with a clear superior portion, forming a “boat shape.” 8)
Double ring sign: The outer edge of subhyaloid hemorrhage (outer ring) and the edge of sub-ILM hemorrhage (inner ring) are observed simultaneously.
Breakthrough hemorrhage: When the internal limiting membrane ruptures, blood flows into the vitreous cavity, resulting in vitreous hemorrhage. 1)
On OCT, hemorrhage directly beneath the internal limiting membrane is visible as a hyperreflective band. OCT is essential for three-dimensional layer-specific diagnosis (sub-ILM, subhyaloid, subretinal). 6)
Woszczek et al. (2025) reported a case of spontaneous recovery in a 29-year-old man. Initial OCT (Optovue AngioVue) showed sub-internal limiting membrane hemorrhage measuring 524×246 μm. With observation alone, it completely resolved after 35 days, and visual acuity improved from 0.4 to 1.0. 6)
Rajshri et al. (2021) reported a case of a 41-year-old man who presented 6 weeks after weightlifting. It was observed as a semicircular yellowish-white lesion, which was due to dehemoglobinized blood. OCT showed layered sedimentation of blood components. 7)
The color changes to yellowish-white as red blood cells undergo dehemoglobinization. This indicates that the hemorrhage is old, and in this state, drainage with Nd:YAG laser becomes difficult. 7)8)
The following actions or situations corresponding to the Valsalva maneuver act as triggers.
Usually occurs in healthy eyes, but the risk is higher if there are retinal vascular abnormalities such as diabetic retinopathy, hypertensive retinopathy, retinal telangiectasia, or congenital retinal arterial tortuosity.
Yes. Parvus et al. (2023) reported a case of Valsalva retinopathy in a healthy 36-year-old woman without predisposing factors during a yoga backbend posture. Even without headstands or breathing exercises, the backbend can compress the abdominal and thoracic cavities, leading to onset. 2)
Diagnosis is primarily based on medical history and fundus examination. A history of sudden painless vision loss after Valsalva maneuver is the most important clue.
It is important to differentiate from diseases that cause preretinal hemorrhage.
| Disease | Key Points for Differentiation |
|---|---|
| Diabetic Retinopathy | Accompanied by other diabetic fundus findings (dot hemorrhages, hard exudates) |
| Hypertensive retinopathy | Arteriosclerotic findings, history of systemic hypertension |
| Retinal arteriolar microaneurysm rupture | White plaque in retinal arteriole around hemorrhage |
| Terson syndrome | History of subarachnoid hemorrhage or intracranial hemorrhage |
| Sickle cell retinopathy | Confirmed by blood test |
If differentiation is difficult, use OCT to check for retinal pigment epithelium elevation. If there is no pigment epithelium elevation, age-related macular degeneration is unlikely.
Treatment strategy depends on the size, location, and patient’s condition of the hemorrhage.
| Hemorrhage status | Recommended treatment |
|---|---|
| Small (within 1 disc diameter) | Observation |
| Moderate (covering the macula) | Observation or Nd:YAG laser |
| Large or rapidly enlarging | Nd:YAG laser or vitrectomy |
| Breakthrough into the vitreous cavity | Vitrectomy |
| Subretinal hemorrhage (submacular) | Vitrectomy + subretinal tPA |
In many cases, first-line treatment. Spontaneous absorption occurs within weeks to months. 6)7)
If the hemorrhage is within 1 disc diameter, spontaneous recovery can be expected. Avoidance of strenuous physical activity is advised. 6)
This is an outpatient procedure in which the posterior vitreous membrane or internal limiting membrane is perforated with an Nd:YAG laser to drain the hemorrhage into the vitreous cavity and promote absorption. 3)8)
Indications for treatment:
Procedure (Hernández-Emanuelli et al. 2024): 3) Under mydriasis (1% tropicamide) and topical anesthesia, using a Goldmann three-mirror contact lens, a single 1.8 mJ pulse is applied to the most elevated area of the hemorrhage (avoiding the fovea and retinal vessels) to perforate the posterior hyaloid membrane.
Nd:YAG laser procedure (Leite et al. 2022): 8) Starting with a spot size of 50 μm and pulse width of 100 ms, power is gradually increased from 300 mW in 50 mW increments. Successful posterior hyaloid perforation was achieved at a final power of 500 mW, and vision recovered to 20/20 after one week.
Leite et al. (2022) reported a case of subhyaloid hemorrhage in a 32-year-old woman that occurred after vomiting, treated with Nd:YAG laser hyaloidotomy, with visual recovery to 85 ETDRS letters (20/20) after one week. 8)
Note: Drainage becomes difficult once the hemorrhage turns yellowish-white (dehemoglobinization). The procedure is typically indicated within 3–4 weeks of symptom onset, although successful cases have been reported even after 45 days. 8)
This is performed when observation or Nd:YAG laser does not improve the condition, or when breakthrough vitreous hemorrhage occurs. 1)
Standard procedure:
Han et al. (2023) performed standard 25G vitrectomy for a 45-year-old woman with COVID-19-related Valsalva retinopathy. Using intraoperative OCT, they confirmed that the foveal hemorrhage was intraretinal and avoided manipulation of this area, thereby protecting the fovea. Best corrected visual acuity (BCVA) improved from hand motion to 20/20 at 6 weeks postoperatively. 1)
Although a rare subtype, early intervention after detection is crucial for visual prognosis. Subretinal hemorrhage is toxic to photoreceptors (fibrin, iron, hemosiderin), so early treatment before clot formation is desirable. 4)
Conci et al. (2024) performed vitrectomy, subretinal tPA injection (25 μg/0.1 mL using a 38G subretinal infusion needle), and air tamponade for a 35-year-old male with subretinal hemorrhage-type Valsalva retinopathy that developed after vomiting. The patient maintained a 45° reading position for 2 days postoperatively. Best corrected visual acuity of 20/30 was achieved at 1 month. 4)
Sotani et al. (2024) first attempted intravitreal tPA (GRTPA 40,000 IU) + SF6 gas injection for bilateral subretinal hemorrhage-type (48-year-old female, onset during CT breath-holding). Due to insufficient effect, 27G vitrectomy was performed, creating a fistula in the internal limiting membrane inferior to the fovea (4–5 o’clock direction) and draining the hematoma into the vitreous cavity with balanced salt solution jet. The hemorrhage was removed while preserving 100% of the foveal internal limiting membrane, and best corrected visual acuity improved to 1.2 at 6 months. 5)
It depends on the size and location of the hemorrhage. For small sub-internal limiting membrane hemorrhages within 1 disc diameter, natural recovery is expected, so observation is the basic approach. 6) On the other hand, if the hemorrhage is large and covers the entire macula, or if breakthrough into the vitreous cavity occurs, early Nd:YAG laser or vitreous surgery should be considered. If subretinal hemorrhage is suspected, early intervention is important due to toxicity to photoreceptors. 4)
When the Valsalva maneuver, which involves a sudden increase in intrathoracic or intra-abdominal pressure with the glottis closed, is performed, the following physiological changes occur in sequence.
Mechanisms of damage due to prolonged contact with blood:
Han & Adrean (2023) reported that using intraoperative OCT during vitrectomy allowed intraoperative determination that a foveal hemorrhage, which appeared indistinguishable from subvitreal or sub-internal limiting membrane hemorrhage, was actually intraretinal. Since attempting to peel and remove the internal limiting membrane risks damaging the fovea, intraoperative OCT-based layer diagnosis was shown to be useful for determining treatment strategy. 1)
Sotani et al. (Kobe University, 2024) reported a “fovea-sparing internal limiting membrane surgery” as an alternative to conventional complete internal limiting membrane peeling. By creating a fissure in the internal limiting membrane around the fovea to drain sub-ILM hemorrhage into the vitreous cavity, the hemorrhage can be removed while preserving 100% of the foveal internal limiting membrane. This method is attracting attention as an excellent approach for preventing macular holes (FTMH). 5)
Multiple reports indicate that severe coughing and vomiting caused by SARS-CoV-2 infection can trigger Valsalva retinopathy. Han & Adrean (2023) detailed a severe case in a 45-year-old woman who tested positive for COVID-19. This condition should be recognized as an emerging risk factor after the pandemic. 1)
Parvus et al. (2023) reported the first case of Valsalva retinopathy occurring without traditional triggers (such as headstands or breath-holding). They suggest that backbend postures may compress the abdominal and thoracic cavities, potentially triggering the condition, though establishing causality is challenging. It should be kept in mind that even young, healthy individuals may experience ophthalmic complications during yoga. 2)
