Valsalva Retinopathy in Pregnancy: A Case Report from the Emergency Department

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Rapid increases in intraocular pressure can result in sudden-onset vision loss in a self-limiting condition known as Valsalva Retinopathy. Pregnancy is a known risk factor. A pregnant woman presents to the Emergency Department with complaints of unilateral central vision loss after an episode of vomiting. Fundus exam of the left eye identified haemorrhages consistent with Valsalva Retinopathy. Superficial retinal capillaries can hemorrhage as a result of Valsalva maneuvers. Natural pregnancy changes with other stressors like vomiting can leave a woman at higher risk for Valsalva retinopathy. Valsalva Retinopathy patients can be discharged with close follow-up.

Нe Valsalva maneuver is a forceful expiration against a closed glottis that causes increased intra-thoracic or intra-abdominal pressures It is associated with events such as coughing, sneezing, vomiting, strain with stooling, weightliіing and pushing during delivery. Нese pressures can be transmitted through the valveless orbital vessels, rapidly increasing intraocular pressure and causing rupture of superficial retinal capillaries. Нe haemorrhage that ensues can cause sudden-onset vision loss in a self-limiting, and welldescribed condition known as Valsalva Retinopathy (VR). Pregnancy, due to common physiologic mechanisms, is a known risk factor for VR. We present a case of VR in a young woman in her 36th week of pregnancy.

A 19-year old woman in her 36th week of pregnancy presented to the Emergency Department from an outside hospital with complaints of unilateral central vision loss. Нe night before presentation, she had an episode of vomiting that was immediately followed by painless vision loss in the leі eye. Нe central vision loss remained constant throughout the following day. Нe patient was otherwise healthy and she denied any other vision changes. She denied wearing glasses or contact lenses, using steroids, history of trauma, autoimmune conditions, bleeding diatheses, vascular disease, or diabetes. Нe patient had not experienced similar episodes prior to this one. Нe patient had hyperemesis gravidarum earlier in her pregnancy. Her past medical history was only remarkable for post-concussion syndrome, goitre, smoking one half pack of cigarettes per day and a remote childhood history of strabismus that self-corrected.

On exam in the ED, the patient’s blood pressure was transiently elevated to 151/87 and then decreased to 134/64 four and half hours later. Her pulse was first documented at 98 and aіer 4.5 hours, she was tachycardic to 102 bpm. Her vitals were otherwise unremarkable. Нe patient noted that in her leі eye, central vision was lost but her peripheral vision was intact. Нere was neither visible foreign body nor fluorescein uptake.

Ophthalmology was consulted, and their exam demonstrated 20/20 visual acuity in her right eye and around the central scotoma in her leі eye. Tonometry was 13 mmHg on the right and 14 mmHg on the leі Pupillary exam, eye movement, and slit lamp evaluations were unremarkable. Fundus exam of the leі eye identified a superonasal and inferonasal haemorrhages around a pink disc with sharp borders and a healthy rim, 7-10 intra-retinal haemorrhages without exudate or thickening in the macula, a few intra-retinal and sub-retinal haemorrhages outside of the macula in the posterior pole. VR is a clinical diagnosis based on the patient’s features and history, VR was confirmed‑ labs were not necessary at this point. Conservative management (i.e. watch-and-wait, versus laser therapy) was recommended with follow-up in 2 weeks. Нe patient was counseled that this condition usually resolves without further intervention in 1-3 months, but she was also encouraged to return if symptoms changed or worsened.

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