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 Table of Contents  
CASE REPORT
Year : 2017  |  Volume : 8  |  Issue : 2  |  Page : 94-96

Valsalva retinopathy following an aborted attack of destructive self-harm by strangulation


Department of Ophthalmology, Government Medical College, Kozhikode, Kerala, India

Date of Web Publication7-Aug-2017

Correspondence Address:
Padma B Prabhu
Department of Ophthalmology, Government Medical College, Kozhikode - 673 008, Kerala
India
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/mjmsr.MJMSR_53_16

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  Abstract 

We describe a case of Valsalva retinopathy that occurred after near hanging. A 23-year-old female presented 5 days after destructive self-harm by attempted hanging, complaining of defective vision in the right eye which started immediately after she regained consciousness after resuscitation. The vision was counting fingers close to face. Fundus examination showed a large preretinal hemorrhage at the macular region. She failed to respond to conservative management and was successfully treated with neodymium-doped yttrium aluminum garnet hyaloidotomy. Hanging can cause Valsalva-like retinopathy.

Keywords: Near hanging, neodymium-doped yttrium aluminum garnet laser hyaloidotomy, premacular hemorrhage, strangulation, Valsalva retinopathy


How to cite this article:
Prabhu PB, Amitha NP, Reshma B, Unnikrishnan S. Valsalva retinopathy following an aborted attack of destructive self-harm by strangulation. Muller J Med Sci Res 2017;8:94-6

How to cite this URL:
Prabhu PB, Amitha NP, Reshma B, Unnikrishnan S. Valsalva retinopathy following an aborted attack of destructive self-harm by strangulation. Muller J Med Sci Res [serial online] 2017 [cited 2019 Oct 16];8:94-6. Available from: http://www.mjmsr.net/text.asp?2017/8/2/94/212414


  Introduction Top


Valsalva retinopathy was first described by Duane in 1972.[1] It occurs due to rupture of retinal capillaries following sudden increase in intrathoracic or intra-abdominal pressure.[2] It is usually associated with weight lifting, coughing, vomiting, vigorous sexual activity, and straining.[2],[3],[4],[5],[6] Hanging is a form of mechanical asphyxia resulting from constriction of neck by a ligature where the constricting force is the weight of the body. In India, hanging is the most common method of committing suicide. Conjunctival hemorrhage is commonly associated with hanging. Valsalva retinopathy has not been reported widely in relation to hanging.


  Case Report Top


A 23-year-old female who attempted suicide by hanging presented in the ophthalmology department after 5 days, complaining of defective vision in the right eye. It was noticed immediately after she regained consciousness posthanging, being rescued by her relatives. There was no history of pain in the eye, floaters, or flashes of light. There was a mark of aberration on the right submandibular area due to traction of the knot. On ocular examination of the right eye, anterior segment was within normal limits and best-corrected vision was counting fingers close to face. Fundus examination showed massive preretinal hemorrhage at and above the macular area [Figure 1]. The optic nerve head and the vessels were normal. The left eye was within normal limits [Figure 2]. B-scan showed preretinal hemorrhage in the macular region [Figure 3]. Optical coherence tomography (OCT) confirmed the presence of sub-internal limiting membrane (ILM) bleed. The patient was followed up for 3 weeks with restriction of strenuous activities, systemic aminocaproic acid, and topical nonsteroidal anti-inflammatory drugs. In view of incomplete resolution, neodymium-doped yttrium aluminum garnet (Nd-YAG) hyaloidotomy was performed (6 mJ 3 burns). The hemorrhage was drained. Vision improved to 6/12P immediately [Figure 4] and 6/6 after 1 week [Figure 5].
Figure 1: Fundus right eye

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Figure 2: Fundus left eye

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Figure 3: Ultrasonography showing premacular hemorrhage

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Figure 4: Fundus right eye showing drainage of preretinal blood after neodymium-doped yttrium aluminum garnet hyaloidotomy

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Figure 5: Fundus right eye after 1 week

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  Discussion Top


Valsalva hemorrhagic retinopathy describes retinal hemorrhages observed in association with weight lifting, coughing, vomiting, sexual activity, childbirth, vomiting, or straining.[1],[2],[3],[4],[5],[6] The patient complains of sudden loss of vision. Typical fundus findings include well-circumscribed, round or dumbbell-shaped red elevation beneath the ILM or intraretinal hemorrhage in or near fovea. Blood is initially red which later develops fluid level with settling of red blood cell and may turn yellow after several days.

The reason for Valsalva retinopathy after hanging is sudden elevation of venous pressure.[7],[8] Forceful exhalation against a closed glottis adds on to this insult. Sudden elevation of intrathoracic or intra-abdominal pressure is directly transmitted to the head and neck as a result of lack of valves in the venous system of head and neck. Increased venous pressure in the retinal vessels is reflected in the retinal capillary bed resulting in sub-ILM hemorrhages. These may occasionally break through and become subhyaloid or intravitreal.[8] With the advent of OCT, it has been found that sub-ILM hemorrhage is more common than subhyaloid hemorrhage.[9],[10]

Although the clinical picture is diagnostic, OCT, B-scan, and computed tomography orbit help in documentation of the disease and its progress. Mild cases can be managed conservatively with good outcome.[11] However, delay in spontaneous absorption of the preretinal blood can predispose to the formation of epiretinal membrane and toxic maculopathy.[12] In moderate to severe cases, laser hyaloidotomy may be considered with Nd-YAG laser. Nd-YAG laser treatment is suggested in a case of premacular subhyaloid hemorrhage of more than 3 disc diameter size and a duration of 3 weeks.[13],[14] An energy level of 1.9–11.5 mJ is used to create 2–3 openings for the blood to drain into vitreous cavity. The long-term complications of Nd-YAG laser membranotomy include macular hole, retinal detachment, epiretinal membrane formation, and a persistent premacular cavity.[15] The laser perforations and any elevations of the ILM usually seal and reattach within 2–6 months without any significant retinal changes. However, persistence has been reported.[16]

In individuals with coexistent intraretinal hemorrhage, focal retinal pigment epithelial proliferation can prevent complete visual recovery after reabsorption of the retinal hemorrhage. Vitrectomy is the treatment of choice in such cases. OCT helps delineate the level of hemorrhages.[17] Intravitreal bevacizumab has been reported to improve the resorption of vitreous bleed when coupled with YAG hyaloidotomy.[18]

Our case is unique in its rare presentation, unilaterality, occurrence on the side of knot suggesting differential compression of the jugular veins, and good response to laser hyaloidotomy.


  Conclusion Top


Near hanging can cause Valsalva retinopathy.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Duane TD. Valsalva hemorrhagic retinopathy. Trans Am Ophthalmol Soc 1972;70:298-313.  Back to cited text no. 1
[PUBMED]    
2.
Tara F, Sharifi M, Hoseini E. VR in pregnancy: A case report. Case Rep Ophthalmol 2015;6:88-92.  Back to cited text no. 2
    
3.
Uchida K, Takeyama M, Zako M. Valsalva-like retinopathy spontaneously occurred after ocular massage. BMC Ophthalmol 2014;14:98.  Back to cited text no. 3
    
4.
Xie ZG, Yu SQ, Chen X, Zhu J, Chen F. Macular hole secondary to Valsalva retinopathy after doing push-up exercise. Indian J Ophthalmol 2003;51:279.  Back to cited text no. 4
    
5.
Sen J, Palimar P. Seizure related Valsalva-like retinopathy. Arch Ophthalmol 1995;113:738-42.  Back to cited text no. 5
    
6.
Xie ZG, Yu SQ, Chen X, Zhu J, Chen F. Macular hole secondary to Valsalva retinopathy after doing push-up exercise. BMC Ophthalmol 2014;14:98.  Back to cited text no. 6
    
7.
Wang BS, Xiao L, Liu J, Dong N, Aung T. Dynamic changes in anterior segment morphology during the Valsalva maneuver assessed with ultrasound Biomicroscopy. Invest Ophthalmol Vis Sci 2012;53:7286-9.  Back to cited text no. 7
    
8.
Szelog JT, Lally DR, Heier JS. Natural history of Valsalva-induced subhyaloid hemorrhage. JAMA Ophthalmol 2015;133:e143268.  Back to cited text no. 8
    
9.
Shukla D, Naresh KB, Kim R. Optical coherence tomography findings in Valsalva retinopathy. Am J Ophthalmol 2005;140:134-6.  Back to cited text no. 9
    
10.
Sabella P, Bottoni F, Staurenghi G. Spectral-domain OCT evaluation of Nd: YAG laser treatment for Valsalva retinopathy. Graefes Arch Clin Exp Ophthalmol 2010;248:599-601.  Back to cited text no. 10
    
11.
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;136:763-6.  Back to cited text no. 11
    
12.
Ulbig MW, Mangouritsas G, Rothbacher HH, Hamilton AM, McHugh JD. Long-term results after drainage of premacular subhyaloid hemorrhage into the vitreous with a pulsed Nd: YAG laser. Arch Ophthalmol 1998;116:1465-9.  Back to cited text no. 12
    
13.
Puthalath S, Chirayath A, Shermila MV, Sunil MS, Ramakrishnan R. Frequency-doubled Nd: YAG laser treatment for premacular hemorrhage. Ophthalmic Surg Lasers Imaging 2003;34:284-90.  Back to cited text no. 13
    
14.
Kuruvilla O, Munie M, Shah M, Desai U, Miller JA, Ober MD. Nd: YAG membranotomy for preretinal hemorrhage secondary to Valsalva retinopathy. Saudi J Ophthalmol 2014;28:145-51.  Back to cited text no. 14
    
15.
Durukan AH, Kerimoglu H, Erdurman C, Demirel A, Karagul S. Long-term results of Nd: YAG laser treatment for premacular subhyaloid haemorrhage owing to Valsalva retinopathy. Eye (Lond) 2008;22:214-8.  Back to cited text no. 15
    
16.
Zou M, Gao S, Zhang J, Zhang M. Persistent unsealed internal limiting membrane after Nd: YAG laser treatment for Valsalva retinopathy. BMC Ophthalmol 2013;13:15.  Back to cited text no. 16
    
17.
Kim KY, Yu SY, Kim M, Kwak HW. Macular hole formation after pars plana vitrectomy for the treatment of Valsalva retinopathy: A case report. Korean J Ophthalmol 2014;28:91-5.  Back to cited text no. 17
    
18.
Hua R, Liu LM, Hu YD, Zhou Y, Chen L. Combine intravitreal bevacizumab with Nd: YAG laser hyaloidotomy for Valsalva pre-macular haemorrhage and observe the internal limiting membrane changes: A spectralis study. Int J Ophthalmol 2013;6:242-5.  Back to cited text no. 18
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]



 

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