Geç gebelik döneminde Valsalva manevrası nedeniyle oluşan atipik yerleşimli subhiyaloid hemorajide Nd:YAG lazer tedavisi: olgu sunumu

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Introduction
Valsalva retinopathy results from Valsalva maneuver and leads to sudden and painless visual loss. The
most common activities related with Valsalva maneuver include vomiting, heavy lifting, coughing and
compression injuries (1). Valsalva maneuver produces a sudden increase in abdominal or intrathoracic
pressure against a closed glottis. This leads to a rise
in intraocular venous pressure and spontaneous rupture of perifoveal capillaries, also known as Valsalva
maculopathy. The hemorrhage typically occurs at
the macula, and fundoscopy demonstrates well circumscribed, dome-shaped premacular hemorrhage
and vitreous hemorrhage. Nd:YAG laser treatment
is a non-invasive method, which enables the drainage of the subhyaloid hemorrhage into the vitreous
cavity. In this report, we present a case of atypically
located Valsalva retinopathy in pregnancy treated by
Nd:YAG laser hyaloidotomy.
Case Report
A 27-year-old pregnant woman presented with
complaints of sudden onset of temporal visual scotoma and floaters in her right eye. The symptoms occurred 6 days previously after intense vomiting. She
was in the 25th week of her pregnancy. Visual acuity in the right eye was 20/20. There was no history
of trauma or medication use. Systemic examination
was normal with a blood pressure of 130/75 mmHg.
Complete blood count, platelet count, bleeding and
clotting time were normal. Right eye fundoscopy revealed a large and well circumscribed dome-shaped
preretinal hemorrhage located in the nasal retina
close to the optic nerve head accompanied by a few
macular hemorrhages and mild vitreous hemorrhage inferonasally (Figure 1). The patient had no other
vascular alterations or retinal anomaly in her right
eye. Left fundus examination revealed no abnormality, and visual acuity was 20/20.
*Department of Ophthalmology, Gulhane Military Medical Faculty
Reprint request: Dr. F.Cüneyt Erdurman, Department of Ophthalmology,
Gulhane Military Medical Faculty, Etlik-06018, Ankara, Turkey
E-mail: erdurman@yahoo.com
Date submitted: July 13, 2010 • Date accepted: October 20, 201064 • March 2011 • Gulhane Med J Erdurman et al.
regress spontaneously from a few weeks to several
months with good visual outcomes (1). In our previous report, we have demonstrated that drainage of
premacular subhyaloid hemorrhage into the vitreous
using the Nd:YAG laser is a safe and efficient treatment (4). In this case, although the visual acuity was
20/20, the area of subhyaloid hemorrhage was large
and the patient was seriously complaining about the
visual scotoma in her temporal visual field. Because
of this reason we preferred to perform Nd:YAG laser
instead of a long observation period. After treatment,
the patient was satisfied with the fast recovery from
her temporal scotoma.
Optimal delivery management and anesthesia method are also controversial in patients with antenatal retinal hemorrhages (5-7). It may be considered
that vaginal delivery has the risk of developing new
hemorrhages and cesarean section could be the preFigure 1. Fundus photograph of the right eye, showing a large and
well demarcated subhyaloid hemorrhage located inferonasally to
the optic nerve head (arrows) and macular and retinal hemorrhages
(arrowheads)
Figure 2. Dispersion of subhyaloid hemorrhage into the vitreous
cavity following Nd:YAG laser treatment
Figure 3. Fundus photograph showing resolution of the subhyaloid
hemorrhage at the visit three weeks after treatment
We informed our patient about treatment alternatives in Valsalva retinopathy. Although, the patient
was expecting a faster visual recovery because of occupational needs, we observed for spontaneous resolution. After 10 days, we decided to perform Nd:YAG
laser hyaloidotomy for rapid recovery. The anterior
surface of the hemorrhage was perforated at the lower margin, and subhyaloid hemorrhage located in
the nasal retina was drained into the vitreous cavity
in the Q-switched mode using 2.2 mJ energy pulses
(Figure 2). During the following 3 weeks, subhyaloid hemorrhage and vitreous hemorrhage cleared up
rapidly without any complication (Figure 3). After
Nd:YAG laser treatment, the remainder of the pregnancy passed without additional incident. Thirteen
weeks later, an uneventful delivery was performed
at full term with cesarean section under epidural
anesthesia.
Discussion
Valsalva retinopathy develops in response to strenuous physical exertion (1). In our case, the hemorrhage developed as a result of violent and intense vomiting. It has been reported that pregnancy is one
of the reasons associated with Valsalva retinopathy
(2). The hemorrhage typically occurs at the macula,
and also known as Valsalva maculopathy. Although
a large number of cases of premacular subhyaloid
hemorrhage have been reported, extramacular involvement is an uncommon presentation of subhyaloid
hemorrhage associated with Valsalva maneuver (3).
Preretinal hemorrhages secondary to Valsalva retinopathy usually occur in healthy young adults who are
expecting a faster visual recovery. Most cases usually Volume 53 • Issue 1 Treatment of atypical subhyaloid hemorrhage • 65
ferred delivery method. It has been reported that general anesthesia may cause rebleeding due to vasodilatation and an increase in intracranial pressure, with
an associated increase in retinal venous pressure (5).
Moreover coughing may also lead to rise in venous
pressure during extubation. It has been postulated
that epidural anesthesia may increase retinal venous pressure secondary to a rise in cerebrospinal fluid
pressure (6-7). On the other hand Chidley has observed a decrease in the intraocular pressure during cesarean section under fractionated dose epidural anesthesia (5). In our case cesarean delivery was performed
under epidural anesthesia without any additional
ocular complications.
In conclusion, although it has not been reported
previously, it is quite possible that Nd:YAG laser
treatment may be an alternative choice for the treatment of extramacular subhyaloid hemorrhages in
patients complaining of visual scotoma. We suggest
that the occupational needs and expectations of young patients must also be taken into consideration in
the management of subhyaloid hemorrhages.