Valsalva retinopathy (VR) is a retinal hemorrhagic condition caused by rupture of superficial capillaries due to a sudden increase in intrathoracic or intra-abdominal pressure. Blood extravasation typically occurs between the internal limiting membrane (ILM) and the posterior hyaloid, potentially leading to significant visual impairment. Clinically, it presents as a sudden, painless central scotoma, making it essential to differentiate from other retinal hemorrhages, such as macroaneurysms and Terson syndrome.⁽¹⁾

The management of VR with small hemorrhages is usually conservative with spontaneous hemorrhage resorption occurring within 6 to 9 months.⁽²⁾ However, it should be highlighted that in cases of extensive hemorrhage or patients requiring rapid visual recovery, intervention may be considered.⁽³⁾ YAG laser membranectomy is an effective alternative, promoting blood dispersion into the vitreous cavity and accelerating visual improvement, thereby avoiding the need for vitreoretinal surgery.⁽⁴⁾

In this case report, we present a young patient with VR secondary to an episode of vomiting. The patient was treated with YAG laser membranectomy, resulting in significant visual recovery within a few weeks. This case reinforces the importance of quick individualized treatment and the potential benefits of laser therapy in selected cases. This study was approved by the Ethics Committee (CAAE: 77888423.1.0000.0093).

A 26-year-old male presented to the emergency department with a sudden painless central scotoma in OS, after an episode of vomiting. His BCVA was counting fingers at 1 m in OS, with no afferent pupillary defect. Dilated fundus examination showed circumscribed hemorrhage in the pre-macular region (Figure 1). Given the need for rapid visual rehabilitation, immediate YAG laser membranectomy was performed in OS. Five ampere laser shots were applied to the inferior portion of hemorrhage, targeting the hyaloid membrane and dispersing blood into the vitreous cavity. One week post-procedure, the patient was asymptomatic with BCVA of 20/60 in OS. Fundus evaluation showed vitreous hemorrhage in partial resolution in the inferior posterior pole and no pre-macular hemorrhage (Figure 2). After one month, BCVA improved to 20/25 in OS with complete hemorrhage absorption and a physiological foveal reflex (Figure 3).

Valsalva retinopathy is caused by rupture of superficial retinal capillaries due to a sudden increase in intrathoracic or intra-abdominal pressure.⁽⁴⁾ In the presented case, the Valsava maneuver was secondary to episodes of vomiting. These pre-retinal hemorrhages occur between the posterior hyaloid and the ILM or – less frequently – between the ILM and the retinal nerve fiber layer (RNFL).⁽⁴⁾

Valsalva retinopathy can manifest with floaters, central scotoma, and – in severe cases – reduced visual acuity due to hemorrhagic detachment of the ILM.⁽⁴⁾ The patient in the case had BCVA of counting fingers at 1 m in OS alone, with no other symptoms. The diagnosis is clinical, with fundoscopic examination being essential to differentiate from ruptured macroaneurysm, hemorrhagic detachment, and Terson syndrome.⁽⁵⁾ The optical coherence tomography (OCT) is fundamental to locate the pre-macular hemorrhage, since the biomicroscopy is not accurate to determinate the exact location between layers of the retina.^(6,7) Despite that, OCT may be limited due to the high reflectivity of recent blood.⁽⁸⁾

Management is primarily conservative with observation. Focal opening of the posterior hyaloid or ILM with YAG laser has been described as a non-invasive alternative to surgical approach, achieving rapid intravitreal drainage.⁽⁹⁾ This method offers an effective treatment to restoring vision in a short period.⁽¹⁰⁾ The patient of the case had improved best-corrected visual acuity (BVCA) from counting on fingers 1 m to 20/60 in only one week and 20/25 after a month. In these cases, YAG laser membranectomy has proven effective in dispersing the blood, accelerating visual recovery, and preventing a vitreoretinal surgery.^(11,12)

Extensive or persistent cases may cause permanent damage to the photoreceptors. There is no consensus on the effects of long contact between blood and retina, but the formation of epiretinal membrane and toxic effect on the retina after dissolving hemoglobin was observed.^(13,14) In some cases, a pars plana vitrectomy for membrane removal is necessary after YAG.⁽¹⁵⁾