Laser membranotomy by Nd:YAG laser in a pregnant female with Valsalva retinopathy with double-ring sign

Sugandha Goel; Eesh Nigam; Kumar Saurabh; Rupak Roy; Sudipta Das; Debmalya Das

doi:10.4103/ijo.IJO_1993_20

PHOTO ESSAY

Year : 2021 | Volume : 1 | Issue : 2 | Page : 221-222

Laser membranotomy by Nd:YAG laser in a pregnant female with Valsalva retinopathy with double-ring sign

Sugandha Goel, Eesh Nigam, Kumar Saurabh, Rupak Roy, Sudipta Das, Debmalya Das
Department of vitreoretina, Aditya Birla Sankara Nethralaya, Kolkata, West Bengal, India

Date of Submission	18-Jun-2020
Date of Acceptance	07-Oct-2020
Date of Web Publication	01-Apr-2021

Correspondence Address:
Dr. Eesh Nigam
Aditya Birla Sankara Nethralaya, 147, Mukundapur, E.M.Bypass, Kolkata - 700 099, West Bengal
India

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijo.IJO_1993_20

Abstract

Keywords: Double-ring sign, pregnancy, sub-ILM hemorrhage, subhyaloid hemorrhage, Valsalva retinopathy

How to cite this article:
Goel S, Nigam E, Saurabh K, Roy R, Das S, Das D. Laser membranotomy by Nd:YAG laser in a pregnant female with Valsalva retinopathy with double-ring sign. Indian J Ophthalmol Case Rep 2021;1:221-2

How to cite this URL:
Goel S, Nigam E, Saurabh K, Roy R, Das S, Das D. Laser membranotomy by Nd:YAG laser in a pregnant female with Valsalva retinopathy with double-ring sign. Indian J Ophthalmol Case Rep [serial online] 2021 [cited 2023 Jun 2];1:221-2. Available from: https://www.ijoreports.in/text.asp?2021/1/2/221/312349

Valsalva retinopathy is characterized by a sudden visual loss due to preretinal hemorrhage, caused by a rapid increase in intraocular venous pressure. We hereby report a case of Valsalva retinopathy in a pregnant woman who was treated with Nd: YAG laser membranotomy.

Case Report

A 23-year-old pregnant female with 36 weeks of gestation presented with a sudden decrease in vision in her right eye for 2 days. She gave a history of severe vomiting before the onset of symptoms. Best-corrected visual acuity (BCVA) was counting fingers at 2 m in the right eye and 6/6 in the left eye. Fundus of the right eye showed premacular hemorrhage with a glistening white reflex and double-ring sign [Figure 1]a. Spectral Domain-Optical Coherence Tomography (SD-OCT) showed hemorrhage in sub-internal limiting membrane (ILM) space with a peg-shaped structure in the outer retina [Figure 1]b and [Figure 1]c. Blood pressure and random blood glucose were within normal limits. The patient was treated using a Q-switched Nd: YAG laser. A single burst of pulsed Nd: YAG laser was applied, starting with low energy (2 mJ) and then gradually increased until membranotomy became visible. The total energy used was 4 mJ. Nd: YAG laser membranotomy was done at the inferior aspect of premacular hemorrhage causing rapid dispersion of the hemorrhage into the vitreous cavity [Figure 2]a and [Figure 2]b. On 6 weeks follow-up after delivery, vision improved to 6/6 in the right eye. Fundus showed resolved premacular hemorrhage and little hemorrhage was noted in vitreous inferiorly [Figure 3]. SD-OCT showed a hyporeflective premacular cavity lined by the prominent hyperreflective membrane, presumably ILM. Another fainter reflecting layer, the posterior hyaloid, was visible separately and partly fused with the ILM in some areas [Figure 4]. Peg-shaped structure was noted in the outer retina corresponding to yellowish-white arcs at the outer margin of hemorrhage [Figure 4]b and [Figure 5].

Figure 1: Color fundus photograph (a) of the right eye showing preretinal hemorrhage located in the macula (star) with a double-ring sign (arrows). SD-OCT (b and c) showing sub-ILM hemorrhage in the macula (yellow arrow) with the peg-shaped structure in the outer retina (red arrow)

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Figure 2: Color fundus photograph (a and b) shows rapid dispersion of the hemorrhage into the vitreous cavity immediately after Nd: YAG laser membranotomy

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Figure 3: Montage color fundus photograph showing resolved premacular hemorrhage and little hemorrhage in vitreous inferiorly on follow up

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Figure 4: Color fundus photograph (a) showing resolved premacular hemorrhage (arrow). SD-OCT (b) showing a hyporeflective premacular cavity lined by a prominent hyperreflective membrane, presumably ILM (yellow arrow). Another fainter reflecting layer, the posterior hyaloid, is visible separately and partly fused with the ILM in some areas (blue arrow). Peg-shaped structure is noted in the outer retina (red arrow)

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Figure 5: SD-OCT showing a peg-shaped structure in outer retina corresponding to yellowish-white arcs at the outer margin of hemorrhage (arrows)

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Discussion

Valsalva retinopathy often occurs in healthy young adults and has been reported following coughing, weight lifting, vomiting, jumping, end-stage of labor, episodes of constipation, vomiting, and lifting in pregnant women.^[1] It is important to rule out systemic diseases such as diabetes, hypertension, sickle cell disease, anemia, coagulopathy, blood dyscrasias, and previous ocular vein occlusions.^[1] Valsalva maneuvers typically cause superficial retinal hemorrhages (sub-ILM and/or subhyaloid) with a predilection for the macula. If blood is localized in both spaces, it presents a “double-ring sign.”^[2] The outer and inner rings represent subhyaloid and sub-ILM bleed, respectively. Furthermore, subretinal, retinal, and vitreous hemorrhages have also been reported. It is difficult to distinguish between subhyaloid hemorrhage and sub-ILM hemorrhage clinically. The presence of glistening white reflex suggests sub -LM hemorrhage. SD-OCT can be used to differentiate between both. “Arcus retinalis” is a novel clinical sign described in a case of sub-ILM hemorrhage. A yellowish-white arc corresponds to a vertical peg-like structure in the outer retina on OCT as a result of localized traction on the retina by stretched ILM.^[3] Intervention should be done early in cases of sub-ILM hemorrhage to prevent toxic damage leading to irreversible visual loss. Nd: YAG laser treatment provides early visual rehabilitation in patients with Valsalva retinopathy irrespective of pregnancy status. It allows complete drainage of hemorrhage.^[4] However, there is a risk of photomechanical retinal injury and iatrogenic macular hole following laser.^[5] Vitrectomy surgery has also been done with success.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1.	Al-mujiani AS, Montana CC. Valsalva retinopathy in pregnancy: A case report. J Med Case Reports 2008;2:101.
2.	Mathew DJ, Sarma SK. Valsalva retinopathy with double ring sign: Laser membranotomy for twin bleeds. Saudi J Ophthalmol 2016;30:68-70.
3.	Kumar V, Goel N. “Arcus retinalis”: A novel clinical marker of sub-internal limiting membrane hemorrhage. Eur J Ophthalmol 2020. doi: 10.1177/1120672120934958.
4.	Ulbig MW, Mangouritsas G, Rothbacher HH, Hamilton AM, McHugh JD. Long term results after drainage of premacular subhyaloid hemorrhage into the vitreous with pulsed Nd: YAG laser. Arch Ophthalmol 1988;116:1465-9.
5.	Bypareddy R, Chawla R, Azad SV, Takkar B. Iatrogenic parafoveal macular hole following Nd-YAG posterior hyaloidotomy for premacular haemorrhage. BMJ Case Rep 2016;2016:bcr2016217234.