Letter to the Editor
AN ALARMING CONDITION AFTER UPPER GASTROINTESTINAL ENDOSCOPY: VALSALVA RETINOPATHY To the Editor, A 33-year-old-man was admitted to our outpatient clinic for dyspeptic complaints. A routine upper gastrointestinal endoscopy was performed by an experienced endoscopist without sedation. The patient suffered from multiple sustained Valsalva maneuvers during the procedure. Shortly after the procedure, he reported painless blurred vision and frightening red appearance in his eyes (Figure 1). His medical history was unremarkable, and he did not receive any medication. Blood pressure, full blood count, coagulation profile, and sickle cell tests were all within normal limits. Additional tests for a hypercoaguable state and autoimmune diseases were negative. Retinal examination showed subhyaloid hemorrhage overlying the macula. On the basis of the history and retinal examination, the patient was diagnosed with Valsalva retinopathy. The hemorrhage resolved spontaneously and the patient’s vision returned to normal within a month without any consequences. Valsalva’s hemorrhagic retinopathy was first described in 1972 for the retinal hemorrhages that occurred immediately after heavy lifting, coughing, vomiting, or straining. Valsalva maneuvers cause a sudden increase in intrathoracic, intra-abdominal, and intraocular venous pressure. Valsalva retinopathy occurs when this increased retinal venous pressure may cause local rupture of superficial retinal capillaries and leads to retinal hemorrhage (Albert & Jakobiec, 2000) (see Figure 1). The authors declare no conflict of interest. Correspondence to: Serta Kilincalp, MD, Dıs˛kapı Education and Research Hospital Gastroenterology Clinic, Altındag˘, Ankara, Turkey (serta80@ gmail.com). DOI: 10.1097/SGA.0000000000000010
VOLUME 36
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NUMBER 6
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NOVEMBER/DECEMBER 2013
FIGURE 1. Valsalva retinopathy following endoscopic procedure.
Both vomiting and labor cause increased intrathoracic pressure against a closed glottis (Wickremasinghe, Tranos, & Davey, 2003). Valsalva retinopathy usually occurs in healthy individuals when this increased intrathoracic pressure transmitted to the eye causes a sudden rise in the intraocular venous pressure leading to spontaneous rupture of superficial retinal capillaries. Valsalva maneuvers typically result in superficial retinal hemorrhages with a predilection for the macula. Patients usually give a history of sudden visual loss following an event that diminishes the intrathoracic pressure like heavy lifting, blowing balloons, straining, coughing, or vomiting (e.g., in pregnancy) (Hassan & Tajunisah, 2011). Although it can alarm the patient and possibly the physician, the prognosis of Valsalva hemorrhagic retinopathy is generally good. It is a self-limited event and in most cases, the hemorrhage resolves within a month without any sequelae. These patients, however, should be referred for ophthalmologic evaluation and followup because the hemorrhage may cause a visual loss of up to 6 months if left untreated (Rennie, Newman, Snead, & Flanagan, 2001). To avoid complications, hemorrhage may be managed with laser therapy (Kwok, Lai, & Chan, 2003). Adequate explanation of the procedure and sufficient sedation may prevent this potential ocular complication, especially in vulnerable patients with diabetes mellitus and bleeding tendency (Chan, Liu, Tham, Wu, & Lam, 2003; O’Hanley & Canny, 1985). To our knowledge, this is the second report of the occurrence 465
Copyright © 2013 Society of Gastroenterology Nurses and Associates. Unauthorized reproduction of this article is prohibited.
GNJ-D-13-00092.indd 465
22/11/13 11:38 AM
Letter to the Editor of Valsalva retinopathy following a routine upper gastrointestinal endoscopy. Serta Kilincalp, MD Gastroenterology Fellow Department of Gastroenterology Ankara Dıs¸kapı Yıldırım Beyazıt Education and Research Hospital Ankara, Turkey Dıs¸kapı Education and Research Hospital Gastroenterology Clinic Altındag˘, Ankara, Turkey S¸ahin Çoban, MD Associate Professor Department of Gastroenterology Ankara Dıs¸kapı Yıldırım Beyazıt Education and Research Hospital Ankara, Turkey . Ilhami Yüksel, MD Department of Gastroenterology Ankara Dıs¸kapı Yıldırım Beyazıt Education and Research Hospital Ankara, Turkey
Department of Gastroenterology Ankara Yıldırım Beyazıt University Hospital Ankara, Turkey
REFERENCES Albert, D. M., & Jakobiec, F. A. (2000). Principles and Practice of Ophthalmology (2nd ed., Vol. 2). Philadelphia, PA: Saunders. Chan, W. M., Liu, D. T., Tham, C. C., Wu, R. M., & Lam, D. S. (2003). Bilateral subhyaloid haemorrhage in aplastic anaemia. British Journal of Haematology, 123, 757. Hassan, M., & Tajunisah, I. (2011). Valsalva haemorrhagic retinopathy after push-ups. Lancet, 377(9764), 504. Kwok, A. K., Lai, T. Y., & Chan, N. R. (2003). Epiretinalmembrane formation with internal limiting membrane wrinkling after Nd:YAG laser membranotomy in Valsalva retinopathy. American Journal of Ophthalmology, 136, 763–766. O’Hanley, G. P., & Canny, C. L. B. (1985). Diabetic dense premacular hemorrhage. Ophthalmology, 4, 507–511. Rennie, C. A., Newman, D. K., Snead, M. P., & Flanagan, D. W. (2001). Nd:YAG laser treatment for premacular subhyaloid haemorrhage. Eye, 15, 519–524. Wickremasinghe, S., Tranos, P., & Davey, C. (2003). Valsalva retinopathy in a pregnant woman: Implications for delivery. Acta Ophthalmologica, 81, 420.
466 Copyright © 2013 Society of Gastroenterology Nurses and Associates
Gastroenterology Nursing
Copyright © 2013 Society of Gastroenterology Nurses and Associates. Unauthorized reproduction of this article is prohibited.
GNJ-D-13-00092.indd 466
22/11/13 11:38 AM
AN ALARMING CONDITION AFTER UPPER GASTROINTESTINAL ENDOSCOPY: VALSALVA RETINOPATHY To the Editor, A 33-year-old-man was admitted to our outpatient clinic for dyspeptic complaints. A routine upper gastrointestinal endoscopy was performed by an experienced endoscopist without sedation. The patient suffered from multiple sustained Valsalva maneuvers during the procedure. Shortly after the procedure, he reported painless blurred vision and frightening red appearance in his eyes (Figure 1). His medical history was unremarkable, and he did not receive any medication. Blood pressure, full blood count, coagulation profile, and sickle cell tests were all within normal limits. Additional tests for a hypercoaguable state and autoimmune diseases were negative. Retinal examination showed subhyaloid hemorrhage overlying the macula. On the basis of the history and retinal examination, the patient was diagnosed with Valsalva retinopathy. The hemorrhage resolved spontaneously and the patient’s vision returned to normal within a month without any consequences. Valsalva’s hemorrhagic retinopathy was first described in 1972 for the retinal hemorrhages that occurred immediately after heavy lifting, coughing, vomiting, or straining. Valsalva maneuvers cause a sudden increase in intrathoracic, intra-abdominal, and intraocular venous pressure. Valsalva retinopathy occurs when this increased retinal venous pressure may cause local rupture of superficial retinal capillaries and leads to retinal hemorrhage (Albert & Jakobiec, 2000) (see Figure 1). The authors declare no conflict of interest. Correspondence to: Serta Kilincalp, MD, Dıs˛kapı Education and Research Hospital Gastroenterology Clinic, Altındag˘, Ankara, Turkey (serta80@ gmail.com). DOI: 10.1097/SGA.0000000000000010
VOLUME 36
|
NUMBER 6
|
NOVEMBER/DECEMBER 2013
FIGURE 1. Valsalva retinopathy following endoscopic procedure.
Both vomiting and labor cause increased intrathoracic pressure against a closed glottis (Wickremasinghe, Tranos, & Davey, 2003). Valsalva retinopathy usually occurs in healthy individuals when this increased intrathoracic pressure transmitted to the eye causes a sudden rise in the intraocular venous pressure leading to spontaneous rupture of superficial retinal capillaries. Valsalva maneuvers typically result in superficial retinal hemorrhages with a predilection for the macula. Patients usually give a history of sudden visual loss following an event that diminishes the intrathoracic pressure like heavy lifting, blowing balloons, straining, coughing, or vomiting (e.g., in pregnancy) (Hassan & Tajunisah, 2011). Although it can alarm the patient and possibly the physician, the prognosis of Valsalva hemorrhagic retinopathy is generally good. It is a self-limited event and in most cases, the hemorrhage resolves within a month without any sequelae. These patients, however, should be referred for ophthalmologic evaluation and followup because the hemorrhage may cause a visual loss of up to 6 months if left untreated (Rennie, Newman, Snead, & Flanagan, 2001). To avoid complications, hemorrhage may be managed with laser therapy (Kwok, Lai, & Chan, 2003). Adequate explanation of the procedure and sufficient sedation may prevent this potential ocular complication, especially in vulnerable patients with diabetes mellitus and bleeding tendency (Chan, Liu, Tham, Wu, & Lam, 2003; O’Hanley & Canny, 1985). To our knowledge, this is the second report of the occurrence 465
Copyright © 2013 Society of Gastroenterology Nurses and Associates. Unauthorized reproduction of this article is prohibited.
GNJ-D-13-00092.indd 465
22/11/13 11:38 AM
Letter to the Editor of Valsalva retinopathy following a routine upper gastrointestinal endoscopy. Serta Kilincalp, MD Gastroenterology Fellow Department of Gastroenterology Ankara Dıs¸kapı Yıldırım Beyazıt Education and Research Hospital Ankara, Turkey Dıs¸kapı Education and Research Hospital Gastroenterology Clinic Altındag˘, Ankara, Turkey S¸ahin Çoban, MD Associate Professor Department of Gastroenterology Ankara Dıs¸kapı Yıldırım Beyazıt Education and Research Hospital Ankara, Turkey . Ilhami Yüksel, MD Department of Gastroenterology Ankara Dıs¸kapı Yıldırım Beyazıt Education and Research Hospital Ankara, Turkey
Department of Gastroenterology Ankara Yıldırım Beyazıt University Hospital Ankara, Turkey
REFERENCES Albert, D. M., & Jakobiec, F. A. (2000). Principles and Practice of Ophthalmology (2nd ed., Vol. 2). Philadelphia, PA: Saunders. Chan, W. M., Liu, D. T., Tham, C. C., Wu, R. M., & Lam, D. S. (2003). Bilateral subhyaloid haemorrhage in aplastic anaemia. British Journal of Haematology, 123, 757. Hassan, M., & Tajunisah, I. (2011). Valsalva haemorrhagic retinopathy after push-ups. Lancet, 377(9764), 504. Kwok, A. K., Lai, T. Y., & Chan, N. R. (2003). Epiretinalmembrane formation with internal limiting membrane wrinkling after Nd:YAG laser membranotomy in Valsalva retinopathy. American Journal of Ophthalmology, 136, 763–766. O’Hanley, G. P., & Canny, C. L. B. (1985). Diabetic dense premacular hemorrhage. Ophthalmology, 4, 507–511. Rennie, C. A., Newman, D. K., Snead, M. P., & Flanagan, D. W. (2001). Nd:YAG laser treatment for premacular subhyaloid haemorrhage. Eye, 15, 519–524. Wickremasinghe, S., Tranos, P., & Davey, C. (2003). Valsalva retinopathy in a pregnant woman: Implications for delivery. Acta Ophthalmologica, 81, 420.
466 Copyright © 2013 Society of Gastroenterology Nurses and Associates
Gastroenterology Nursing
Copyright © 2013 Society of Gastroenterology Nurses and Associates. Unauthorized reproduction of this article is prohibited.
GNJ-D-13-00092.indd 466
22/11/13 11:38 AM
