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Sir,

The Valsalva manoeuvre comprises forcible exhalation against a closed glottis, thereby creating a sudden increase in the intrathoracic or intraabdominal pressure.1 Spontaneous rupture of peri-foveal capillaries may develop, leading to a characteristic clinical picture of a retinal haemorrhage in an otherwise healthy eye.2 The haemorrhage typically occurs at the macula and in the vast majority of cases is an isolated and self-limited event.2 A case is presented of a transient maculopathy in a young healthy male attributable to a Valsalva manoeuvre associated with riding a motorbike on one wheel.

Case presentation

A 14-year-old male presented to our clinic having been referred by his optician for a sudden onset of visual loss in the left eye, which occurred while riding a motorcycle 3 days previously. Detailed history revealed considerable straining while trying to perform the stunt of riding the motorcycle on its back wheel. There was no history of having sustained a fall or head injury. He was otherwise well with no previous past medical or ophthalmic history of note. Snellen acuity was 6/5 and 6/36 not improving on pinhole. There was no afferent papillary defect and examination of the anterior segment was unremarkable. Intraocular pressures were normal at 11 mmHg bilaterally.

Dilated fundal examination revealed a deep intraretinal haemorrhage at the left fovea with no evidence of other retinal pathology (see Figure 1). The optic disc was normal and there was no preretinal or vitreous haemorrhage. Investigations including blood pressure, full blood count, and clotting studies were normal. A diagnosis of Valsalva retinopathy was made based on the history and management consisted of rest, avoidance of strenuous activity, and observation. At 4-week follow-up, the visual acuity had improved to 6/5 in the affected eye and fundal examination revealed total resolution of the foveal haemorrhage.

Figure 1
figure 1

Colour photograph showing an intraretinal haemorrhage at the left macula following a Valsalva manoeuvre associated with riding a motorcycle.

Full size image

Comment

Valsalva retinopathy is a known complication of physical exertion.3 It can arise due to an increase in intrathoracic or abdominal pressure against a closed glottis. The rapid rise in venous pressure may lead to the rupture of normal/abnormal superficial retinal capillaries, leading to haemorrhagic detachment of the internal limiting membrane and possibly intragel haemorrhage. It has been associated with certain sports such as weight-lifting,2 aerobic exercise3 and on a day-to-day basis with constipation,4 pregnancy,5 labour,6 and blowing up balloons.7 Congenital abnormalities of the retinal vasculature such as familial retinal arteriolar tortuosity have also been implicated.8 This is the first reported case occurring in association with riding a motorcycle. The mechanism in this case was considerable straining while the subject was trying to lift the machine on its back wheel while in motion.

The presentation of Valsalva retinopathy can be variable depending on the size of the vessel involved and the location of the haemorrhage; subretinal, intraretinal, and/or subhyaloid.9 Prognosis is generally favourable with most cases resolving spontaneously over a span of several weeks, leaving little if any visual impairment. Large subhyaloid haemorrhages have been treated with Nd : YAG laser to facilitate evacuation of the blood into the vitreous and accelerate resolution.10

Our case describes a rare mechanism of Valsalva retinopathy, which developed while performing the stunt of riding a motorcycle on its back wheel. Since this manoeuvre is not uncommon especially among the younger riders, we highlight a previously unreported ocular complication that may occur.