Sir,

Valsalva retinopathy may occur during a sudden increase in intraocular venous pressure caused by forced exhalation against a closed glottis.

Patients with idiopathic thrombocytopenic purpura (ITP) and positive antiphopholipid antibodies (aPL) are at particular risk for developing both bleeding and thrombotic complications.1

Case report

A 32-year-old female patient presented with sudden visual loss in the right eye during sexual intercourse. There was no past ocular history of note but she was known to have ITP with positive aPL. On presentation, her best corrected visual acuities (BCVA) were 6/36 in the right eye and 6/5 in the left. The anterior segments were normal, but in the right eye there was a submacular trilaminar haemorrhage (subretinal, intraretinal, and subhyaloid) involving the superior arcade. (Figure 1a). Fundus biomicroscopy of the left eye was normal. Systemically, she was well and was on no medications. The blood pressure was 100/70 mmHg on presentation. All blood tests were normal except for raised IgM anticardiolipin antibody consistent with her past medical history. Her platelet count was 195 × 103/mm3.

Figure 1
figure 1

(a) Colour fundus picture on presentation showing the trilaminar submacular haemorrhage extending up to the superior arcade. (b) Fluorescein angiography showing an area of hypofluorescence corresponding to the haemorrhage. (c, d) Indocyanine green angiography showing an area of hypofluorescence corresponding to the haemorrhage but no underlying neovascularization.

Within a few days, there was further reduction of vision with the BCVA dropping to 2/60. A fluorescein angiography (FA) and indocyanine green angiography (ICG) were performed. (Figure 1b–d). Both examinations showed an area of hypofluorescence corresponding to the haemorrhage but no underlying neovascularization. The diagnosis of Valsalva retinopathy was made and all management options were explained. The patient elected not to undergo any surgical treatment. On subsequent follow-up at 3 weeks, 2, 4, and 6 months, the haemorrhage gradually absorbed leaving an area of atrophy of the retinal pigment epithelium (RPE) under the right fovea and an epiretinal membrane along the superior arcade (Figure 2a–d). Her BCVA remained at 6/60.

Figure 2
figure 2

(a–c) Colour fundi pictures 3 weeks, 2, and 4 months later showing gradual absorption of the haemorrhage leaving an area of atrophy of the RPE under the fovea. (d) Colour fundus picture 6 months later showing complete absorption of the haemorrhage leaving an epiretinal membrane along the superior arcade (white arrow).

Comment

Valsalva retinopathy is characterized by the presence of a pre-retinal haemorrhage following a Valsalva maneuver and in most cases resolves spontaneously with favourable visual outcome.

A total of 30% of patients with ITP are positive for aPL2 and are at particular risk of developing both bleeding and thrombotic complications.1 Patients with primary antiphospholipid syndrome alone are more likely to present with ocular vaso-occlusive accidents involving the retinal and choroidal vessels.3 It is known that aPL are directed against cell membranes2 and they play a role in mediating platelet activation and aggregation. However, the exact role of aPL in the pathophysiology of thrombocytopenia remains obscure.1

Ocular associations with ITP include hemianopia secondary to intracranial haemorrhage and massive subretinal haemorrhage in association with age-related macular degeneration.4

The association between sudden loss of vision owing to retinal haemorrhage and sexual intercourse has been previously reported.5

The extent and trilaminar nature of the haemorrhage and the severity of retinal damage in this case were probably contributed by the presence of ITP with positive aPL.

In conclusion, this case highlights the severity of Valsalva retinopathy in association with ITP and positive aPL. We are not aware of any previous reports in spite of a medline search that was conducted by us.