A case of Valsalva hemorrhagic retinopathy treated with Nd:YAGlaser indescribed. The patient presented decreased visual acuityafter coughing, and a preretinal hemorrhage was diagnosed in theposterior pole; puncturing the posterior hyaloid face was performedwith Nd:Yag laser. Rapid hemorrhage absorption was observedafter the therapy proposed and visual acuity was recovered. Nd:Yaglaser proved to be safe and efficient in the management of preretinalhemorrhage

Cláudio Póla

Eduardo Felippe

Jean Soglia

Jorge Mitre

José Ricardo Carvalho de Lima Rehder

Rodrigo Ribeiro

Álvaro Sales

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einstein. 2004; 2(4):314-5314 Felippe EP, Sales Á, Soglia J, Ribeiro R, Póla C, Mitre J, Rehder JRCLPreretinal hemorrhageHemorragia pré-retinianaEduardo Felippe1, Álvaro Sales2, Jean Soglia3, Rodrigo Ribeiro4, Cláudio Póla5, Jorge Mitre6, José Ricardo Carvalhode Lima Rehder7CASE REPORTABSTRACTA case of Valsalva hemorrhagic retinopathy treated with Nd:YAGlaser indescribed. The patient presented decreased visual acuityafter coughing, and a preretinal hemorrhage was diagnosed in theposterior pole; puncturing the posterior hyaloid face was performedwith Nd:Yag laser. Rapid hemorrhage absorption was observedafter the therapy proposed and visual acuity was recovered. Nd:Yaglaser proved to be safe and efficient in the management of preretinalhemorrhage.Keywords: Valsalva maneuver; Lasers/therapeutic use; Visualacuity; Eye hemorrhageRESUMODescreve-se um caso de hemorragia pré-retiniana por Valsalvatratado com Nd:YAG laser. Paciente apresentou baixa da acuidadevisual após crise de tosse, sendo diagnosticada hemorragia pré-retiniana no pólo posterior; foi realizado pertuito na hialóideposterior com Nd:Yag laser. Após tratamento proposto, observou-se rápida absorção da hemorragia com o restabelecimento daacuidade visual. Nd:Yag laser mostrou-se seguro e eficaz no manejoda hemorragia pré-retiniana.Descritores: Manobra de Valsalva; Lasers/uso terapêutico;Acuidade visual; Hemorragia ocularINTRODUCTIONPreretinal hemorrhage may occur after rupture ofretinal vessels and is associated with physical exercisesand increased venous pressure (Valsalva retinopathy)or retinal vascular alterations, such as macroaneurismasand proliferative diabetic retinopathy(1).Valsalva retinopathy is characterized by a sudden decreasein visual acuity. It may be treated by vitrectomy, Nd:YAGlaser membranotomy or observation. We described a case ofpreretinal hemorrhage, its treatment with Nd:YAG laserand a favorable progression within a short period of time.CASE REPORTPatient I.M.M.L, a white, 40-year old housewife soughtan ophthalmologic service due to decreased visualacuity for one day and history of dyspnea associatedwith coughing and vomiting.Her blood pressure was borderline and she was onbehavioral and dietetic treatment. She smoked approximately20 cigarettes/day. Her parents were hypertensive and shedenied any past ophthalmologic history. On ophthalmologicexamination, she presented visual acuity with no correctionof finger counting at 15 centimeters in the right eye (OD)and 20/20 in the left eye (OL).On biomicroscopic examination, a slightconjunctival hyperemia was observed in OD and therewere no alterations in OL. The intraocular pressure(IOP) was 10 mm Hg in OD and 12 mm Hg in OL, at 4o’clock. In OD retinal mapping, it was difficult to assesspapillary excavation due to hemorrhage in the papillaryedge from 7 to 1 o’clock. Nevertheless, the visualizedarea presented clear edges, preserved neuroretinal rimwith normal color, attached retina with normal color,slightly increased vascular tortuosity and presence ofpreretinal hemorrhage of 10 papillary diameters (PD).On OL examination, vertically oval papilla with clearedges, preserved ISNT rule, neuroretinal rim withnormal color and 0.5 vertical/0.4 horizontal excavation,attached retina with normal color and macula withpreserved foveal reflex. Posterior hyaloidphotodisruption was performed with Nd:YAG laser (21pulses with 6 mJ-energy, total energy of 142 mJ). Inthe first week after Nd:YAG laser, the patient alreadyInstitution: Department of Ophthalmology of the Faculdade de Medicina do ABC.1 Second-year resident in Ophthalmology in the Faculdade de Medicina do ABC.2 Second-year resident in Ophthalmology in the Faculdade de Medicina do ABC.3 Third-year resident in Ophthalmology in the Faculdade de Medicina do ABC.4 Fifth-year resident in Ophthalmology in the Faculdade de Medicina do ABC.5 Fourth-year resident in Ophthalmology in the Faculdade de Medicina do ABC.6 Full professor and Head of the Retina Service of the Faculdade de Medicina do ABC.7 Full professor and Head of the Department of Ophtalmology of the Faculdade de Medicina do ABC.Corresponding author: Eduardo P. Felippe - Faculdade de Medicina do ABC - Av. Príncipe de Gales, 821 - Anexo 3 - 1º andar - Departamento de Oftalmologia - CEP 09060-260 - Santo André (SP), Brazil- Fax (5511) 4993-5408 - e-mail: edu.felippe@uol.com.brReceived on March 18, 2004 – Accepted on July 15, 2004einstein. 2004; 2(4):314-5315 Preretinal hemorrhagepresented visual acuity of 20/20 in both eyes; however,cellularity in the anterior chamber and turbid vitreous++/4+ persisted for 15 days and clinical treatmentwith VUEFFE® 3 times/day for 30 days was initiated.After this period, the patient was asymptomatic andwas submitted to a fluorescein angiography thatdemonstrated a hyperfluorescent area uniformlycomprising the macular region in all phases of the exam.Figure 1a and figure 1b shows the comparison betweenthe two eyes by retinography.observation, Nd:YAG laser photodisruption andvitrectomy. Although hemorrhage resulting from Valsalvaretinopathy has spontaneous resolution, it presents someinconveniences, such as long waiting period for visualrecovery and some complications, such as epiretinalmembrane. In vitrectomy, a more invasive procedure, thecomplication rate in both peri- and postoperative periodsis higher and potentially more severe. Faulborn was thefirst author to describe photodisruption in the treatmentof premacular hemorrhage(9).Puncturing the posterior hyaloid of the internallimiting membrane in the hemorrhagic site is a feasiblealternative to vitrectomy in the management of extensivepremacular hemorrhage(3-8). Laser membranotomy enableserythrocytes accumulated in the macula to leak to vitreous,where they are more rapidly absorbed(3-8).Most studies describing the treatment of premacularhemorrhage with photodisruption aimed to open asingle passage, the most distant possible from the foveaand trying to not achieve areas in which there wouldbe clotted blood. The energy used ranges from 3 to 8mJ and the number of pulses may increase up to 54(3-8).In the case mentioned above, we chose treating withNd:YAG laser photodisruption since hemorrhage hadmore than three papillary diameters, a thick bloodcolumn protecting the retina. We were cautious to usethe lesser possible effective amount of energy(5,10).CONCLUSIONNd:Yag laser proved to be an efficient and safetechnique for treating preretinal hemorrhagesconsidering the safety criteria.REFERENCES1. Gas JDM. Stereoscopic atlas of macular diseases: Diagnosis and treatment. 4aed. St Louis: CV Mosey; 1997.2. Gabel VP, Birngruber R, Gunther-Koszka H, Puliafito CA. Nd:YAG laserphotodisruption of hemorrhagic detachment of the internal limiting membrane.Am J Ophthalmol.1989;107(1):33-7.3. Stempels N, Tassignon MJ, Worst J. Les hemorragies dans la bourse premaculairetraitées par le Q-switched Nd:YAG laser. Ophtalmologie. 1990;4(3):314-6.4. Raymond LA. Neodymium:YAG laser treatment for hemorrhages under theinternal limiting membrane and posterior hyaloid face in the macula.Ophthalmology. 1995;102(3):406-11.5. Ulbig MW, Mangouritsas G, Rothbacher HH, Hamilton AM, McHugh JD. Long-term results after drainage of premacular subhyaloid hemorrhage into thevitreous with a pulsed Nd:YAG laser. Arch Ophthalmol. 1998; 116(11):1465-9.6. Kaynak S, Eryildirim A, Kaynak T, Durak I, Saatci O, Eryildirim S, et al. Nd:YAGlaser posterior hyaloidotomy in subhyaloid hemorrhage. Ophthalmic Surg.1994;25(7):474-6.7. Ezra AND, Dowler JG, Burgess F, Sehmi K, Hamilton PA. Identifying maculopathyafter neodymium: YAG membranotomy for dense diabetic premacularhemorrhage. Ophthalmology. 1996;103(10):1568-74.8. Diniz AV. Manifestações do trauma ocular contuso. In: Abujamra S. Retina eVítreo: clínica e cirurgia. São Paulo:Roca; 2000. p. 769-77.9. Faulborn J. Behandlung Einer Diabetischen Praemaculaeren Blutung mit demQ-switched Neodym:YAG Laser. Spektrum Augenheilkd. 1998; 18:4-6. German.10.Dori D, Gelfand Y, Erlik N, Miller B. Nd:YAG laser treatment for premacularhemorrhage. Ophtalmic Surg Lasers 1998;29(12):998-1000.DISCUSSIONMacular preretinal hemorrhage generally causes severevisual loss. The most common etiologies areproliferative diabetic retinopathy, macroaneurisma,Valsalva retinopathy and blood dyscrasias(2).The frequency of Valsalva retinopathy has not beenestimated due to the reduced number of reported cases.A sudden increase in intra-abdominal or intrathoracicpressure against a closed glottis (Valsalva maneuver)may cause fast rise in venous pressure, leading tospontaneous rupture of superficial retinal capillaries(1).According to the literature, the visual acuity of thispatient was within the limits(3-8), as well as hemorrhagesize(3,6). The most common site for hemorrhage inValsalva retinopathy is the posterior pole because of apreexisting anatomical space - premacular bursa. Sinceit is difficult to indicate the accurate site of hemorrhage- between retina and internal limiting membrane, orinternal limiting membrane and hyaloid, we decidedto use the term preretinal hemorrhage.The presence of a light reflex and the fluid level onfundoscopy may indicate the involvement of the internallimiting membrane(1,6). Other therapeutical options areFigure 1aFigure 1b

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