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   Table of Contents      
Year : 2019  |  Volume : 67  |  Issue : 4  |  Page : 553-554

Valsalva retinopathy following transesophageal echocardiography

Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India

Date of Submission16-Sep-2018
Date of Acceptance06-Jan-2019
Date of Web Publication22-Mar-2019

Correspondence Address:
Dr. Vinod Kumar
Dr R P Centre, All India Institute of Medical Sciences, New Delhi - 110 029
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijo.IJO_1565_18

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Keywords: Premacular hemorrhage, transesophageal echocardiography, valsalva retinopathy

How to cite this article:
Bhayana AA, Kumar V. Valsalva retinopathy following transesophageal echocardiography. Indian J Ophthalmol 2019;67:553-4

How to cite this URL:
Bhayana AA, Kumar V. Valsalva retinopathy following transesophageal echocardiography. Indian J Ophthalmol [serial online] 2019 [cited 2019 Jul 16];67:553-4. Available from:

  Case Report Top

A 25-year-old female, known case of cardiac atrial septal defect, presented with sudden painless diminution of vision in OS for past 3 days following transesophageal echocardiography. OD was normal. OS best-corrected visual acuity (BCVA) was 20/400 with normal anterior segment. Fundus [Figure 1]a and swept-source optical coherence tomography [SSOCT, [Figure 1]b showed premacular hemorrhage. Patient was diagnosed as OS Valsalva retinopathy following transesophageal echocardiography and kept on close follow-up. At 6 weeks, BCVA OS improved to 20/60. Premacular hemorrhage decreased in size [arrow, [Figure 1]c]. Small area of hyper-reflectivity was persisting on SSOCT [arrow, [Figure 1]d]. At 6 months, BCVA improved to 20/25. The hemorrhage resolved clinically [Figure 1]e. The patient reported metamorphopsia that could be attributed to internal limiting membrane thickening visible on SSOCT [Figure 1]f. In view of good visual acuity, the patient was not keen for surgical intervention.
Figure 1: Sequential color fundus photographs and SSOCT of a patient post transesophageal echocardiography. (a), (b) Fundus and SSOCT at presentation showing fresh premacular bleed. (c), (d) Fundus and SSOCT at 6 weeks showing resolving bleed (arrow) – hyper-reflective band over the foveal dip on OCT. (e), (f) Fundus and SSOCT at 6 months showing almost resolved hemorrhage with persistent ILM thickening as seen on OCT

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  Discussion Top

A transesophageal echocardiogram (TEE) involves passage of a specialized probe with ultrasound transducer at its tip into the esophagus to obtain an echocardiogram. Valsalva maneuver is done with TEE to detect patent foramen ovale[1] and TEE (or other endoscopic procedures like bronchoscopy) may itself produce Valsalva-like stress. Therefore, the treating physician should be aware of possibility of Valsalva retinopathy following TEE and should also counsel the patient accordingly.

Most premacular hemorrhages tend to get absorbed spontaneously within 2–4 months. An Nd-YAG laser membranotomy may be performed in fresh cases (it disperses the contained blood in to the vitreous cavity), which clears visual axis.[2],[3] Nonresolving premacular hemorrhages may require vitrectomy.

To conclude, TEE can lead to Valsalva retinopathy and should be explained to the patients in preoperative counseling as a cause of visual decline. Though premacular haemorrhage may resolve spontaneously, patient may have residual visual disturbances.

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.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Rodrigues AC, Picard MH, Carbone A, Arruda AL, Flores T, Klohn J, et al. Importance of adequately performed Valsalva maneouvre to detect patent foramen ovale during transesophageal echocardiography. J Am Soc Echocardiogr 2013;26:1337-43.  Back to cited text no. 1
Raymond LA. Neodymium: YAG laser treatment for hemorrhages under the internal limiting membrane and posterior hyaloid face in the macula. Ophthalmology 1995;102:406-11.  Back to cited text no. 2
Shukla D, Naresh KB, Kim R. Optical coherence tomography findings in Valsalva retinopathy. Am J Ophthalmol 2005;140:134-6.  Back to cited text no. 3


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