RELATIONSHIP BETWEEN RETINAL HEMORRHAGE ON GREEN AND RED CHANNELS OF ULTRA-WIDEFIELD FUNDUS IMAGES AND RETINAL PERFUSION IN ACUTE BRANCH RETINAL VEIN OCCLUSION

PURPOSE

To explore the relationship between retinal hemorrhage in the green and red channels on ultra-widefield fundus images and the nonperfusion area (NPA) on ultra-widefield fundus fluorescein angiography in patients with acute branch retinal vein occlusion (BRVO).

METHODS

This was a retrospective cross-sectional study with 96 patients, including 46 with ischemic BRVO and 50 with nonischemic BRVO. Correlation analysis between green channel hemorrhage (GCH), red channel hemorrhage (RCH), and NPA was performed. Panretina was divided into posterior and peripheral areas.

RESULTS

Ischemic BRVO showed significantly higher GCH% and RCH% than nonischemic BRVO in the peripheral regions (both P < 0.001), whereas no significant differences were observed in the panretinal and posterior areas (all P > 0.05). Significant correlations were found between NPA% in the panretinal and peripheral areas and the corresponding GCH% and RCH% (all P < 0.01). However, no significant correlation was observed between posterior NPA% and posterior GCH% or RCH% (both P > 0.05). In addition, peripheral GCH% and RCH% were related to panretinal NPA% (r = 0.506, P < 0.001; r = 0.558, P < 0.001).

CONCLUSION

Retinal hemorrhage on ultra-widefield fundus image was significantly associated with NPA, providing insights for assessing retinal perfusion status in acute BRVO patients.

Prognostic factors for visual acuity improvement after treatment of submacular hemorrhage secondary to exudative age-related macular degeneration

PURPOSE

To recognize prognostic factors for better final visual acuity (VA) in patients presenting with submacular hemorrhage (SMH) secondary to exudative age-related macular degeneration.

METHODS

This retrospective study included patients who presented to a tertiary ophthalmology department between 2012 and 2019 with SMH and were treated by pars plana vitrectomy (PPV) or injection of tissue plasminogen activator (tPA) with pneumatic displacement. Baseline characteristics included demographic data, VA and optical coherence tomography (OCT) characteristics of the SMH. Patients were divided into groups by improvement of at least 2 lines in BCVA (best corrected visual acuity), and by having a final BCVA better than 20/200.

RESULTS

Forty-three eyes of 43 patients were included. Mean age was 86.72 ± 7.18. Prognostic factors for final VA better than 20/200 included better VA at presentation (1.25 vs 1.90 logMAR, p < 0.001), smaller area of SMH in the infra-red image (19.47 mm2 vs 38.45 mm2, p = 0.024), and lower height of SMH as measured by OCT (713.5 µm vs 962.5 µm, p = 0.03). Third of the patients improved in ≥2 lines from presentation, all in the group of the pneumatic and TPA displacement.

CONCLUSION

Smaller SMHs with good VA at presentation have a better chance for improvement and result in a better final VA. These patients may benefit the most from pneumatic displacement of the SMH with intravitreal tPA and gas.

RESPONSE TO INTRAVITREAL AFLIBERCEPT IN A PATIENT WITH PERIPHERAL EXUDATIVE HEMORRHAGIC CHORIORETINOPATHY

PURPOSE

To draw attention to a novel treatment agent for vision loss associated with peripheral exudative hemorrhagic chorioretinopathy.

METHODS

The case of an 83-year-old man suffering with loss of left visual acuity vision in the context of vitreous hemorrhage secondary to peripheral exudative hemorrhagic chorioretinopathy is described.

RESULTS

Resolution of vitreous hemorrhage and subretinal hemorrhage was demonstrated after treatment with aflibercept.

CONCLUSION

Peripheral exudative hemorrhagic chorioretinopathy is discussed in terms of its presentation, pathophysiology, and existing treatment methodologies.

Retinal and visual function in infants with non-accidental trauma and retinal hemorrhages

PURPOSE

To investigate retinal function and visual outcomes in infants with retinal hemorrhages due to non-accidental trauma (NAT).

METHODS

This is a retrospective review of full-field or multifocal electroretinogram (ERG) recordings, visual acuity in log minimum angle of resolution (logMAR), clinical status, and neuroimaging. Multifocal ERGs from the central 40° were compared to corresponding fundus imaging. Visual acuity was measured by Teller cards at follow-up. ERGs were compared to controls recorded under anesthesia.

RESULTS

Sixteen children met inclusion criteria (14 recorded during the acute phase and 2 during long-term follow-up). During the acute phase, ERGs (n = 4 full field; n = 10 multifocal ERG) showed abnormal amplitude, latency, or both in at least one eye. Ten subjects had significantly reduced responses in both eyes, 3 of which had an ERG dominated by a negative waveform (absent b-wave or P1). The remaining six subjects had responses in one eye that were near normal (≥ 50% of controls). ERGs were sometimes abnormal in local areas without hemorrhage. ERGs could be preserved in local areas adjacent to traumatic retinoschisis. Two subjects with reduced visual acuity had belated ERGs: One had an abnormal macular ERG and the other had a normal macular ERG implying cortical visual impairment. At follow-up, 10 of 14 subjects had significant visual acuity loss (≥ 0.7 age-corrected logMAR); four subjects had mild vision loss (≤ 0.5 age-corrected logMAR). Visual acuity outcome was not reliably associated with the fundus appearance in the acute phase. All subjects with a negative ERG waveform had severe vision loss on follow-up.

CONCLUSIONS

Retinal dysfunction was common during the acute phase of NAT. A near normal appearing fundus did not imply normal retinal function, and ERG abnormality did not always predict a poor visual acuity outcome. However, a negative ERG waveform was associated severe visual acuity loss. Potential artifacts of retinal hemorrhages and anesthesia could not fully account for multifocal ERG abnormalities. Retinal function can be preserved in areas adjacent to traumatic retinoschisis.

Large-scale death of retinal astrocytes during normal development is non-apoptotic and implemented by microglia

Naturally occurring cell death is a fundamental developmental mechanism for regulating cell numbers and sculpting developing organs. This is particularly true in the nervous system, where large numbers of neurons and oligodendrocytes are eliminated via apoptosis during normal development. Given the profound impact of death upon these two major cell populations, it is surprising that developmental death of another major cell type—the astrocyte—has rarely been studied. It is presently unclear whether astrocytes are subject to significant developmental death, and if so, how it occurs. Here, we address these questions using mouse retinal astrocytes as our model system. We show that the total number of retinal astrocytes declines by over 3-fold during a death period spanning postnatal days 5–14. Surprisingly, these astrocytes do not die by apoptosis, the canonical mechanism underlying the vast majority of developmental cell death. Instead, we find that microglia engulf astrocytes during the death period to promote their developmental removal. Genetic ablation of microglia inhibits astrocyte death, leading to a larger astrocyte population size at the end of the death period. However, astrocyte death is not completely blocked in the absence of microglia, apparently due to the ability of astrocytes to engulf each other. Nevertheless, mice lacking microglia showed significant anatomical changes to the retinal astrocyte network, with functional consequences for the astrocyte-associated vasculature leading to retinal hemorrhage. These results establish a novel modality for naturally occurring cell death and demonstrate its importance for the formation and integrity of the retinal gliovascular network.

A study of the neonatal mouse retina shows that developmental cell death of retinal astrocytes does not occur by apoptosis but is instead mediated by microglia, which kill and engulf astrocytes to effect their developmental removal.

Ocular Decompression Retinopathy : A Case Series

INTRODUCTION

Ocular decompression retinopathy (ODR) is a relatively rare entity with variable prognosis depending on extent and pre-existing condition. This article describes profile of two cases with a brief review of the condition.

CASE REPORT

Case 1 highlights extensive choroidal detachment with subhyaloid haemorrhage and multiple intra-retinal hemorrhages in the posterior pole seen on first post-operative day in a 6 year old child with congenital glaucoma who underwent Trab & Trab. Case 2 describes multiple intraretinal hemorrhages seen at posterior pole on second post-operative day in a 24 year old pregnant lady with post traumatic cataract and secondary glaucoma who underwent cataract extraction with Cionni ring. Both patients had complete resolution of the haemorrhages with topical steroids.

CONCLUSION

Ocular decompression retinopathy is mostly seen after operations on cases with advanced glaucoma and those with vulnerable blood flow fluidics. Adequate precautions to prevent this entity should be adopted during surgery and management of the manifest entity is conservative with good prognosis.

Submacular Hemorrhage: Visual Outcomes and Prognostic Factors

PURPOSE

To describe causes, visual outcomes, and prognostic factors in patients with submacular hemorrhage (SMH).

DESIGN

Retrospective case review.

METHODS

We performed a retrospective review of SMH with a size of at least 1 disc diameter. SMH causes were classified into 3 groups: 1) neovascular age-related macular degeneration (nAMD), 2) polypoidal choroidal vasculopathy (PCV), and 3) other miscellaneous causes.

RESULTS

Ninety-eight eyes of 98 patients were included. Based on clinical presentation and indocyanine green angiography (ICGA), the diagnoses of PCV (59%), nAMD (31%), and miscellaneous other causes (10%) were made. PCV patients were younger (P = 0.005) and had larger SMH size than nAMD patients (P = 0.008). Poor visual outcome [>1.0 logarithm of the minimum angle of resolution (logMAR)] at 6 months was associated with low initial visual acuity (VA; >1.0 logMAR; P = 0.002) and with the diagnosis of nAMD (P = 0.02). In addition, limited visual outcomes were noted for patients older than 65 years and those with persistent SMH for at least 2 months.

CONCLUSIONS

PCV was the most common cause of SMH in Thailand. ICGA represented a valuable tool for the diagnosis. Visual outcomes were limited for patients with nAMD and for patients who presented with poor initial VA.

Diabetic phenotype of transgenic pigs introduced by dominant-negative mutant hepatocyte nuclear factor 1α

AIM

The present study aimed to identify the characteristics of genetically modified pigs carrying a mutant human gene as a research model for diabetes and its complications.

METHODS

We developed a transgenic cloned pig (founder, male) carrying a mutant gene, i.e., human HNF-1α (P291fsinsC), which is responsible for maturity-onset diabetes of the young type 3. Transgenic progeny obtained via the artificial insemination of wild type (WT) sows with the cryopreserved sperm derived from the founder pig was pathologically examined.

RESULTS

The transgenic progeny maintained a high blood glucose level (>200mg/dL). Additionally, the oral glucose tolerance test results showed that the recovery of blood glucose levels in the transgenic progeny was significantly delayed compared with that in the WT semi-siblings. Hypoplasia of the islets of Langerhans was confirmed by the histopathological image of the pancreas, based on the hyperglycemia noted in the progeny being ascribed to decreased insulin secretion. Retinal hemorrhage and cotton-wool spots, i.e., findings consistent with non-proliferative diabetic retinopathy, were detected, and these progressed over time. The histopathological image of the renal glomeruli showed a nodular lesion that is characteristic of diabetic nephropathy in humans.

CONCLUSIONS

These data demonstrated that the genetically modified pig that we developed is a promising model for research on diabetes and its complications.

Higher skin autofluorescence in young people with Type 1 diabetes and microvascular complications

AIM

To test the hypothesis that non-invasive skin autofluorescence, a measure of advanced glycation end products, would provide a surrogate measure of long-term glycaemia and be associated with early markers of microvascular complications in adolescents with Type 1 diabetes.

METHODS

Forearm skin autofluorescence (arbitrary units) was measured in a cross-sectional study of 135 adolescents with Type 1 diabetes [mean ± sd age 15.6 ± 2.1 years, diabetes duration 8.7 ± 3.5 years, HbA_1c 72 ± 16 mmol/mol (8.7 ± 1.5%)]. Retinopathy, assessed using seven-field stereoscopic fundal photography, was defined as ≥1 microaneurysm or haemorrhage. Cardiac autonomic function was measured by standard deviation of consecutive RR intervals on a 10-min continuous electrocardiogram recording, as a measure of heart rate variability.

RESULTS

Skin autofluorescence was significantly associated with age (R² = 0.15; P < 0.001). Age- and gender-adjusted skin autofluorescence was associated with concurrent HbA_1c (R² = 0.32; P < 0.001) and HbA_1c over the previous 2.5-10 years (R² = 0.34-0.43; P < 0.002). Age- and gender-adjusted mean skin autofluorescence was higher in adolescents with retinopathy vs those without retinopathy [mean 1.38 (95% CI 1.29, 1.48) vs 1.22 (95% CI 1.17, 1.26) arbitrary units; P = 0.002]. In multivariable analysis, retinopathy was significantly associated with skin autofluorescence, adjusted for duration (R² = 0.19; P = 0.03). Cardiac autonomic dysfunction was also independently associated with skin autofluorescence (R² = 0.11; P = 0.006).

CONCLUSIONS

Higher skin autofluorescence is associated with retinopathy and cardiac autonomic dysfunction in adolescents with Type 1 diabetes. The relationship between skin autofluorescence and previous glycaemia may provide insight into metabolic memory. Longitudinal studies will determine the utility of skin autofluorescence as a non-invasive screening tool to predict future microvascular complications.

Lipid Subhyaloid Maculopathy and Exposure to High Altitude

BACKGROUND

High altitude retinopathy (HAR) includes a number of diseases related to high altitude such as acute mountain sickness (AMS), high altitude pulmonary edema (HAPE) and high altitude cerebral edema (HACE). High altitude retinopathy is mainly characterized by retinal hemorrhages, usually sparing the macular region, a condition specifically known as high altitude retinal hemorrhages (HARH). The pathogenesis of HARH is unclear. Many studies show that lack of oxygen causes an inadequate autoregulation of retinal circulation, causing vascular incompetence. Other retinal changes described in HAR have been reported, such as optical disk edema, optic disc hyperemia, cotton wool exudates, venous occlusions, and macular edema.

CASE REPORT

In this paper we present a case of an aviator who developed a unilateral maculopathy through subhyaloid lipid accumulation on a climb to the top of Mt. Everest. The clinical findings are suggestive of an apparent case of temporary altitude-induced visual disruption maybe by the same presumable pathogenesis of HARH. Right eye visual loss was perceived at 5150 m when he was trying to take a photograph 40 d into the expedition.

DISCUSSION

The maculopathy developed by this patient adds to the discussion on the pathogenesis of HARH, especially the aspect of this maculopathy and its complete resolution. It seems that autoregulation failure could lead to exudation and lipid deposits in the foveal area. Although macular damage is not a common signal in HARH, checking visual acuity during high altitude expeditions remains an important procedure to avoid late diagnosis as unilateral blindness may not be detected early. Rosas Petrocinio R, Gomes ED. Lipid subhyaloid maculopathy and exposure to high altitude. Aerosp Med Hum Perform. 2016; 87(10):898-900.

Optical Coherence Tomography Follow-up of an Unusual Case of Old Rhegmatogenous Retinal Detachment With a Hemorrhagic Macrocyst at the Macula

A 32-year-old female presented with visual acuity of hand movement close to face, an old inferior rhegmatogenous retinal detachment (RRD), and a large hemorrhagic macular macrocyst (HMM) in the right eye. After 2 weeks of successful vitreoretinal surgery, the HMM started decreasing in height and resolved by 3 months. On optical coherence tomography, a zone of hyperreflectivity in the outer retinal layers was evident on resolution of the cyst. At final follow-up, the visual acuity improved to 1/60 only. Though HMM resolved completely after retinal reattachment, alteration and thickening of microarchitecture of the outer retinal layers ensued.

Visual prognosis of massive submacular hemorrhage in polypoidal choroidal vasculopathy with or without combination treatment

BACKGROUND

Submacular hemorrhage associated with polypoidal choroidal vasculopathy (PCV) may cause severe visual loss. The purpose of this study is to report the visual prognosis of massive submacular hemorrhage in patients with PCV.

METHODS

Twenty patients with PCV and submacular hemorrhage who received either subretinal tissue plasminogen activator (TPA) with vitrectomy or intravitreal injection of TPA and gas to achieve pneumatic displacement of the hemorrhage were enrolled. Additionally, combination treatment with either photodynamic therapy (PDT) or intravitreal injection of vascular endothelial growth factor inhibitors (anti-VEGF) was performed to treat the underlying PCV.

RESULTS

Five patients received subretinal TPA with vitrectomy and 15 patients received intravitreal injection of TPA and gas to remove or displace the submacular hemorrhage. Combination treatment with PDT and intravitreal anti-VEGF was performed in three patients and intravitreal anti-VEGF injection alone in 13 patients. The mean logarithm of the minimal angle of resolution converted from the best corrected visual acuity (BCVA) were improved at 3 months, 6 months, and 12 months. Better initial BCVA, smaller size of submacular hemorrhage and younger age were statistically significant predictors for BCVA. Combination treatment with PDT showed significant efficacy in the improvement of BCVA.

CONCLUSION

Combination treatment of submacular hemorrhage secondary to PCV may yield visual and anatomic improvements. Initial BCVA, the initial size of submacular hemorrhage and age were significant predictors for visual prognosis.

Macular Cavernous Hemangioma Associated With Peripheral Vascular Anomalies and Nonperfusion

Retinal cavernous hemangiomas are benign vascular anomalies that are typically unilateral and located outside of the macula. Fluorescein angiography findings include an early slow-filling, non-leaking lesion with late intermixed lobules of hyperfluorescence and hypofluoresence secondary to plasma and erythrocyte sedimentation. We present a novel case of unilateral macular cavernous hemangioma with bilateral peripheral vascular anomalies and nonperfusion. This may represent a phenotypic variation of hemangiomas that, in conjunction with recent histopathologic and genetic findings, may aid in future therapies for a disease that has been traditionally observed due to slow progression.

Anti-vascular endothelial growth factor with or without pneumatic displacement for submacular hemorrhage

PURPOSE

To compare the treatment outcomes of a combination of pneumatic displacement and intravitreal anti-vascular endothelial growth factor, and anti-vascular endothelial growth factor monotherapy for submacular hemorrhage resulting from exudative age-related macular degeneration.

DESIGN

Retrospective, comparative, interventional case series.

METHODS

Forty eyes treated with a combination therapy and 42 eyes treated with monotherapy for submacular hemorrhage resulting from exudative age-related macular degeneration with no significant difference in baseline central foveal thickness were compared. Central foveal thickness and best-corrected visual acuity (BCVA) at baseline, 1, 3, and 6 months after initial treatment were measured and compared between the 2 groups after adjustment of baseline central foveal thickness.

RESULTS

Central foveal thickness (P < .0001) and BCVA (combination, P < .0001; monotherapy, P = .022) were improved after both treatments. Combination therapy showed more rapid improvement of central foveal thickness (P = .009) and BCVA (P = .007) within 1 month than monotherapy, but there was no difference at 6 months (P = .385 and P = .303, respectively). In eyes with subretinal hemorrhage thicker than 450 μm, visual outcome at 6 months was better in the combination therapy group than in the monotherapy group (P = .021), whereas BCVA showed no significant difference between groups in eyes with subretinal hemorrhage less than 450 μm (P = .930).

CONCLUSIONS

Both treatments are useful options for submacular hemorrhage resulting from exudative age-related macular degeneration. Combination therapy may yield a better treatment outcome than monotherapy in eyes with thick subretinal hemorrhage. Nevertheless, the potential for adverse events resulting from pneumatic displacement should be considered.

Subinternal limiting lamina hemorrhages associated with sudden vascular pressure rise: yellow preretinal hemorrhages

A group of patients with subinternal limiting lamina hemorrhages associated with the Valsalva maneuver have been described. A majority of the patients have shown a striking yellowish coloration to the globular preretinal lesions during their evolution. This unique coloration is probably due to the accumulation of bilirubin during hemoglobin disintegration. Visual prognosis is usually excellent and no retinal or vascular abnormalities have been found after the hemorrhage disappears. The unusual fundus picture presented by this lesion may pose diagnostic problems if the patient is initially seen when this yellow mass is present.

Swept-source optical coherence tomography of retinal cavernous hemangioma: a new imaging modality

The authors report a new, non-invasive diagnostic method in the diagnosis of retinal cavernous hemangioma (RCH). A 6-year-old girl was referred for a non-clearing retinal hemorrhage of 6 months' duration. Fourier-domain optical coherence tomography (FD-OCT) showed an intraretinal lesion with cystic-like internal appearance. Optical shadowing was present, preventing establishment of any subretinal component to the lesion. Swept-source OCT (SS-OCT) showed an intraretinal lesion consisting of a group of clearly defined grape-like caverns with overlying preretinal tissue. Wide-field fundus fluorescein angiography (WF-FFA) confirmed the diagnosis of RCH. SS-OCT was superior to FD-OCT in showing the internal anatomy of the RCH and allowing for the measurement of its structures, confirming the intraretinal location of the lesion and the presence of an associated preretinal tissue. SS-OCT may assist in cases in which hemorrhage prevents an accurate diagnosis by ophthalmoscopy or angiography, thus becoming an alternative imaging method to confirm the diagnosis of RCH while avoiding the risks of fluorescein angiography in children.

Long-term follow-up in preperimetric open-angle glaucoma: progression rates and associated factors

PURPOSE

To investigate the rate of progressive visual field (VF) loss and associated factors for structural or functional progression in preperimetric open-angle glaucoma (OAG).

DESIGN

Longitudinal, observational study.

METHODS

We included 127 eyes of 127 preperimetric OAG patients who were treated with topical medication and followed for more than 5 years. All patients underwent stereo optic disc photography, red-free retinal nerve fiber layer (RNFL) photography, frequency doubling technology perimetry, and standard automated perimetry (SAP). Progression was defined as a structural (glaucomatous change confirmed by stereo optic disc and red-free RNFL photography) or functional (new glaucomatous defect on SAP) deterioration. The progression rate of SAP mean deviation (dB/year) and factors associated with progression were evaluated.

RESULTS

Glaucoma progression was detected in 72 of 127 eyes (56.7%). Mean rate of VF progression was -0.39 ± 0.64 dB/year in all patients; -0.66 ± 0.60 dB/year in progressors and -0.03 ± 0.24 dB/year in nonprogressors. A multivariate Cox proportional hazard model revealed that optic disc hemorrhage (hazard ratio [HR] = 1.718, P = .031) and the percentage reduction in intraocular pressure (IOP; HR = 0.964, P = .002) were significantly associated with disease progression. Patients with disc hemorrhage had a greater cumulative probability of progression than those without disc hemorrhage (P = .014 by log-rank test).

CONCLUSIONS

Our results support the importance of lowering IOP, even at the preperimetric stage. Preperimetric glaucoma patients with disc hemorrhage and insufficient IOP control should be carefully monitored for greater risk of progression.

Multilayered optic disc hemorrhages in adolescents

PURPOSE

To describe the clinical characteristics of multilayered optic disc hemorrhages, which are defined as subretinal, superficial retinal, and subhyaloid or vitreous hemorrhages in adolescents.

METHODS

Case records of adolescents with acute multilayered optic disc hemorrhages were identified and evaluated retrospectively from 1994 to 2012. The appearance of the hemorrhages including the size, location, extension, and disc anatomy was recorded. Fluorescein angiography, visual field examination, and spectral-domain optical coherence tomography were performed in select cases.

RESULTS

Nine boys and 7 girls were included, with a mean age of 15.0 ± 2.6 years. No precipitating factor, such as involuntary Valsalva maneuver, was identified in the majority of patients (93.75%). All eyes were myopic with an average refraction of -4.64 ± 1.88 diopters. Fifteen (93.75%) of the affected optic discs were crowded and tilted with small cups. Peripapillary subretinal hemorrhages were all crescent in shape and located at the nasal disc. Eight (50%) eyes had marked subretinal blood extension exceeding 1 disc diameter away from the disc edge. Superficial flame hemorrhages were predominantly located in the superotemporal part of the disc. Spectral-domain optical coherence tomography of the disc showed vitreopapillary traction and obvious subretinal hemorrhage with increased thickness. All multilayered optic disc hemorrhages resolved spontaneously.

CONCLUSIONS

Multilayered optic disc hemorrhages in adolescents more commonly affect myopic eyes with crowded and tilted discs. The visual outcome is excellent.

[Unique mechanism in heart-shaped balloon burst resulting in blunt ocular injury]

We have previously shown that heart-shaped balloons have a different explosion mechanism than spherical balloons in which the former splits into two rubber parts still attached to the balloon base with a backward whiplash motion. This backward whiplash motion may cause significant blunt ocular trauma if the balloon is inflated by mouth. In this article, the energy of the blunt ocular trauma is estimated by the high speed camera photos analysis of the balloon burst. Furthermore, we describe the followup of eight patients with ocular trauma following inflation of heart-shaped balloons.

Electroretinography combined with spectral domain optical coherence tomography to detect retinal damage in shaken baby syndrome

In order to correlate anatomical changes with visual function in shaken baby syndrome, we performed electroretinography and spectral domain optical coherence tomography on a 2-month-old girl and a 9-month-old girl after the retinal hemorrhages absorbed. Both patients had significant abnormalities in spectral domain optical coherence tomography images of the macular area. The amplitudes of the focal macular electroretinograms were more severely decreased than those of the full-field electroretinograms. Combining spectral domain coherence tomography with focal macular electroretinograms might better estimate the functional damage to the macula in patients with shaken baby syndrome.

Efficacy and safety of recombinant tissue plasminogen activator and gas versus bevacizumab and gas for subretinal haemorrhage

PURPOSE

To report the 12 months efficacy of initial intravitreal bevacizumab or intravitreal recombinant tissue plasminogen activator (rtPA) combined with expansile gas in patients with subretinal haemorrhage caused by neovascular age-related macular degeneration (AMD).

METHODS

Forty-five eyes of 45 patients with subretinal haemorrhage (1-5 disc diameters) involving the fovea secondary to neovascular AMD were evaluated retrospectively consecutively. Thirty-two eyes underwent treatment with rtPA (50 μg/0.05 ml) combined with intravitreal sulphur hexafluoride (SF6). The other 13 eyes were treated with bevacizumab (1.25 mg/0.05 ml) and SF6. Thereafter, all patients received Vascular Endothelial Growth Factor (anti-VEGF) treatment according to modified PrONTO criteria. Main outcome was change of best-corrected visual acuity (VA) at 12 months as determined by Early Treatment Diabetic Retinopathy (ETDRS).

RESULTS

There was more improvement in patients initially treated with rtPA and gas (14 letters; bevacizumab and gas eight letters) and not suffering from adverse events. The incidence of vitreous haemorrhages was significantly higher in the rtPA group (nine of 32 versus one of 13, p < 0.01). In both groups, an average of 3.5 anti-VEGF injections were performed per patient during 12 months (no difference between both groups).

CONCLUSION

Both initial treatment regimen lead to improved functional results after 1 year. However, patients, not suffering from adverse events, who underwent initial treatment with rtPA and gas showed better results. To maintain VA, controlling neovascular AMD by anti-VEGF treatment regime after initial treatment with rtPA+gas is important for all cases.

Intravitreal recombinant tissue plasminogen activator without and with additional gas injection in patients with submacular haemorrhage associated with age-related macular degeneration

PURPOSE

To compare intravitreal recombinant tissue plasminogen activator (rt-PA) treatment with and without gas injection in patients with submacular haemorrhage associated with age-related macular degeneration.

METHODS

We conducted a retrospective, non-randomized comparative case study of 110 eyes from 76 women and 34 men (mean age 78.1 ± 6.9 years). Evaluations of the data were performed for baseline visit (t1), and visits 1-3 weeks (t2), 3 months (t3) and 6 months after (t4). The patients were classified according to gas treatment into group A (without gas, n = 46) and group B (with gas, n = 64) and according to rt-PA-dosage into group A1 and B1 (50 μg), group A2 and B2 (100 μg), and group A3 and B3 (200 μg).

RESULTS

 At t4, the patients in group A had a median increase of 0.4 logMAR, and those in group B had a decrease of 0.1 logMAR (p = 0.183). The best corrected visual acuity (BCVA) remained stable or increased in 55% and 62% of patients in groups A and B, respectively (p = 0.151), in 50% and 68% of patients in groups A1 and B1, respectively (p = 0.620), in 40% and 100% of patients in groups A2 and B2, respectively (p = 0.250), and in 75% and 63% of patients in groups A3 and B3, respectively (p = 0.463). Complications were observed in 13.6% of patients.

CONCLUSIONS

Best results were obtained in patients treated with 50 and 100 μg of rt-PA and in those cases BCVA development was more beneficial if additional gas was injected.

Retinal changes in various altitude illnesses

INTRODUCTION

This study aimed to evaluate the retinal changes associated with altitude illness in young soldiers.

METHODS

A total of 50 young soldiers with altitude illness, who were referred to a tertiary care hospital between October 2003 and January 2006, were included in the study.

RESULTS

All the soldiers were male. The mean age of the subjects was 30.3 (range 20-44) years. Nine (18 percent) soldiers had acute mountain sickness (AMS), nine (18 percent) had high-altitude pulmonary oedema (HAPE) and 20 (40 percent) had high-altitude cerebral oedema (HACE). Retinal haemorrhages were observed in 29 soldiers (58 percent). Among these 29 cases, two also had symptoms of AMS, five had symptoms of HAPE and twelve had symptoms of HACE. High-altitude retinal haemorrhage alone as a sign of altitude illness was seen in ten cases. Severe grades of high-altitude retinopathy were found mostly in soldiers who suffered from HAPE and HACE. Visual recovery was complete in 22 (76 percent) soldiers. High-altitude retinal haemorrhage was associated with partial visual impairment in five (17 percent) soldiers and permanent visual loss in two (seven percent) soldiers.

CONCLUSION

Retinal haemorrhages were noticed in 58 percent of soldiers with altitude illness. The association of severe grades of high-altitude retinopathy with HAPE and HACE was statistically significant. Branch retinal vein occlusion with macular oedema is an additional finding in our study, which has not been previously reported.

Central and hemicentral retinal vein occlusion: role of anti-platelet aggregation agents and anticoagulants

OBJECTIVE

To investigate systematically the role of anti-platelet-aggregating drugs or anticoagulants in central retinal vein occlusion (CRVO) and hemi-CRVO.

DESIGN

Cohort study.

PARTICIPANTS

Six hundred eighty-six consecutive patients with CRVO (567 patients, 585 eyes) and nonischemic hemi-CRVO (119 patients, 122 eyes).

METHODS

At first visit, all patients had a detailed ophthalmic and medical history (including the use of anti-platelet aggregating drugs or anticoagulants), and comprehensive ophthalmic and retinal evaluation. Visual evaluation was carried out by recording visual acuity, using the Snellen visual acuity chart, and visual fields with a Goldmann perimeter. The same ophthalmic evaluation was performed at each follow-up visit. At the initial visit, CRVO and hemi-CRVO were classified as nonischemic and ischemic.

MAIN OUTCOME MEASURES

Visual acuity, visual fields, and severity of retinal hemorrhages.

RESULTS

All 3 types of CRVO, showed a significantly greater severity of retinal hemorrhages among aspirin users than nonusers (P<0.001). Initial visual acuity and visual fields were significantly worse in aspirin users than nonusers in nonischemic CRVO and hemi-CRVO, but did not differ for ischemic CRVO. Among patients with nonischemic CRVO who initially had 20/60 or better visual acuity, there was a significant association of aspirin use with visual acuity deterioration. The odds ratio of visual acuity deterioration, adjusting for age, diabetes, ischemic heart disease, and hypertension, for aspirin users relative to nonusers was 2.24 (95% confidence interval [CI], 1.14-4.41; P = 0.020). Of those whose macular edema resolved, overall cumulative visual acuity outcome also suggested a higher percentage with deterioration among aspirin users, odds ratio for deterioration of 3.62 (95% CI, 0.97-13.54; P = 0.05) for aspirin users relative to nonusers. For the nonischemic CRVO patients with 20/70 or worse visual acuity at the initial visit, after resolution of macular edema, improvement in visual acuity was less likely in the aspirin users than in nonusers (odds ratio, 0.18; 95% CI, 0.04-0.72; P = 0.016).

CONCLUSIONS

Findings of this study indicate that, for patients with CRVO and hemi-CRVO, the use of aspirin, other anti-platelet aggregating agents, or anticoagulants was associated with a worse visual outcome and no apparent benefit.

FINANCIAL DISCLOSURE(S)

The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Characteristics of eyes with secondary loss of visual acuity receiving variable dosing ranibizumab for neovascular age-related macular degeneration

PURPOSE

The aim of this work is to investigate the characteristics of eyes failing to maintain visual acuity (VA) receiving variable dosing ranibizumab for neovascular age-related macular degeneration (nAMD) after three initial loading doses.

METHODS

A consecutive series of patients with nAMD, who, after three loading doses of intravitreal ranibizumab (0.5 mg each), were re-treated for fluid seen on optical coherence tomography. After exclusion of eyes with previous treatment, follow-up less than 12 months, or missed visits, 99 patients were included in the analysis. The influence of baseline characteristics, initial VA response, and central retinal thickness (CRT) fluctuations on the VA stability from month 3 to month 24 were analyzed using subgroups and multiple regression analyses.

RESULTS

Mean follow-up duration was 21.3 months (range 12-40 months, 32 patients followed-up for ≥24 months). Secondary loss of VA (loss of five letters or more) after month 3 was seen in 30 patients (mean VA improvement from baseline +5.8 letters at month 3, mean loss from baseline -5.3 letters at month 12 and -9.7 at final visit up to month 24), while 69 patients maintained vision (mean gain +8.9 letters at month 3, +10.4 letters at month 12, and +12.8 letters at final visit up to month 24). Secondary loss of VA was associated with the presence of pigment epithelial detachment (PED) at baseline (p 0.01), but not with baseline fibrosis/atrophy/hemorrhage, CRT fluctuations, or initial VA response. Chart analysis revealed additional individual explanations for the secondary loss of VA, including retinal pigment epithelial tears, progressive fibrosis, and atrophy.

CONCLUSIONS

Tissue damage due to degeneration of PED, retinal pigment epithelial tears, progressive fibrosis, progressive atrophy, or massive hemorrhage, appears to be relevant in causing secondary loss of VA despite vascular endothelial growth factor suppression. PED at baseline may represent a risk factor.

Delayed appearance of high altitude retinal hemorrhages

BACKGROUND

Retinal hemorrhages have been described as a component of high altitude retinopathy (HAR) in association with altitude illness. In this prospective high altitude study, we aimed to gain new insights into the pathophysiology of HAR and explored whether HAR could be a valid early indicator of altitude illness.

METHODOLOGY/PRINCIPAL FINDINGS

28 mountaineers were randomly assigned to two ascent profiles during a research expedition to Mt. Muztagh Ata (7546 m/24,751 ft). Digital fundus photographs were taken prior to expedition at 490 m (1,607 ft), during expedition at 4497 m (14,750 ft = base camp), 5533 m (18,148 ft), 6265 m (20,549 ft), 6865 m (22,517 ft) and 4.5 months thereafter at 490 m. Number, size and time of occurrence of hemorrhages were recorded. Oxygen saturation (SpO₂) and hematocrit were also assessed. 79% of all climbers exhibited retinal hemorrhages during the expedition. Number and area of retinal bleeding increased moderately to medium altitudes (6265 m). Most retinal hemorrhages were detected after return to base camp from a high altitude. No post-expeditional ophthalmic sequelae were detected. Significant negative (SpO₂ Beta: -0.4, p<0.001) and positive (hematocrit Beta: 0.2, p = 0.002, time at altitude Beta: 0.33, p = 0.003) correlations with hemorrhages were found.

CONCLUSIONS/SIGNIFICANCE

When closely examined, a very large amount of climbers exhibit retinal hemorrhages during exposure to high altitudes. The incidence of retinal hemorrhages may be greater than previously appreciated as a definite time lag was observed between highest altitude reached and development of retinal bleeding. Retinal hemorrhages should not be considered warning signs of impending severe altitude illness due to their delayed appearance.

[Diabetic retrohialoidian hemorrage--invasive minimal treatment]

Subhyaloid hemorrhage is defined as a localized detachment of vitreous from the retina caused by the accumulation of blood, which can lead to sudden and severe loss of vision when it takes place in the macular area. The treatment ranges from conservative to posterior vitrectomy depending on the cause, age and the status of other eye.

Clinical features and follow-up results of pulsating polypoidal choroidal vasculopathy treated with photodynamic therapy

PURPOSE

 To report on the clinical course of pulsating polypoidal choroidal vasculopathy (PCV) treated with photodynamic therapy (PDT).

METHODS

  A total of 63 eyes of 58 consecutive patients diagnosed with PCV, treated with PDT and followed up for at least 6months were enrolled. Best-corrected visual acuity (BCVA), fluorescein angiography and high-speed indocyanine green angiography (ICGA) using confocal scanning laser ophthalmoscopy (HRA) were performed.

RESULTS

  Of the 63 PCV eyes, 14 eyes (22.2%) of 14 patients were classified as having pulsating PCV. The mean age of pulsating PCV patients was 60.6±7.0years (48-69years), which was younger than non-pulsating PCV patients (65.7years, p=0.035). The mean follow-up period was 23.9±10.7months, and PDT was administered 1.6±0.9 times to pulsating PCV patients. The mean logMAR BCVAs were 0.85±0.47 at presentation and 0.71±0.52 at final examination. Extensive haemorrhagic events were more common in pulsating than in non-pulsating PCV patients (57.1% versus 26.5%, p=0.032). However, the risk of haemorrhage within 3months of PDT was similar for both pulsating PCV and the remaining patients (14.3% versus 20%, p=0.723).

CONCLUSION

  Pulsating PCV showed distinctive features including a relatively younger patient age at presentation, and a haemorrhagic tendency (especially extensive). However, the use of PDT did not directly increase the risk of haemorrhage in pulsating PCV patients.

Predictable signs of benign course of polypoidal choroidal vasculopathy: based upon the long-term observation of non-treated eyes

PURPOSE

To find predictable signs of benign polypoidal choroidal vasculopathy (PCV).

METHODS

Medical records of 13 eyes from 12 patients who were followed up for 5 years or longer without treatment among 258 consecutive patients with PCV were reviewed retrospectively. The main outcomes measured were best corrected visual acuity (BCVA) and fundus findings during the follow-up period.

RESULTS

The average age at presentation was 68 years, and the average follow-up period after diagnosis was 80 months (range, 62-119 months). The initial mean logarithmic value of the minimal angle of resolution (logMAR) BCVA was 0.28 +/- 0.26, and the final mean logMAR BCVA was 0.62 +/- 0.72. The difference in the logMAR BCVA values between the two points was not statistically significant (p > 0.05). The trend of change from baseline at 2-year follow-up was consistent with those at 5-year follow-up in nine eyes. Fundus findings at the initial examination were classified into two patterns: (i) reddish-orange nodules and detachment of the retinal pigment epithelium with/without detachment of the neurosensory retina (nine eyes); (ii) reddish-orange nodules alone, or nodules and small subretinal haemorrhage (four eyes). In the eyes with the first pattern, clinical course and visual prognosis were variable. An absence of hard exudates could be a sign to maintain a benign clinical course or stable vision with this pattern. The eyes with the second pattern took a benign clinical course with stable vision.

CONCLUSIONS

There is certainly a group of PCV eyes with a benign prognosis. Considering the huge cost and risk of current therapies, the initial ocular findings could be deciding factors that determine the necessity for further treatment.

Finite element model of ocular injury in abusive head trauma

PURPOSE

To develop a finite element analysis of the eye and orbit that can be subjected to virtual shaking forces.

METHODS

LS-DYNA computer software was used to design a finite element model of the human infant eye, including orbit, fat, sclera, retina, vitreous, and muscles. The orbit was modeled as a rigid solid; the sclera and retina as elastic shells; the vitreous as viscoelastic solid or Newtonian fluid; and fat as elastic or viscoelastic solid. Muscles were modeled as spring-damper systems. Orbit-fat, fat-sclera, sclera-retina, and vitreous nodes-retina interfaces were defined with the use of the tied surface-surface function in LS-DYNA. The model was subjected to angular acceleration pulses obtained from shaking tests of a biofidelic doll (Aprica 2.5 kg dummy). Parametric studies were conducted to evaluate the effect of varying the material properties of vitreous/fat on maximum stress and stress distribution.

RESULTS

With the vitreous modeled as a Newtonian fluid, the repeated acceleration-deceleration oscillatory motion characteristic of abusive head trauma (AHT) causes cumulative increases in the forces experienced at the vitreoretinal interface. Under these vitreous conditions, retinal stress maximums occur at the posterior pole and peripheral retina, where AHT retinal hemorrhage is most often found.

CONCLUSIONS

Our model offers an improvement on dummy and animal models in allowing analysis of the effect of shaking on ocular tissues. It can be used under certain material conditions to demonstrate progressive "stacking" of intraocular stresses in locations corresponding to typical AHT injury patterns, allowing a better understanding of the mechanisms of retinal hemorrhage patterns.

Violence is not necessary to produce subdural and retinal haemorrhage: a reply to Puntet al

In this article we reply to the recent critique by Punt et al. in Pediatric Rehabilitation. Our hypothesis about the pathogenesis of intracranial bleeding in infants has three important implications. First, in the case of an infant with a swollen brain, subdural and retinal haemorrhage but no objective evidence of trauma, the findings by themselves are not certain evidence of abuse; second, violence is not necessary to produce subdural and retinal haemorrhage; and lastly, non-traumatic events producing apnoea with a catastrophic rise in intracranial pressure could produce a clinical picture identical to that seen in trauma.

[Surgical treatment policy using recombinant prourokinase for submacular hemorrhages]

An immunofluorescence technique was used to study the transretinal penetration of intravitreal fibrinolytic agent Hemase (a recombinant urokinase) in an experiment on 4 rabbit eyes. Hemase (54 kD) was proved to be able to penetrate across all retinal layers 2 hours after intravitreal administration. The efficacy of Hemase was tested in the treatment of submacular hemorrhages (SMH) of various etiology. Thirteen patients with SMH associated with age-related macular degeneration or ophthalmic injury were enrolled in the study. Hemase 500 IU was intravitreally injected 24 hours before pneumatic dislocation of SMH in 10 patients. In 3 patients with massive SMH, the proposed vitrectomy procedure was employed, by epiretinally injecting the fibrinolytic agent under a gas bubble, followed by drainage of the subretinal space. The operation was ended, by administering air and Hemase, and then by putting the patient in the supine position for 3-4 hours, thereafter his/her position was recommended to be changed to the prone position to realize the mechanism of pneumatic dislocation. The studies suggest that pneumatic SMH dislocation in combination with Hemase administration permits visual acuity to be increased in 80% of cases. The efficiency of manipulation and the functional outcome of treatment depend on the etiology of hemorrhage. The proposed vitrectomy technique using Hemase reduces neuroepithelial injury, effectively drains SMH, and dislocates its remnants from the foveal area.

Combined treatment of acute subretinal haemorrhages with intravitreal recombined tissue plasminogen activator, expansile gas and bevacizumab: a retrospective pilot study

PURPOSE

To assess the effectiveness of consecutive intravitreal injections of recombined tissue plasminogen activator (rtPA), expansile gas and bevacizumab in eyes with acute subretinal haemorrhage (SRH).

METHODS

A retrospective, non-randomized consecutive case series included 19 eyes in 19 patients with SRH related to exudative age-related macular degeneration (AMD). The initial size of the subfoveal SRH was 1-3 disc diameters. Each patient received a triple procedure using 0.05 ml rtPA (50 microg), 0.3 ml of sulphur hexafluoride (SF6) gas and 0.05 ml bevacizumab (1.25 mg). Lesion size, location of the SRH and early treatment in diabetic retinopathy study (ETDRS) visual acuity were evaluated pretreatment as well as 1 and 3 months after the procedure.

RESULTS

At the initial presentation, the patients' mean age was 77 years (range 63-88 years) and the mean duration of symptoms was 9.3 days (range 4-12 days). The mean visual acuity pretreatment (20/133) improved significantly to 20/86 at 1 month and to 20/74 at 3 months. The mean ETDRS visual acuity improved from baseline by 2.1 lines at 1 month (Wilcoxon ranks test; P < 0.005) and 3.7 lines at 3 months after treatment (Wilcoxon ranks test; P < 0.005). None of our patients had reading visual acuity prior to treatment, with visual acuity below 0.3. One month after the triple procedure, 25% of our patients had reading visual acuity (> or = 0.4); at 3 months, the figure was 35%. A successful inferior displacement of the SRH was achieved in 17/19 eyes. Eyes with elevated intraocular pressure were treated immediately by a corneal paracentesis.

CONCLUSION

The intravitreal application of rtPA, gas and bevacizumab appears to be beneficial and well tolerated in the treatment of SRH in the short term. The triple approach seems a logical alternative to the current combined dual approach in limiting the progression of the underlying disease and achieving better visual outcome. Further randomized evaluations are warranted.

The use of intravitreal etanercept in diabetic macular oedema

The aim of this pilot study was to investigate the effect of intravitreal administration of etanercept in refractory diabetic macular edema. Seven patients diagnosed with diabetic macular edema, refractory to previous treatment, were enrolled. They all received 2 consecutive intravitreal injections of 2.5 mg (0, 1 ml) of Etanercept (Enbrel), with a two-week interval. In all patients visual acuity assessment, fundoscopy and fluorescein angiography were performed prior to the first injection, weekly for the first month, as well as 2 and 3 months following the first injection. No adverse reactions or adverse events were noticed in any patient. Analysis of the data indicates a trend for improvement of visual acuity, a slight worsening of hard exudates and fluorescein leakage, while hemorrhages remained stable, 3 months after initiation of therapy. However, no statistical significance has been reached. This small pilot study did not reveal any improvement in the clinical course of patients with refractory diabetic macular edema after the intravitreal injection of etanercept. Further research is warranted in order to obtain conclusive results concerning the role of anti-TNF therapy in diabetic macular edema.

Nd:YAG laser treatment for Valsalva premacular hemorrhages: 6 month follow up : alternative management options for preretinal premacular hemorrhages in Valsalva retinopathy

The aim of this study was to determine visual outcomes, complications, and long-term effects of drainage of preretinal (premacular) hemorrhage into the vitreous with Neodymium (Nd)-YAG laser in patients due to Valsalva retinopathy. A total of 12 patients with preretinal and premacular hemorrhage presumably caused by Valsalva maneuver was studied. All patients denied any history of ocular disease prior to presentation. Conservative treatment with observation, Nd-YAG hyaloidotomy, and vitrectomy were offered to all patients. A total of 11 patients opted for laser treatment, and one opted for conservative treatment with observation after counseling and informed consent. Nd-YAG-laser hyaloidotomy was performed to drain the hemorrhage into the vitreous cavity. Visual acuity and was recorded prior to treatment and at 1- and 6-month intervals after treatment. Complete retinal examination was undertaken at each visit when possible. Visual acuity improved in 11 patients after the Nd-YAG hyaloidotomy. No postlaser complications were noted at 6 months follow-up. One patient declined treatment and was monitored. Drainage of premacular preretinal hemorrhage due to Valsalva retinopathy into the vitreous with a Nd-YAG laser is a treatment alternative with potential of quick visual rehabilitation. Long-term results are unknown; however, short-term (up to 6 months) follow-up showed good results.

Subhyaloidal and macular haemorrhage: localisation and treatment strategies

Deterioration of visual acuity as a result of haemorrhage

Observation or surgical excision of bilateral subfoveal choroidal neovascularization in Best disease

The purpose of this article is to describe a case of bilateral neovascularization complicating Best Disease. A 12-year-old patient with bilateral neovascularization was managed with observation in the right eye and surgical removal in the other eye. Visual acuity, biomicroscopy and fluorangiography were carried out from 1997 to 2005. The right eye did not experience any change in visual acuity from baseline (20/50) while left eye varied from 20/200 to 20/32. Macular exudative-hemorrhagic manifestations resolved bilaterally. Eight years later, VA and retinal findings were unchanged. In this case, although VA was reasonably good in both eyes, it is difficult to assess the prognosis of surgically excised neovascularization vs natural history, also considering that nowadays photodynamic therapy and antiangiogenetic drugs are considered the therapy of choice in subfoveal neovascularization.

Pneumatic displacement of submacular hemorrhage due to age-related macular degeneration

PURPOSE

Subretinal hemorrhage is one of the most serious complications of exudative age-related macular degeneration (AMD). Treatment with vitreous surgery with or without plasminogen activator, fluid-gas exchange, or perfluorocarbon yields only a small improvement in visual acuity.

PATIENTS AND METHODS

The files of 24 patients with submacular hemorrhage secondary to AMD who were treated by injection of perfluoropropane gas (C(3)F(8)) (11 patients) or sulfur hexafluoride (SF(6)) (13 patients) were reviewed for visual acuity before and after the procedure and time of treatment from onset of symptoms.

RESULTS

For the whole sample, pneumatic displacement led to a statistically significant improvement in mean visual acuity (p = 0.015). A significant difference between pre- and postoperative visual acuity was found for the patients treated with SF(6) (p = 0.034), but not for the patients treated with C(3)F(8) (p = 0.245).

CONCLUSION

The use of gas injection to displace submacular hemorrhage can significantly improve visual acuity.

Valsalva retinopathy associated with fiberoptic gastroenteroscopy

CASE REPORT

A 45-year-old woman presented with a sudden loss of vision in her left eye, which occurred while she was having a routine upper fiberoptic gastroenteroscopy. According to the gastrointestinal specialist, the patient had performed multiple sustained Valsalva maneuvers during the procedure. Funduscopy showed a preretinal hemorrhage with a half disc diameter in the fovea of the left eye.

COMMENTS

A diagnosis of Valsalva retinopathy was made on the basis of history and fundus finding. The hemorrhage resolved within 2 months without any sequelae. To our knowledge, this is the first report of the occurrence of Valsalva retinopathy following a routine upper fiberoptic gastroenteroscopy.