Valsalva retinopathy is a rare disease characterized by a sudden visual loss due to pre-retinal hemorrhage, caused by a rapid increase in intraocular venous pressure  . It often occurs in healthy young adults, following various clinical contexts: intense aerobic exercise, defecation effort, vomiting and in many other circumstances. The associated visual loss can be profound if hemorrhage occurs in the pre-macular region. We report a case of Valsalva retinopathy in a pregnant woman.
This study aims to reinforce conservatory treatment in priority.
2. Case Report
This study aims to highlight the place of pregnancy in this pathology, and to show the therapeutic modalities. A 36-year-old patient who consulted for sudden decrease of visual acuity that had been evolving for 24 hours in the left eye. Pregnant of 24 weeks, she startled after being frightened, then she performed Valsalva maneuvers to calm down her panic and control her breathing. Visual acuity assessment showed an important decrease in the left eye to “see a hand moving”, while visual acuity in the right eye was 20/20. Fundus examination revealed a massive macular pre-retinal hemorrhage in the left eye. We see a bud in front of a temporal vessel of the lesion (Figure 1). The fundus of the right eye was normal.
The biological assessment performed by her obstetrician had found a normal platelet count, there was no blood-clotting. Retinal fluorescein angiography (FGA) performed two months later showed no leakage, justifying a spontaneous and isolated nature of the phenomenon without any other retinal lesion. A slower venous return to the arteriovenous time especially on the lower temporal vein, facing the bud (Figure 2(a)). Late-time dilatation of the same vein (Figure 2(b)) suggesting a venous hemorrhage.
Spontaneous evolution was marked by a fast and progressive reduction of hemorrhage and progressive recovery of vision in the left eye. At one month, the hemorrhage had reduced by almost a quarter (Figure 3(a)), and by two months by almost two-thirds (Figure 3(b)).
The patient gave birth vaginally at 37 weeks of pregnancy, without anesthesia, and without complications. Reviewed 2 months after vaginal delivery, that is 5 months after diagnosis, there was a complete anatomical and functional restoration, with a visual acuity of 20/20 in the left eye.
Valsalva retinopathy was described for the first time by Duane in Philadelphia in 1972  on a series of 3 patients composed of two women and one man. None of
Figure 1. Massive pre-retinal hemorrhage.
Figure 2. (a) Slower venous return on the lower temporal venous at the beginning of the arteriovenous time; (b) Late-time dilatation of the temporal lower vein.
Figure 3. (a) Regression of hemorrhage 1 month later; (b) Regression of 2/3 of the hemorrhage 2 months later.
both women were pregnant. However, several authors have then described this pathology in pregnant women      . Pre-retinal hemorrhage is related to cephalic hypertension   .
The mechanism of this venous cephalic hypertension is explained by the Valsalva maneuver. There are anatomical adhesions of the vitreous to the retinal vessels. The thoracic hypertension by blocking in inspiration has repercussions on the cephalic venous circulation and then on the retinal venous one. Under the effect of retinal venous hypertension, the adhesions pull the vessel that breaks, it is the vitreous traction on a vein that causes its rupture   . Kadrmas  shows the rupture of a large superior temporal vein that is responsible for Valsalva hemorrhage. This let us mention a venous lesion, even though the lesion is not clear in our figures. In Valsava hemorrhage case, initial lesion is not always visible  .
During pregnancy, there is an increase in intra-abdominal pressure. With the Valsalva maneuvers, the pressure becomes considerable to cause the venous rupture   .
In our case, this maneuver was initially due to a reflex, because frightened the patient blocked her breathing in inspiration in a start, then voluntary hyperventilation to calm the panic.
In the case of Nghiem-Buffet, Tara F, Sanjeewa S and García-Fernández     , the maneuver was related to vomiting. El-Khayat  has found Yoga apnea exercises.
Aside from pregnant women, Valsalva hemorrhagic retinopathy has also been found regardless of sex, in other circumstances, such as: 1) after a sneeze crisis  ; 2) in post coital  ; 3) after general anesthesia associated with vomiting   ; 4) after traumatic thoracic compression  ; 5) in the practice of weightlifting  .
Expectancy is often recommended. The usual resorption of hemorrhage without sequelae is common     . The timing of spontaneous resorption is very variable. In our case, it was 5 months, as for El-Khayat  . Guignon Souquet  noticed resorption after 8 months without treatment. Physical or surgical interventions are likely to bring visual recovery more quickly.
In a series of 6 cases of Valsava hemorrhage, García-Fernández  has realized for the first case a derivation of blood in the vitreous with Nd:Yag laser firstly, but the maneuver failed. Finally she performed a vitrectomy, and the patient indeed completely recovered his vision 10 days after operation. For the 4 remaing patients, vitrectomy was performed as first-intention with total visual recovery. For the last patient who had a small hemorrhage less troublesome for vision she had performed a conservative treatment and the haemorrhage resorbed spontaneously after one month.
In a series of 12 cases, Khan  performed Nd:Yag laser treatment on 11 patients without any complication, the 12th who preferred a conservative treatment recovered more slowly. Bypareddya  has noted an iatrogenic macular hole with Nd:Yag laser in the treatment of a case of pre-retinal hemorrhage, which shows that these interventions are associated with some degree of risk.
Despite the great potential of vaginal delivery to replicate the Valsalva maneuver  , Wickremasinghe  , who analyzed these deliveries in pregnant women with Valsalva hemorrhage, sustains that vaginal delivery without epidural or other intervention is the method that presents the least risk of hemorrhage aggravation.
Valsalva hemorrhagic retinopathy is a rare pathology that is often responsible for sudden unilateral poor vision associated with pre-macular retinal hemorrhage. Visual recovery usually occurs after six months without treatment. Nd:Yag laser treatment can quickly help to clear the posterior pole by dispersing the blood in the vitreous. Vitrectomy makes it possible to clean up all the hemorrhage more quickly. We should specify that these two interventions are not without complications.
Written informed was obtained from the patient for publication of this case report and any accompanying images.
 García-Fernández, M., Castro-Navarro, J. and Gonzalez-Castano, C. (2012) Long-Term Evolution of Valsalva Retinopathy: A Case Series. Journal of Medical Case Reports, 6, 346.
 Wickremasinghe, S.S., Tranos, P.G. and Davey, C. (2003) Valsalva Haemorrhagic Retinopathy in a Pregnant Woman: Implications for Delivery. Acta Ophthalmologica Scandinavica, 81, 420-422.
 Matonti, F., Donadieu, V., Hoffart, L., Dornadin, A., Nadeau, S., Roux, S. and Denis, D. (2013) Traitement précoce par laser Nd:YAG de la rétinopathie de Val-salva: Resultants à propos de cinq cas et revue de la literature. Journal Français d’Ophtalmologie, 36, 604-609.
 Guigon-Souquet, B., Salaun, L., Macarez, R., Bazin, S., De La Manierre, E. and Mazdou, M. (2004) Hemorragie rétrohyaloïdienne secondaireà une manœuvre de Valsalva. Journal Français d’Ophtalmologie, 27, 1159-1162.
 Patane, P.S., Krummenacher, T.K. and Rao, R.C. (2015) Valsalva Hemorrhagic Re-tinopathy Presenting as a Rare Cause of Impaired Vision after a General Anesthetic—A Case Report and Review of the Literature. Journal of Clinical Anesthesia, 27, 341-346.
 Khan, M.T., Saeed, M.U., Shehzad, M.S. and Qazi, Z.A. (2008) Nd:YAG Laser Treatment for Valsalva Premacular Hemorrhages: 6 Month Follow up: Alternative Management Options for Preretinal Premacular Hemorrhages in Valsalva Retinopa-thy. International Ophthalmology, 28, 325-327.
 Eneh, A. and Almeida, D. (2013) Valsalva Hemorrhagic Retinopathy during Labour: A Case Report and Literature Review. Canadian Journal of Ophthalmology, 48, 145-147.