Case of the Month I September 2020

Case of the Month
September 23, 2020

The Case

The patient was a 30-year-old healthy woman who experienced a sudden loss of vision in her right eye. She said that she was not doing anything unusual at the time. The visual acuity was finger counting OD and 20/20 OS. The examination was unremarkable in each eye, except for the fundus findings in the right eye (see photo). What was the most likely diagnosis? What treatment, if any, would you recommend?

The patient had a large subhyaloid hemorrhage, as well as a smaller vitreous hemorrhage.

There are many causes of preretinal hemorrhaging, which is often subhyaloid in younger patients who have not had separation of the posterior hyaloid face. Our patient denied straining at the time of the incident, but it was possible that Valsalva retinopathy could explain the hemorrhage. Perhaps the history was inaccurate, or perhaps she sneezed or coughed hard prior to bleed. Another leading diagnostic consideration is a congenital vascular anomaly that spontaneously bled. It would be unusual, but not impossible, for someone her age without a significant past medical history to have a retinal artery macroaneurysm or neovascularization, for example from a branch retinal vein occlusion.

Subhyaloid hemorrhages generally do not resolve in a timely fashion. We did vitrectomy to remove the blood, and the patient had excellent post-operative vision. Interestingly, there were no remarkable vascular findings, indicating that the underlying cause was likely Valsalva retinopathy.

Case Photos

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The patient had a large subhyaloid hemorrhage, as well as a smaller vitreous hemorrhage.

There are many causes of preretinal hemorrhaging, which is often subhyaloid in younger patients who have not had separation of the posterior hyaloid face. Our patient denied straining at the time of the incident, but it was possible that Valsalva retinopathy could explain the hemorrhage. Perhaps the history was inaccurate, or perhaps she sneezed or coughed hard prior to bleed. Another leading diagnostic consideration is a congenital vascular anomaly that spontaneously bled. It would be unusual, but not impossible, for someone her age without a significant past medical history to have a retinal artery macroaneurysm or neovascularization, for example from a branch retinal vein occlusion.

Subhyaloid hemorrhages generally do not resolve in a timely fashion. We did vitrectomy to remove the blood, and the patient had excellent post-operative vision. Interestingly, there were no remarkable vascular findings, indicating that the underlying cause was likely Valsalva retinopathy.

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