Clinical

n Afro-Caribbean male patient PJ aged 36 was sent by the diabetic Blood pressure changes and nurse for his first diabetic screening at this practice. His previous pre-retinal haemorrhage eyeA examination was three years ago and he had no visual complaint except Kirit Patel takes a look at a two cases from his practice where the to mention that his left eye had been amblyopic and he used to have a patch retinal signs betrayed significant changes in systemic blood pressure over one eye when he was a small child. He did confess to smoking and for his OCT examination he used metformin, gliclazide, ● The left macula showed cystoid aspirin and statins. maculopathy as well as central macular R +3.00DS/-0.25DC X 175 thickening in all quadrants and VA 6/6 & N5 specifically centrally. The central left L +4.50DS VA 6/60 macular thickness was 621 microns ● The right fovea appeared normal Fundus examination with a normal foveal pit. Surrounding ● Right eye had numerous cotton- the central macula there is thickening wool spots, numerous deep red in all quadrants (Figure 3) haemorrhages, exudates and tortuosity ● Left optic disc image also showed of retinal veins new vessels on the disc nasal and ● The central macula appeared clear temporal. but surrounding the macula there was sign of retinal oedema Decision taken ● The right optic disc was also slightly Figure 1 ● The left optic disc was swollen and the This patient was immediately referred to swollen Grade 2-3 left macula had central haemorrhages an ophthalmic surgeon for proliferative ● Right eye would be classified as hypertensive and appeared oedematous in the left eye and pre-proliferative diabetic retinopathy retinopathy ● The left optic disc also had fine new pre-proliferative diabetic retinopathy and grade 2-3 vessels both on the nasal and temporal in the right eye. There were also signs (Figure 1) aspect and this is seen more clearly with of severe hypertensive retinopathy and ● The left eye was classified as a magnifying lens (Figure 2) his general practitioner was informed proliferative diabetic retinopathy R3 ● Nasal to the optic disc there of the findings so as to act on this ● The left eye consisted of multiple were pre-retinal haemorrhages and swiftly. The hypertensive retinopathy cotton-wool spots, multiple deep red this indicates retinal ischemia and was diagnosed from numerous nerve haemorrhages proliferative retinopathy. fibre haemorrhages, cotton-wool spots, oedema together with disc and macular oedema especially in the left eye. In fact, the left eye would also be Figure 2 New vessels both described as having severe hypertensive on the nasal and temporal retinopathy. It would have been foolish aspect to assume that he had a lazy eye when

Figure 3 Macular thickening in all quadrants

36 | Optician | 10.09.10 opticianonline.net Clinical

the features of the macula suggest a (a) (b) problem of cystoid maculopathy. He was vague in terms of explaining when he last had an and who his previous optician was and so it was difficult to confirm his last prescription and true acuity. The patient was told about the findings and the various tests that the eye specialist would undertake, including flourescein angiography and the high likelihood of laser photocoagulation in both eyes. The most important advice given to the patient was to improve his lifestyle, ie quit smoking, increase exercise and good diet control. This patient showed retinopathy which Figure 4 ● R3 = pre-retinal haemorrhage inferior base fairly clearly (Figure 6) was close to malignant hypertensive Pre-retinal temporal of right eye (Figure 4). ● There were no signs of new vessels retinopathy and he was at a very high haemorrhage This was observed clearly when initial on the surface of the retina. Definite risk of developing cardiac problems as Volk lens examination was undertaken signs of posterior vitreous detachment well as a stroke. (if, according to the diabetic guideline in the right eye. Hypertensive retinopathy is more just nasal and temporal retinal images commonly observed in African or taken, the pre-retinal haemorrhage Decision taken Afro-Caribbeans and men are more would have been missed) Further questioning of the patient likely to be affected than women. The ● No associated neovascularisation revealed that he had been digging a mean age for diagnosis is 40 years. One ● Signs of posterior vitreous changes pond over a three-day period. This per cent of patients with hypertensive in both eyes but no obvious signs of involved strenuous physical work retinopathy develop malignant vitreous detachment such as ring of that he does not normally do. As the and most deaths occur from Weiss haemorrhage was peripheral, the stroke, renal failure or heart failure. If no ● Fundus imaging of the temporal patient did not notice any visual loss. effective treatment is given then the life and nasal retina did not show the On further questioning the patient expectancy is less than two years. haemorrhage and hindsight (ie initial did experience a in his field assessment with Volk lens) enabled me of vision three weeks ago but did not Case 2 to zoom into the affected area think much more until prompted ● OCT examination revealed a again at this visit. The causes for this Pre-retinal haemorrhage – definite pre-retinal haemorrhage pre-retinal haemorrhage were either not true R3 located between the vitreous base and Valsalva manoeuvre following the A 74-year-old diet-controlled diabetic the limiting membrane of the retina digging or it could be due to posterior came in for his routine eye test with no ● The size of the pre-retinal vitreous detachment. The OCT scan complaints. haemorrhage was 3.50mm and the shows possible hyaloid membrane height roughly 105 microns detachment, but this was not fully Ocular findings ● The line scan of the OCT shows evident on slit-lamp examination, ● Unaided vision 6/6 and with +2.50 the haemorrhage on the surface of although we cannot rule out pre-retinal add N5 for reading the retina (Figure 5, the dark area haemorrhage due to posterior vitreous ● Intraocular pressures on the higher underneath is the result of the . side of normal – right eye 22mmHg surface haemorrhage not letting in any The patient was referred to an eye and left eye 20mmHg light and casting a shadow) specialist, to be seen within two weeks ● R0 = no diabetic retinopathy in the ● The cross-line scan shows the so as to ensure this did not end up as a left eye haemorrhage underneath the vitreous vitreous haemorrhage. The patient was

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Figure 5 OCT scan of haemorrhage Figure 6 Cross-line scan x-y view reassured that the haemorrhage would ● Now as the venous blood surges back 89, 1646-1654 disappear with no intervention and to the heart there is an abrupt increase Jeganathan VSE, Wang JJ, Wong TY. Ocular only occasionally surgical intervention in blood pressure. The sudden rise in Associations of Diabetes Other Than Diabetic is necessary when central vision is the intraocular venous pressure causes Retinopathy. Diabetes Care , 2008; 31: 1905- affected. The patient was told to a spontaneous rupture of the retinal 1912. abstain from heavy lifting and physical capillaries. Kanski JJ. Clinical , A systemic exercises. To allow the blood to drain Approach. Oxford, Butterworth Heinemann, 199: they should also try and sleep in a Conclusion 479-486. sitting position. A thorough observation with the Volk Keith NM, Wagener HP, Barker Newsome lens allowed the author to pick out the different types of essential hypertension: Pathophysiology of pre-retinal pre-retinal haemorrhage in an instant. their course and prognosis. Am J Med Sci, haemorrhage With diabetic screening the protocol is 1974;268:336-45. Pre-retinal haemorrhages occur to undertake nasal and temporal retinal Kifley A, Liew G, Wang JJ, Kaushik S, Smith with neovascularisation of the retina imaging. As you can see, if we relied on W, Wong TY, Mitchell P. Long-term Effects of following proliferative diabetic the fundus image only, the pre-retinal Smoking on Retinal Microvascular Caliber. Am J retinopathy. They can also occur haemorrhage would have been missed. Epidemiol, 2007; 166: 1288-1297. as a result of a posterior vitreous The peripheral retina hides a multitude Kincaid-Smith P. Assessment of the detachment or it can occur following of sins. ● hypertensive. Aust Fam Physician, 1980; Apr, Valsalva manoeuvre. 9(4):222-7. In our patient’s case it appears that he Further reading Kocak N, Kaynak S, Kaynak T, et al. Unilateral had a Valsalva retinopathy following Abdelwahab W, Frishman W, Landau A. Purtscher-like retinopathy after weight-lifting. the heavy digging. This event occurs Management of hypertensive urgencies and Eur J Ophthalmol, 2003; May, 13(4):395-7. during coughing, sneezing, bungee emergencies. J Clin Pharmacol, 1995; Aug, Raymond LA. Neodymium:YAG laser treatment jumping, aerobic exercises, blowing 35(8):747-62. for hemorrhages under the internal limiting musical instruments, vomiting or Bourne RA, Talks SJ, Richards AB. Treatment membrane and posterior hyaloid face in the following heavy lifting and is termed of pre-retinal Valsalva haemorrhages with macula. Ophthalmol, 1995; Mar, 102(3):406-11. Valsalva retinopathy. This pathological neodymium: YAG laser. Eye, 1999; Dec, 13 (Pt Romano PE. Exhale while lifting or straining syndrome presents with a pre-retinal 6):791-3. to avoid Valsalva retinopathy or bleeding from haemorrhage and occasionally vitreous Chopdar A. Valsalva hemorrhagic retinopathy. stressed retinal vessels. Eur J Ophthalmol, Jan- haemorrhages have been noted. Eye, 1996;10 (Pt 5):650. Feb 2003;13(1):113. Valsalva retinopathy takes four stages: Cugati S, Mitchell P, Wang JJ. Do retinopathy Shukla D, Naresh KB, Kim R. Optical coherence ● When we lift a heavy object or signs in non-diabetic individuals predict the tomography findings in Valsalva retinopathy. Am cough we hold our breath, enabling us subsequent risk of diabetes?. Br J Ophthalmol, J Ophthalmol, 2005; Jul, 140(1):134-6. to increase the force we can produce. 2006; 90, : 928-929 Van den Born, B-JH, Hulsman CAA, Hoekstra We, therefore, are trying to exhale Day MW. . Nursing, JBL, Schlingemann RO, van Montfrans GA. against a closed windpipe and this 2004; Jul, 34(7):88. Value of routine funduscopy in patients creates increased pressure in the trunk. Duane TD. Valsalva hemorrhagic retinopathy. Am with hypertension: systematic review. BMJ, A sudden increase in thoracic pressure J Ophthalmol, 1973; Apr, 75(4):637-42. 2005;331: 73. diminishes the venous return to the Georgiou T, Pearce IA, Taylor RH. Valsalva Van Rens E. Traumatic ocular haemorrhage right side of the heart retinopathy associated with blowing balloons. related to bungee jumping. Br J Ophthalmol, ● The heart fills up less and this lowers Eye, 1999; Oct, 13 (Pt 5):686-7. 1994; Dec,78(12):948. the mean arterial pressure, leading to Gibran SK, Kenawy N, Wong D, Hiscott P. Changes Zhao J, Sastry SM, Sperduto RD, et al: peripheral vasoconstriction in the retinal inner limiting membrane associated Arteriovenous crossing patterns in branch retinal ● The blood pressure is further lowered with Valsalva retinopathy. Br J Ophthalmol, 91 vein occlusion. Ophthalmology, 1993; 100: and the cardiac pressure increases due 2007; May, 91 (5): 701–2. 423-428. to prompt reduction in intra-thoracic Grosso A, Veglio F, Porta M, Grignolo FM, Wong pressure following release of the strain TY. Hypertensive retinopathy revisited: some ● Kirit Patel practises in Radlett, from heavy lifting (by exhaling out) answers, more questions. Br J Ophthalmol, 2005: Hertfordshire

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