Multiple Sub–Internal Limiting Membrane Hemorrhages With Double Ring Sign in Eyes With Valsalva Retinopathy

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Sub–internal limiting membrane (ILM) hemorrhages are observed in various vitreoretinopathies including Valsalva retinopathy.1–4 We present our findings in a 42-year-old woman who was suffering from spasmodic coughing because of asthma and had 3 localized, dome-shaped sub-ILM hemorrhages with the classic double ring sign without vitreous hemorrhage in the left eye (Figure 1).
The ILM over the macula developed a tear 2 days later causing subhyaloid and vitreous hemorrhages. An intraretinal hemorrhage was detected as a flame-shaped hemorrhage in the outer ring more than 1 month after the first visit. The ILM was separated from the sensory retina, and it was easily removed with a vitreous cutter during vitrectomy 2 months later. The vestige of the boundary of the sub-ILM hemorrhage, which had been seen from the first visit, was observed as a thinner retina and the disruption of the ellipsoid zone in the optical coherence tomographic image even 4 months after the vitrectomy.
These findings suggested that the sub-ILM hemorrhage must have exerted severe pressure on the ILM causing a detachment of the ILM leading to the inner ring. The ILM was not ruptured by the intense pressure exerted after the hemorrhage occurred indicating that the ILM is a stable basement membrane. However, the ILM developed a tear 2 days later indicating that a detached ILM can develop a tear spontaneously, and subhyaloid hemorrhages can be observed over a wider area.
There have been reports that the outer ring represents a subhyaloid hemorrhage, and the inner ring represents a sub-ILM hemorrhage.1,4 However, the present case had flame-shaped hemorrhages in the fundus and no hyaloid hemorrhage in the optical coherence tomographic images of the outer ring indicating that the outer ring represents a retinal hemorrhage in the nerve fiber layer.5 Similar outer retinal changes have been reported in the shaken baby syndrome.6
Taken together, these findings indicate that the hemorrhage exerted severe pressure on the ILM leading to a detachment of the ILM and the inner ring of sub-ILM hemorrhage and would invade into the nerve fiber layer space leading to the outer ring of the double ring sign.
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