Valsalva vs Terson vs Purtscher Retinopathy
Last updated: October 2026
Short answer: Valsalva retinopathy is a premacular haemorrhage after a sudden rise in chest pressure (coughing, lifting, vomiting). Terson syndrome is intraocular haemorrhage with subarachnoid or other intracranial bleeding. Purtscher retinopathy shows white retinal patches and haemorrhages after severe trauma, with "Purtscher-like" retinopathy in conditions such as pancreatitis. History is the key to telling them apart.
Comparison
| Valsalva retinopathy | Terson syndrome | Purtscher retinopathy | |
|---|---|---|---|
| Trigger | Sudden rise in intrathoracic or abdominal pressure: coughing, vomiting, heavy lifting, straining, pregnancy | Subarachnoid haemorrhage or other intracranial bleeding with raised intracranial pressure | Severe trauma (chest compression, long-bone fractures); "Purtscher-like" in pancreatitis, renal failure, connective tissue disease, childbirth |
| Mechanism | Rupture of superficial perifoveal capillaries | Sudden rise in intracranial and venous pressure transmitted to the eye | Microembolisation (for example, complement-activated leukocyte aggregates or fat), causing occlusion of small arterioles |
| Fundus | Dome-shaped premacular haemorrhage (sub-ILM or subhyaloid) | Vitreous, subhyaloid or retinal haemorrhages, often bilateral | Purtscher flecken (polygonal white patches with a clear zone beside the arterioles), cotton-wool spots, haemorrhages |
| Management | Observation; Nd:YAG membranotomy to drain a large premacular haemorrhage; vitrectomy if non-clearing | Observation; vitrectomy for non-clearing haemorrhage, especially in children (amblyopia risk) | Treat the underlying cause; no proven specific treatment |
| Prognosis | Usually good | Usually good after clearing; its presence is linked to more severe intracranial bleeding | Variable; may leave permanent vision loss |
Clinical pearls
- Any patient with an intracranial bleed and reduced vision should have a dilated fundus examination for Terson syndrome.
- In infants with retinal haemorrhages, consider non-accidental injury and follow child protection procedures.
- Nd:YAG membranotomy can drain a large premacular haemorrhage into the vitreous, speeding visual recovery in selected Valsalva cases.
- Purtscher flecken lie in the inner retina between the arterioles and venules, with a characteristic clear zone next to the vessels.
Frequently asked questions
What is Valsalva retinopathy?
A premacular haemorrhage caused by rupture of small perifoveal capillaries after a sudden rise in chest or abdominal pressure, such as coughing, vomiting or heavy lifting.
What is Terson syndrome?
Intraocular haemorrhage, often bilateral, associated with subarachnoid or other intracranial haemorrhage. Its presence is linked to more severe intracranial bleeding.
What are Purtscher flecken?
Polygonal white patches of inner retinal whitening, with a clear zone next to the retinal arterioles, seen in Purtscher and Purtscher-like retinopathy.
Related: emergencies on call, retina notes and triads in ophthalmology.
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