Heart-Shaped Subhyaloid Haemorrhage in Valsalva Retinopathy With Successful Delayed Minimally Invasive Management

Valsalva retinopathy is a recognised cause of acute painless visual loss resulting from a sudden increase in intrathoracic or intra-abdominal pressure, leading to subhyaloid haemorrhage. While most reported cases describe rounded or boat-shaped haemorrhages, atypical morphologies documented with multimodal imaging are infrequently reported. We describe a 45-year-old female with long-standing insulin-treated diabetes mellitus who developed sudden visual blurring following a violent coughing episode. Fundoscopic examination revealed a sharply demarcated, heart-shaped subhyaloid haemorrhage involving the macula, and optical coherence tomography confirmed a subhyaloid haemorrhage. Despite intervention occurring almost three weeks after symptom onset, intravitreal tissue plasminogen activator combined with expansile gas resulted in significant anatomical and functional recovery, with visual acuity improving from 6/36 to 6/9 and sustained improvement on follow-up. This case highlights the importance of recognising atypical haemorrhage morphology, accurately localising haemorrhage depth using optical coherence tomography, and individualising management. It also demonstrates that delayed minimally invasive intervention may achieve excellent visual outcomes, even in the presence of pre-existing retinal disease.