Spontaneous retinal venous pulsations

For patients

Here are answers to some of the most common questions about testing for spontaneous retinal venous pulsations using an ophthalmoscope.

What is this test?	This test uses an ophthalmoscope (device for looking at the back of the eye) to assess the presence or absence of certain blood vessel pulsations in the retina (the back of the eye).
What is this test looking for?	This test looks for whether certain blood vessels in the back of the eye pulsate.
Is this test experimental or investigational?	This test is approved by the Food and Drug Administration. It is neither experimental nor investigational.
What happens during this test?	During this test the examiner uses a hand-held ophthalmoscope (device for looking at the back of the eye), brings it very close to your eye (without touching the eye), and uses it to look at the retina (in the back of the eye).
Is this test uncomfortable?	The ophthalmoscope shines a bright light into the eye, which some people find uncomfortable. That discomfort usually only lasts for the few seconds that it takes to perform the test.
How long does this test take?	The test takes about several seconds per eye; it is usually performed on each eye.
Do I have to prepare for this test?	There are no specific preparations for this test.
Are there any special instructions for what to do after the test?	There are no special instructions for what to do after this test.

For clinicians

Practical summary

In most healthy individuals, ophthalmoscopy shows spontaneous retinal venous pulsations (SRVPs) whose frequency matches the heart rate. These SRVPs usually disappear in the presence of increased intracranial pressure. The sensitivity and specificity of this test are good, but not perfect; some normal individuals lack SRVPs; rarely, some patients with increased intracranial pressure exhibit SRVPs.

Introduction

In most healthy individuals, ophthalmoscopy shows spontaneous retinal venous pulsations (SRVPs) whose frequency matches the heart rate. These SRVPs disappear in the presence of increased intracranial pressure.

A small percentage of healthy people (specifically with normal intracranial pressure) lack SRVPs. Rarely, SRVPs are observed in patients with increased intracranial pressure. The exact sensitivity and specificity of SRVPs for increased intracranial pressure has been debated.

History (how the test came to be developed)

German ophthalmologist Dr. Ernst Adolf Coccius (1825 – 1890) was the first to publish an observation of retinal venous pulsations (Coccius 1853).

Physiology and neuroanatomy

Veins do not normally pulsate, but the retinal veins are an exception to that general rule. The main mechanisms proposed to explain the phenomenon of SRVP have included:

During cardiac systole, intraocular pressure increases, which compresses the retinal veins and propels venous blood through the lamina cribrosa faster than the movement of that venous blood during diastole. As a result, during cardiac systole (when intraocular pressure also increases), the retinal veins near the optic disc appear to engorge. By this model, SRVPs are synchronous with fluctuations in intraocular pressure.
During cardiac systole, intracranial pressure is elevated and approaches intraocular pressure, which slows venous outflow from the globe; then during cardiac diastole the intracranial pressure lowers, and the (relatively higher) intraocular pressure propels venous blood through the lamina cribrosa. As a result, during cardiac diastole (when intracranial pressure decreases), the retinal veins near the optic disc appear to engorge. By this model, SRVPs are synchronous with fluctuations intracranial pressure (Jacks and Miller 2003; Jonas et al. 2012).
It may also be that SRVPs are the composite result of both intraocular and intracranial pressure fluctuations (Kain et al. 2010; Levine and Bebie 2016; Morgan et al. 2016), and perhaps other factors.

Phrased in another way, blood passes through the retinal veins at the optic disc when there is a differential between:

The pressure of the segment of the vein that is in the globe. This is mostly the result of intra-ocular pressure. Intraocular pressure fluctuates slightly as a function of arterial pressure (which is higher during cardiac systole).
The pressure of the segment of the vein that is more proximal (i.e., behind the globe). This is mostly the result of intracranial pressure. Intracranial pressure also fluctuates slightly as a function of arterial pressure.

If the absolute magnitude of the intraocular pressure fluctuations and the absolute magnitude of intracranial pressure fluctuations were identical, and if those fluctuations were perfectly in phase, then the differential between intraocular pressure and intracranial pressure would be constant, blood would flow through the retinal veins at a uniform rate, and there would be no spontaneous retinal venous pulsations. Consequently, the cyclical change of the pressure differential probably results from two factors:

The absolute magnitude of intraocular pressure fluctuation is different from the absolute magnitude of intracranial pressure fluctuation.
The fluctuations are not in perfect phase — in other words, the timing of the peaks and troughs of intraocular pressure is not completely synchronous (not simultaneous) with the peaks and troughs of intracranial pressure.

It is probably the fluctuation in this pressure differential that accounts for the finding of spontaneous retinal venous pulsations. Specifically:

When the intraocular pressure is greater than the intracranial pressure, then the pressure differential will compress the retinal veins, propelling blood toward the heart, and those deflated veins will appear smaller.
When the intracranial pressure is greater than the intraocular pressure, then blood will no longer be propelled along the retinal veins, but will pool in those veins, and those engorged veins will appear larger.

According to (Morgan et al. 2016), Lorentzen reports that the frequency of occurrence increases with increasing age (Lorentzen 1970).

Potentially confounding factors include abnormal (usually elevated) intraocular pressure (Donnelly and Subramanian 2009; Jonas 2005; Nowroozzadeh and Saki 2009), abnormal (usually elevated) intracranial pressure (Ghate et al. 2021), and optic disc edema (Choudhari et al. 2009; McCulley et al. 2003). Morgan and colleagues (Morgan et al. 2016) report that the frequency of occurrence of SRVPs is reduced in the presence of increased intracranial pressure (Firsching et al. 2000; Walsh et al. 1969), increased intraocular pressure, central retinal vein occlusion (Beaumont and Kang 1994; Jonas 2003), various disorders of the orbit, and disorders of neighboring vasculature.

Intraocular vascular dynamics have been studied in animal models (Dattilo et al. 2019; Ghate et al. 2021).

Equipment needed

Observation of SRVPs requires a bedside ophthalmoscope.

More elaborate instrumentation for quantification of SRVPs has been studied (Morgan et al. 2015), some of which leverage existing video-ophthalmoscopic devices (Kolar et al. 2016) or optical coherence tomography (McHugh et al. 2020), some through photoplethysmography (Morgan et al. 2014), some through ophthalmodynamometry (Firsching et al. 2000; Jonas et al. 2008; Motschmann et al. 2001) aa (Moss 2021), and some by smartphone-based ophthalmoscopy (Mbanugo et al. 2023).

Analysis of videos has been challenging (Moret et al. 2011); machine learning (Panahi et al. 2023) and other methods (Hamann et al. 2022) have been applied, using a variety of mathematical models (Abdul-Rahman et al. 2022; Morgan et al. 2016).

How to perform the test

A clinician uses bedside ophthalmoscopy normally, but in this case is focusing attention on the retinal veins in the vicinity of the optic disc.

What this test assesses

Bedside ophthalmoscopy primarily facilitates fundoscopy, and affords less information about the peripheral retina. As far as SRVPs are concerned, ophthalmoscopy is a reasonably good test.

How to interpret the test results

Early on clinicians identified that the higher the intracranial pressure, the lower the likelihood was that SRVPs would be observed (Walsh et al. 1969). Thus, generally, “the absence of spontaneous retinal venous pulsation on retinal infrared video recordings is significantly associated with higher levels of intracranial pressure” (D’Antona et al. 2019).

A study reported that SRVPs were present in 87.6% of healthy individuals (and thus absent in 12.4%); in contrast, SRVPs were present in 0% of 33% individuals with increased intracranial pressure (Levin 1978).

There are occasional case reports of SRVPs being observed in patients with increased intracranial pressure (Van Uitert and Eisenstadt 1978; Wong and White 2013).

In short, while ophthalmoscopy is not perfect, the presence of SRVPs is reasonable sensitive and specific for normal intracranial pressure.

Below are links to several videos demonstrating SRVPs on ophthalmoscopy:

Limitations

Confounding factors, such as glaucoma (which increases intraocular pressure), may make it difficult to interpret the significance of the presence/absence of SRVPs.

Depending on the clinical scenario, if assessment of SRVP is indeterminate, then direct measurement of intracranial pressure via a lumbar puncture may be warranted.

Contraindications

There are no absolute contraindications for performing ophthalmoscopy. It may be difficult to perform in patients with significant miosis, photophobia or nystagmus.

When is the test indicated

The presence/absence of SRVP may help a clinician in assessing a patient who is being evaluated for disorders that may increase intracranial pressure.

Diseases that may be diagnosed by this test

The absence of SRVP can occur in a variety of disorders that cause increased intracranial pressure, such as hydrocephalus (from any cause), central venous thrombosis, meningitis, encephalitis, intracranial space-occupying lesions, etc.

References

Abdul-Rahman A, Morgan W, Jo Khoo Y, Lind C, Kermode A, Carroll W, Yu DY (2022) Linear interactions between intraocular, intracranial pressure, and retinal vascular pulse amplitude in the fourier domain. PLoS One 17: e0270557. doi: 10.1371/journal.pone.0270557

Beaumont PE, Kang HK (1994) Ophthalmodynamometry and corticosteroids in central retinal vein occlusion. Aust N Z J Ophthalmol 22: 271-4. doi: 10.1111/j.1442-9071.1994.tb00796.x

Choudhari NS, Raman R, George R (2009) Interrelationship between optic disc edema, spontaneous venous pulsation and intracranial pressure. Indian J Ophthalmol 57: 404-6. doi: 10.4103/0301-4738.55061

Coccius EA (1853) Ueber die Pulsiren der Centralvene der Netzhaut [On the pulsations of the central vein of the retina]. Ueber die anwendung des Augen-Spiegels nebst Angabe eines neuen Instrumentes [On the use of the ophthalmoscope and a description of a new instrument]. Immanuel Müller, Leipzig, pp 3-23

D’Antona L, McHugh JA, Ricciardi F, Thorne LW, Matharu MS, Watkins LD, Toma AK, Bremner FD (2019) Association of Intracranial Pressure and Spontaneous Retinal Venous Pulsation. JAMA Neurol 76: 1502-1505. doi: 10.1001/jamaneurol.2019.2935

Dattilo M, Read AT, Samuels BC, Ethier CR (2019) Detection and characterization of tree shrew retinal venous pulsations: An animal model to study human retinal venous pulsations. Exp Eye Res 185: 107689. doi: 10.1016/j.exer.2019.06.003

Donnelly SJ, Subramanian PS (2009) Relationship of intraocular pulse pressure and spontaneous venous pulsations. Am J Ophthalmol 147: 51-55.e2. doi: 10.1016/j.ajo.2008.07.035

Firsching R, Schütze M, Motschmann M, Behrens-Baumann W (2000) Venous opthalmodynamometry: a noninvasive method for assessment of intracranial pressure. J Neurosurg 93: 33-6. doi: 10.3171/jns.2000.93.1.0033

Ghate D, Kedar S, Havens S, Fan S, Thorell W, Nelson C, Gu L, Tong J, Gulati V (2021) The Effects of Acute Intracranial Pressure Changes on the Episcleral Venous Pressure, Retinal Vein Diameter and Intraocular Pressure in a Pig Model. Curr Eye Res 46: 524-531. doi: 10.1080/02713683.2020.1805769

Hamann T, Wiest M, Mislevics A, Bondarenko A, Zweifel S (2022) At the Pulse of Time: Machine Vision in Retinal Videos. Acta Neurochir Suppl 134: 303-311. doi: 10.1007/978-3-030-85292-4_34

Jacks AS, Miller NR (2003) Spontaneous retinal venous pulsation: aetiology and significance. J Neurol Neurosurg Psychiatry 74: 7-9. doi: 10.1136/jnnp.74.1.7

Jonas JB (2003) Ophthalmodynamometric assessment of the central retinal vein collapse pressure in eyes with retinal vein stasis or occlusion. Graefes Arch Clin Exp Ophthalmol 241: 367-70. doi: 10.1007/s00417-003-0643-7

Jonas JB (2005) Retinal venous pulsation and glaucoma. Ophthalmology 112: 948-9; author reply 949. doi: 10.1016/j.ophtha.2004.11.014

Jonas JB, Pfeil K, Chatzikonstantinou A, Rensch F (2008) Ophthalmodynamometric measurement of central retinal vein pressure as surrogate of intracranial pressure in idiopathic intracranial hypertension. Graefes Arch Clin Exp Ophthalmol 246: 1059-60. doi: 10.1007/s00417-008-0780-0

Jonas JB, Wang N, Yang D (2012) Retinal vein pulsation is in phase with intracranial pressure and not intraocular pressure. Invest Ophthalmol Vis Sci 53: 6045. doi: 10.1167/iovs.12-10623

Kain S, Morgan WH, Yu DY (2010) New observations concerning the nature of central retinal vein pulsation. Br J Ophthalmol 94: 854-7. doi: 10.1136/bjo.2009.169813

Kolar R, Tornow RP, Odstrcilik J, Liberdova I (2016) Registration of retinal sequences from new video-ophthalmoscopic camera. Biomed Eng Online 15: 57. doi: 10.1186/s12938-016-0191-0

Levin BE (1978) The clinical significance of spontaneous pulsations of the retinal vein. Arch Neurol 35: 37-40. doi: 10.1001/archneur.1978.00500250041009

Levine DN, Bebie H (2016) Phase and amplitude of spontaneous retinal vein pulsations: An extended constant inflow and variable outflow model. Microvasc Res 106: 67-79. doi: 10.1016/j.mvr.2016.03.005

Lorentzen SE (1970) Incidence of spontaneous venous pulsation in the retina. Acta Ophthalmol (Copenh) 48: 765-70.

Mbanugo TH, Mezue WC, Emejulu JC, Uche EO, Chikani MO, Iloabachie I, Onyia E, Okpalauwaekwe U (2023) Smartphone Ocular Fundal Photography in the Diagnosis of Raised Intracranial Pressure: A Novel Adaptation to Neurosurgical Practice. Cureus 15: e38246. doi: 10.7759/cureus.38246

McCulley TJ, Lam BL, Bose S, Feuer WJ (2003) The effect of optic disk edema on spontaneous venous pulsations. Am J Ophthalmol 135: 706-8. doi: 10.1016/s0002-9394(03)00122-3

McHugh JA, D’Antona L, Toma AK, Bremner FD (2020) Spontaneous Venous Pulsations Detected With Infrared Videography. J Neuroophthalmol 40: 174-177. doi: 10.1097/wno.0000000000000815

Moret F, Poloschek CM, Lagrèze WA, Bach M (2011) Visualization of fundus vessel pulsation using principal component analysis. Invest Ophthalmol Vis Sci 52: 5457-64. doi: 10.1167/iovs.10-6806

Morgan WH, Abdul-Rahman A, Yu DY, Hazelton ML, Betz-Stablein B, Lind CR (2015) Objective detection of retinal vessel pulsation. PLoS One 10: e0116475. doi: 10.1371/journal.pone.0116475

Morgan WH, Hazelton ML, Betz-Stablein BD, Yu DY, Lind CR, Ravichandran V, House PH (2014) Photoplethysmographic measurement of various retinal vascular pulsation parameters and measurement of the venous phase delay. Invest Ophthalmol Vis Sci 55: 5998-6006. doi: 10.1167/iovs.14-15104

Morgan WH, Hazelton ML, Yu DY (2016) Retinal venous pulsation: Expanding our understanding and use of this enigmatic phenomenon. Prog Retin Eye Res 55: 82-107. doi: 10.1016/j.preteyeres.2016.06.003

Moss HE (2021) Retinal Vein Changes as a Biomarker to Guide Diagnosis and Management of Elevated Intracranial Pressure. Front Neurol 12: 751370. doi: 10.3389/fneur.2021.751370

Motschmann M, Müller C, Kuchenbecker J, Walter S, Schmitz K, Schütze M, Behrens-Baumann W, Firsching R (2001) Ophthalmodynamometry: a reliable method for measuring intracranial pressure. Strabismus 9: 13-6. doi: 10.1076/stra.9.1.13.711

Nowroozzadeh MH, Saki S (2009) Intraocular pulse pressure affects the sensitivity and specificity of spontaneous venous pulsation test. Am J Ophthalmol 147: 945; author reply 945-6. doi: 10.1016/j.ajo.2009.01.002

Panahi A, Rezaee A, Hajati F, Shariflou S, Agar A, Golzan SM (2023) Autonomous assessment of spontaneous retinal venous pulsations in fundus videos using a deep learning framework. Sci Rep 13: 14445. doi: 10.1038/s41598-023-41110-8

Van Uitert RL, Eisenstadt ML (1978) Venous pulsations not always indicative of normal intracranial pressure. Arch Neurol 35: 550. doi: 10.1001/archneur.1978.00500320070022

Walsh TJ, Garden JW, Gallagher B (1969) Obliteration of retinal venous pulsations during elevation of cerebrospinal-fluid pressure. Am J Ophthalmol 67: 954-6. doi: 10.1016/0002-9394(69)90094-4

Wong SH, White RP (2013) The clinical validity of the spontaneous retinal venous pulsation. J Neuroophthalmol 33: 17-20. doi: 10.1097/WNO.0b013e3182622207

Page first published on August 16, 2025. Page last updated on August 20, 2025