Ocular Changes In Pregnancy

Dr. Amanpreet Singh

INTRODUCTION

• Pregnancy causes major changes in all the systems of the body.

• Visual Impairment and other ocular changes are rare in pregnancy.

• Ocular changes in pregnancy are categorised as :-1. Physiological2. Pathological

INTRODUCTION

• Pregnancy related pathological changes may present as:-

• 1. New ocular changes• 2. Changes in existing ocular pathology• 3. Ocular complications of systemic diseases.

Physiological Changes in Pregnancy

S No. STRUCTURE PHYSIOLOGICAL CHANGE

1. IOP Low IOP

2. Lid Chloasma (5-70%)

3. Conjunctiva Hyposphagma (10%)

4. Tear Film Tear film composition alterations (14%)

5. Cornea Decreased SensationsKrukenberg’s SpindlesIncreased Thickness (14%)Alteration in refractive power

6. Lens Increased Thickness (14%)Refractive change

7. Optic Nerve Pituitary gland enlargement.

Sharma S RW, Sharma T, Downey G.: Refractive issues in pregnancy.Aust N Z J Obstet Gynaecol 2006; 46: 186–8.

A conjunctival hemorrhage (hyposphagma)

Pathological ChangesS no. STRUCTURE PATHOLOGICAL CHANGE1. Orbit Growth of hemangiomas

Carotid-cavernous fistula2. Lid Ptosis

Horner’s SyndromeFacial nerve palsy

3. Conjunctiva Vasospasm in pre-eclampsia

4. Retina Worsening of Diabetic retinopathy Vascular changes in Pre-eclampsia (40-100%)Serous Retinal Detachment (0.005%)Central serous chorioretinopathyGrowth of melanomas

5. Optic nerve Ischemic optic neuropathyPapilloedema

6. Optic Pathway Cortical Blindness in eclampsia (0.06%)

Reddy SC NS, George S Ra, Who TS: Fundus changes in pregnancy induced hypertension. Int J Ophthalmol 2012; 5: 694–7.

Achanna S, Monga D, Sivagnanam: Transient blindness in pregnancy induced hypertension. Asia-Oceania Journal of Obstetrics and Gynaecology/AOFOG 1994; 20: 49–52.

Physiological Ocular Changes

• Increased pigmentation around eyes.• Darkening of face - Pregnancy Mask or Chloasma or Melasma

• Causes:-1. Increased estrogen2. Increased Progesterone3. Increased melanocyte stimulating hormone (MSH)

Pathological Ocular Changes

• Unilateral Ptosis• Cause:-• Fluid and hormonal effects on the levator aponeurosis.• Course:- It resolves post-partum.

• Check the pupils and extra-ocular movements to differentiate it from 3rd nerve palsy.

Sanke RF. Blepharoptosis as a complication of pregnancy. Ann Ophthalmol. 1984;16:720-722.

Tear Film alterations

1. Increased immune reaction in lacrimal duct cells

2. The destruction of acinar cells by prolactin, transforming growth factor beta-1 and epidermal growth factor.

• Dry eye Is further enhanced by dehydration caused by

1. Nausea and vomiting2. Anti-emetic drugs

Corneal changes

• Corneal changes:-

1.Increased Thickness (14%)• Due to corneal edema

2. Decreased Sensations• Due to increased corneal thickness & Hormonal changes

3. Alteration in refractive power

4. Krukenberg’s Spindles- appear in first two trimesters.• In last trimester- Increased aqueous outflow leads to spindle

shrinkage.

Corneal changes

5. Altered corneal curvature

6. Altered refractive index

• Clinical Importance:-

1. Contact lens intolerance due to corneal changes.

2. Avoid new spectacles prescription

3. Avoid new contact lens prescription

4. Refractive surgery is contra-indicated

Intra-Ocular Pressure (IOP)

Intra-Ocular Pressure (IOP)• 19.6 % reduction – In person with normal IOP• 24.4% reduction – Ocular hypertension pt.

Various proposed mechanisms:-1. Increased Aqueous outflow2. Lower epi-scleral venous pressure due to decreased systemic vascular resistance3. Lower scleral rigidity due to increased tissue elasticity4. General acidosis in pregnancy

1. Horven I, Gjonnaess H. Corneal indentation pulseand intraocular pressure in pregnancy. Arch Ophthalmol.1974;91:92-98.

2. Cantor LB, Harris A, Harris M. Glaucoma medications in pregnancy. Rev Ophthalmol. 2000:91-99.3. Johnson SM, Martinez M, Freedman S. Management of glaucoma in pregnancy and lactation.

Surv Ophthalmol. 2001;45:449-454.

Changes in Lens and Accomodation

• 1. Increased lens curvature – causes Myopic Shift.

• 2. Temporary Accomodation insufficiency or loss.

Retinal Changes• Diabetic Retinopathy• Quick progression of Diabetic Retinopathy

• Cause:-1. Haematological, hormonal, metabolic, cardio-vascular and immunologic

factors.2. Increased retinal capillary blood flow – Increased endothelial cell

damage.3. Progesterone elevates the production of VEGF and other angiogenic

factors

• Dependant on several factors:-• 1. Degree of retinopathy at beginning of pregnancy• 2. Time duration since diabetes• 3. Glycemic contol• 4. Associated hypertension.

Retinal Changes

• Gestational Diabetes – Low risk of developing retinopathy.

• 10% patients without DR at Beginning of pregnancy develop Non proliferative changes.

• NPDR patients – 50% progression • PDR patients – 45 % progression• 5-20% NPDR patients – progress to PDR

• Clinical Importance :- • Pre-pregnancy laser therapy – Recommended for pt. with PDR or severe

NPDR.• Pre- pregnancy laser treatment – Risk of progression is decreased by

50%.

Retinal Changes

• Diabetic Macular edema:-• Develop or worsen during pregnancy.• Observed in pt. with proteinuria or associated hypertension.

• Treatment:-• Observation.• Spontaneous resolution postpartum.• Laser treatment can be done in postpartum period.

Retinal Changes

• Pre-eclampsia related retinopathy:-• Pre-eclampsia – BP> 140/90 mm hg, edema and proteinuria.• Retinal findings:-• Retinal arteriolar narrowing.(most common finding)• Other findings - retinal haemmorrhages, exudates, RNFL defects,

retinal edema, vitreous haemmorrhage.• Exudative RD – 1% in pre-eclampsic patients.

10% in eclampsic patients• Optic nerve findings:- Papillary edema, Ischemic optic neuropathy

and optic atrophy.

Dinn RB, Harris A, Marcus PS. Ocular changes in pregnancy. Obstet Gynecol Surv. 2003;58:137-144.

Hypertensive retinopathy with hemorrhages (solid white arrows), cotton-woolspots (open arrow), and exudates (solid black arrows) in eclampsia.

Retinal Changes

• Central Serous Chorioretinopathy:-

• Most frequently seen in third trimester.• Cause- High cortisol levels in pregnancy• Fibrous subretinal exudates present.• Diagnosis- OCT• Spontaneous regression postpartum.• Recurrence present in subsequent pregnancies.

Tumors

Pituitary Adenoma:-• Micro-adenomas may grow during pregnancy.• Symptoms:- • Headache• Visual Field changes ( Bitemporal hemianopia)• Decreased visual acuity• Diplopia (rarely)

• After pregnancy – Adenomas shrink and no visual sequelae left.

• Known adenoma – Monthly ophthalmological examination and visual field monitoring.

Tumors

• Meningioma – • Pre-existing meningioma – vascularise and grow.• Cause :- Elevated estrogen and progesterone

• Uveal melanoma-• High incidence and reactivation in pregnancy.

Systemic Diseases with Ocular Complications

1. Sheehan syndrome

2. Grave's disease

3. Idiopathic intracranial hypertension (IIH)

4. Anti-phospholipid Antibody Syndrome

5. Disseminated intravascular coagulation (DIC)

Sheehan syndrome

• Ischemic necrosis of the pituitary gland due to severe postpartum

haemorrhage.

• Potentially visually-threatening disorder as a result of sudden increase in

pituitary size from infarction or haemorrhage.

Symptoms:-

1. Sudden onset of headache

2. Visual loss

3. Ophthalmoplegia

• VF defect - 64% of cases

• VA abnormalities - 52% of cases.

Sheehan syndrome

• Cause of VF defect:-

• Expansion of the tumor compresses the optic chiasm

• The classic VF defect is a bitemporal superior quadrantic defect.

• Ophthalmoplegia - 78% of cases.

• Cause:- Compression of the cavernous sinus makes cranial

nerves 3,4 & 6 vulnerable to injury.

• Oculomotor nerve - most commonly involved.

• Resolution of ophthalmoplegia and visual occurs to some extent in

post-partum period.

Grave's disease

• Hyperthyroidism occurs in 2/1000 pregnancies

• Most common cause (85%) – Grave’s disease

• Recognition of hyperthyroidism during pregnancy can be elusive

because signs overlap with pregnancy symptoms such as

1. Nausea and vomiting

2. Increased appetite

3. Heat intolerance

4. Fatigue

5. Irritable or anxious mood.

Grave's disease

• Symptoms uncommon in normal pregnancy, but found in hyperthyroidism

are:-

1. Weight loss or failed weight gain despite increased dietary intake

2. Resting tachycardia

3. Hypertension

4. Tremor

5. Thyroid enlargement or nodule

6. Ocular manifestations

Graves's disease is known to exacerbate in the first trimester and to improve

in the second and third trimesters of pregnancy.

Grave's disease

• Approach to Graves's disease in pregnancy should be

multidisciplinary and involve an obstetrician, an endocrinologist and

an ophthalmologist.

Management

• Observation in asymptomatic cases

• Anti-thyroid medications in symptomatic patients

• Propyl-thiouracil is drug of choice in such cases.

• Surgery for complicated cases.

Idiopathic Intracranial Hypertension (IIH)

• Unknown etiology

• Common in obese females of child-bearing age

• Three times higher incidence in obese females, 15-44 years old

• Symptoms:-

1. Headache is the most common symptom (92% of patients)

2. Nausea and vomiting

3. Obscuration of vision

4. Scotomata

5. Photopsias

6. Diplopia

7. Retrobulbar pain.

Idiopathic Intracranial Hypertension (IIH)

• Fundus Finding:- Papilledema

• Papilledema is typically B/L, but may be markedly asymmetric, U/L.

• 20% of IIH patients- Abducens nerve palsy, a false localizing sign

secondary to elevated intracranial pressure.

• Major goals of IIH treatment include:-

• Alleviation of symptoms and preservation of visual function.

• Once diagnosed, the decision to treat depends on VA and VF loss.

• Medical treatment and observation are usually effective.

Anti-phospholipid Antibody Syndrome

• Is an autoimmune disorder.

• Characterized by either a history of vascular thrombosis or in association

with the presence of anti-phospholipid antibodies.

• Ocular complications of APS involve both the anterior and posterior segment

of the eye.

Anteriorly there are

1. Conjunctival telangiectasia or conjunctival microaneurysms

2. Episcleritis

3. Filamentary keratitis

4. Iritis

Anti-phospholipid Antibody Syndrome

• Posteriorly, there can be

1. Vitritis

2. Retinal detachment

3. Posterior scleritis

4. Branch or central retinal vein occlusion

5. Bilateral choroidal infarction

6. Cilio-retinal artery occlusion

7. Venous tortuosity

8. Retinal haemorrhages

9. Cotton-wool spots

10. Central serous chorio-retinopathy

11. Ischemic optic neuropathy

12. Progressive optic nerve atrophy

Disseminated intravascular coagulation

• Is an acquired syndrome characterized by the systemic

intravascular activation of coagulation

• The common obstetric causes of DIC are:- Amniotic fluid embolism;

intrauterine fetal demise; pre-eclampsia / eclampsia; placental

abruption and placenta praevia.

• The choroid is the most common intraocular structure involved.

• Occlusion of the choriocapillaris by a thrombus lead to disruption of

the overlying RPE causing SRD.

Conclusion

• Visual disturbances are very common during pregnancy.

• A firm understanding of the various ocular conditions that might

appear during pregnancy or get modified by pregnancy is required.

• Prompt evaluation and management of the rare and serious

conditions that may occur in pregnant women with visual

complaints.

•THANK YOU