Ophthalmology Unclassified

8/9/2019 Ophthalmology Unclassified

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Pregnancy, Special Considerations

Sohel Somani, MD, FRCSC, Lecturer, Department of Ophthalmology and Vision Sciences, University of Toronto; Staff Ophthalmologist, William Osler Health entre, Hum!er "iver "egional Hospital, and #rincess $argaret Hospital

Adil Bhatti, BSc, University of Toronto %aculty of $edicine;Iqbal Ike K Ahmed, MD, FRCSC, linical &ssistant #rofessor, Department of Ophthalmology, University of Utah

Introduction'umerous physiologic effects occur (ithin the !ody during pregnancy, and the eye is no e)ception* This

article outlines !oth normal physiologic changes and pathological changes in the eye that can occur from pregnancy*$oreover, a !rief discussion of ocular medications and their potential effects on the fetus are revie(ed*

Physiologic Ocular Changes Occurring During PregnancyCornea

orneal sensitivity has !een found to !e decreased in most pregnant (omen, (here a ma+ority of changesoccur in the third trimester and then reverse in postpartum* One potential mechanism may !e related to the slight

increase in corneal thic ness that may develop from corneal edema*%urthermore, an increase in corneal curvature and steepening may also occur* These changes have !een

reported to develop even in the postpartum period during !reastfeeding* Ho(ever, corneal curvature is reversi!leupon cessation of !reastfeeding*

ontact lens intolerance may occur during pregnancy as a result of a change in corneal curvature, increasedcorneal thic ness-edema, or an altered tear film* .n any case, it is recommended that one should (ait several (ee spostpartum !efore prescri!ing to a ne( refraction* &dditionally, decreased or transient loss of accommodation mayoccur during pregnancy or (ithin the postpartum period*

'e(ly developed /ru en!erg spindles have !een o!served early in pregnancy* The mechanism presuma!lyis related to hormonal changes 0eg, lo( progesterone levels1* Ho(ever, !y the third trimester, an increase inprogesterone and a2ueous outflo( often result in decreased or a!sence of /ru en!erg spindles*

Intraocular pressure & decrease in intraocular pressure has !een sho(n to occur during pregnancy and often persists for several

months postpartum* Various mechanisms have !een descri!ed for this o!servation3 an increase in a2ueous outflo(;a decrease in systemic vascular resistance, leading to decreased episcleral venous pressure; generali4ed increasedtissue elasticity, leading to decreased scleral rigidity; and generali4ed acidemia during pregnancy*

This decrease in intraocular pressure may have implications for pregnant (omen (ith pree)isting glaucoma,since improvement of the disease during pregnancy has !een reported in a fe( cases*

Visual ield chan!esWide speculation e)ists a!out the degree and mechanism of visual field changes that may occur in pregnant

(omen* Types of field loss may include !itemporal loss, concentric constriction, and enlarged !lind spots* #roposedmechanisms are e2ually diverse and include changes to the pituitary gland that may affect the optic chiasm* Theseasymptomatic visual field changes (ere sho(n to !e completely reversi!le postpartum* Ho(ever, pregnant (omen(ith symptomatic visual field loss (arrant further investigations*

"#ternal chan!es & decrease in con+unctival capillaries and an increase in the granularity of con+unctival venules have !een

reported to occur; each !eing reversi!le during the postpartum period*

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&nother common e)ternal result of pregnancy is changes to the s in called chloasma* Due to increasedhormone levels 0ie, progesterone1, some pregnant (omen e)perience increased pigmentation around the eyes andchee s* The pigmentation changes tend to fade slo(ly postpartum*

Pathologic Ocular Changes During Pregnancy

$re!nanc%&induced h%pertension ' preeclampsia( The onset of hypertension 05678-98 after :8 ( 1 in an other(ise normotensive pregnant (oman (ith

proteinemia 05 88 mg-:7 h1 is the minimal criteria needed to diagnose a patient (ith preeclampsia* %urthermore, if these changes are associated (ith sei4ures, (hich are not attri!uted to any other cause, then the disorder isclassified as eclampsia* The incidence of preeclampsia is appro)imately <=, and it is more common in primigravids,in younger and older (omen, and in those patients (ith maternal systemic diseases* The onset of this disorder isusually after the :8th (ee of gestation*

#reeclampsia has various maternal and fetal conse2uences* .n up to one third of cases, ocular se2uelaehave !een reported* The most common ocular complaint is visual !lurriness; ho(ever, other symptoms have also!een noted, including photopsias, scotomas, and diplopia* The protean ocular manifestations include retinopathy,optic neuropathy, serous detachments, and occipital cortical changes*

The changes that occur in retinopathy due to preeclampsia are similar to changes from hypertensiveretinopathy* The most common finding is focal retinal arteriole narro(ing, (hich also may !e diffuse* Other changesmay include retinal hemorrhages, edema, e)udates, nerve fi!er layer infarcts, and vitreous hemorrhage secondary toneovasculari4ation* & positive correlation e)ists !et(een the severity of preeclampsia and the degree of retinopathy;ho(ever, most changes are reversi!le once preeclampsia resolves* #reeclampsia retinopathy may !e more severe(ith underlying dia!etes, chronic hypertension, and renal disease*

Optic nerve changes that have !een reported include papilledema, acute ischemic optic neuropathy, andoptic atrophy*

Serous e)udative retinal detachments may occur in severe preeclampsia or eclampsia* They tend to !e!ilateral, !ullous, and (ith preeclampsia retinopathy changes* The underlying mechanism is thought to !e related tochoroidal nonperfusion and resultant su!retinal lea age* $ost patients (ith serous detachments have resolution of symptoms a fe( (ee s (ithin postpartum*

ortical !lindness, although a rare complication, has !een a reported cause of vision loss in patients (ithpreeclampsia* ere!ral edema is !elieved to !e the mechanism of vision loss* T(o proposed theories may accountfor the cere!ral edema* One theory suggests that vasospasm causes transient ischemia and produces cytoto)icedema* The other theory e)plains that preeclampsia causes increased permea!ility from circulatory dysregulation,thus providing vasogenic edema* Treatment or resolution of preeclampsia and the resultant cere!ral edema usuallyparallels visual recovery*

#reeclampsia may cause certain non>vision?threatening changes in the eye, including con+unctival vascular spasm or tortuosity, papillary mydriasis, ptosis, and nystagmus*

Central serous retinopath% &lthough not typical, central serous retinopathy 0 S"1 has !een reported to occur during pregnancy*

&lthough more common in the third trimester, it may also occur during the first or second trimesters* The conditionresolves spontaneously in the first fe( months postpartum and has !een no(n to recur in future pregnancies,usually in the same eye* The underlying mechanism remains unclear*

Beni!n intracranial h%pertension@enign intracranial hypertension [email protected], also no(n as pseudotumor cere!ri, is defined as increased

intracranial hypertension and its possi!le se2uelae, (ith normal cere!rospinal fluid composition and normal neuro?

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imaging* .t typically occurs in o!ese females in their third decade of life* .nterestingly, pregnancy does not increasethe ris of developing @.H* .f @.H does occur, it usually presents in the first trimester !ut may occur later*

@.H does not carry any fetal conse2uences and carries the same visual outcome in nonpregnant patients*Treatment for @.H in pregnancy is similar to that in nonpregnant patients (ith a fe( considerations* %irst, intense(eight loss is not recommended !ecause of ris to fetal via!ility* Second, car!onic anhydrase inhi!itors are

contraindicated during pregnancy due to the potential fetal teratogenic effects* Thirdly, the use of diuretics poses theris of electrolyte and placental !lood flo( changes* "eports e)ist of spontaneous improvement (ith no treatmentand very close follo(?up care of optic nerve function* Ho(ever, (ith visual compromise, interventions, such as !edrest, lum!ar puncture, optic nerve sheath decompression, and lum!operitoneal shunting, have !een reported*

)cclusi*e *ascular disorders.t is (ell appreciated that pregnancy represents a hypercoagula!le state, through various changes that

occur (ith platelets, clotting factors, and arteriovenous flo( dynamics* Such changes may !e related to thedevelopment of retinal artery and vein occlusions, disseminated intravascular coagulopathy 0D. 1, throm!oticthrom!ocytopenic purpura 0TT#1, amniotic fluid em!olism, and cere!ral venous throm!osis*

@oth !ranch and central retinal artery occlusions have !een reported to occur in pregnancy* &lthough ahypercoagula!le (or up may detect an a!normality, routine hematological (or up may !e unremar a!le* & casereport e)ists of !ilateral central retinal artery occlusion from amniotic fluid em!olism, (hich in and of itself is apotentially fatal condition* "etinal vein occlusions are less common than arterial occlusions*

D. is characteri4ed !y (idespread small vessel throm!osis often associated (ith hemorrhage and tissuenecrosis* .t may occur (ith complications in pregnancy, such as a!ruptio placentae, severe preeclampsia,complicated a!ortion, and intrauterine death* The choroid is the most common location in the eye for D. to manifest*#atients often complain of visual loss from choroidal infarction or hemorrhage, retinal pigment epithelial, or serousdetachments usually located in the posterior pole* Visual recovery usually occurs once the D. resolves; ho(ever,mild pigmentary changes may persist*

TT# is a rare disorder characteri4ed !y small vessel throm!osis, throm!ocytopenia, microangiopathichemolytic anemia, neurologic and renal dysfunction, and fever* Visual symptoms may occur due to serous retinaldetachment, retinal artery narro(ing, retinal hemorrhage, and optic nerve head edema* The central nervous system

may !e involved, and the most common visual complaint is a homonymous hemianopia* &ntiphospholipid anti!ody syndrome is another condition that (arrants consideration* .n this syndrome,

patients are in a throm!ophilic state and are prone to recurrent arterial and-or venous throm!osis* Diagnostic criteriainclude clinical evidence of recurrent pregnancy loss or throm!osis in any organ or tissue as (ell as la!oratoryevidence of circulating antiphospholipid anti!odies or lupus anticoagulant* Ophthalmic manifestations may present inthe form of vascular throm!osis of the retina, the choroid, the optic nerve and visual path(ay, and ocular motor nerves*

Miscellaneous disorders #tosis has !een reported to occur during and after normal pregnancy and usually is unilateral* The

mechanism is thought to !e due to defects that develop in the levator aponeurosis from fluid, hormonal, and other

changes due to the stress of la!or and delivery*Andogenous candidal endophthalmitis, although rare, has !een associated (ith pregnant or postpartum

(omen (ith ind(elling intravenous catheters, systemic anti!iotic use, and surgery* Ho(ever, postpartum candidalendophthalmitis has also !een reported in an other(ise uncomplicated la!or and delivery*

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Effect of Pregnancy on Preexisting Ocular DisordersDiabetic retinopath%

#regnancy can have an adverse outcome on the state of pree)isting dia!etic retinopathy* The (orsening of disease depends on a multitude of factors, as follo(s3 the severity of retinopathy at conception, duration of dia!etes,glycemic control, and presence of coe)isting hypertension* Bestational dia!etes poses a very lo( ris for the

development of retinopathy*Studies on patients (ho have had no initial dia!etic retinopathy sho( that appro)imately 68= of pregnant

(omen (ith dia!etes progress to some !ac ground retinopathy changes* Ho(ever, less than 8*:= of pregnant(omen (ith dia!etes progressed to the proliferative disease* & single !aseline ophthalmologic e)amination may !eade2uate in the first trimester unless visual symptoms occur*

&dditionally, studies in patients (ho had nonproliferative dia!etic retinopathy demonstrated that as many as<8= of them may sho( an increase in their nonproliferative retinopathy, (hich often improves !y the third trimester and postpartum* &ppro)imately <?:8= of patients develop proliferative changes, (here the ris !eing higher in thosepatients (ho had severe nonproliferative retinopathy at the !eginning of their pregnancy* &n ophthalmologice)amination at least once every trimester is recommended for patients (ith nonproliferative dia!etic retinopathy*

.n terms of patients (ith proliferative dia!etic retinopathy, studies have sho(n that a progression of disease

may occur in as many as 7<= of them* Ho(ever, in those patients (ho had laser treatment !efore pregnancy, theris of progression (as reduced !y <8=* $oreover, no cases of recurrence during pregnancy have !een reported, if total regression of proliferative changes occurred prior to onset of pregnancy* Hence, initiation of laser photocoagulation is recommended prior to pregnancy if not during the early trimester once severe nonproliferative or proliferative changes occur* #roliferative retinopathy may regress at the end of the third trimester or postpartum(ithout treatment* .n patients (ith proliferative dia!etic retinopathy, monthly ophthalmologic e)aminations are(arranted*

$acular edema may develop or (orsen during pregnancy* .t has !een sho(n that macular edema is oftenlin ed to pregnant (omen (ho have dia!etes along (ith proteinuria and hypertension* 'o studies have !eenconducted e)amining the initiation of treatment during pregnancy* .t may not !e unreasona!le to o!serve suchpatients until they reach postpartum, especially given that studies have sho(n that most cases have resolvedspontaneously after delivery*

.ntrapartum glycemic control has !een demonstrated to !e a !etter indicator of potential fetal (ell?!eing thanthe grade of dia!etic retinopathy at the onset of pregnancy* Hence, o!stetrical and endocrinological follo(?up care iscritical to the future (ell?!eing of the mother and fetus*

Intracerebral and other tumors

$ituitar% adenomasWith pregnancy, previously asymptomatic pituitary adenomas or microadenomas may enlarge and result in

various ophthalmic symptoms, such as headache, visual field change, and-or visual acuity loss* %or this reason,patients (ith amenorrhea are often screened to rule out pathological causes 0ie, pituitary mass1 prior to initiating pro?ovulation medications* &lthough most pituitary adenomas remain asymptomatic during their pregnancy, a small

proportion may re2uire radiation or surgical intervention if vision !ecomes threatened* @oth radiation and surgicaltherapy is effective and has no perinatal implications*

.n patients (ith a prolactinoma, an alternative treatment is !romocriptine, (hich has !een sho(n not to haveany increased ris to the fetus* orticosteroid therapy has !een reported as a treatment option* &fter pregnancy,pituitary adenomas regress in si4e and usually have no visual se2uelae* .t is recommended that pregnant patients(ith pituitary adenomas and microadenomas have monthly ophthalmic follo(?up care (ith visual field assessment torule out enlargement* Symptomatic pituitary adenomas may re2uire the com!ined efforts of an ophthalmologist,

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o!stetrician, neurosurgeon, and endocrinologist to decide upon the appropriate medical, surgical, or radiationtreatment*

One potentially visual?threatening complication of pituitary adenomas is the sudden increase in pituitary si4efrom infarction or hemorrhage referred to as pituitary apople)y* This condition may present as a sudden onset of headache, visual loss, and-or ophthalmoplegia* #regnancy is one of several potential ris factors for its occurrence*

The management of such patients includes a neurosurgical opinion for potential surgical decompression*Andocrinological coverage also is (arranted !ecause of the ris of hypopituitarism 0Sheehan syndrome1*

Menin!iomas$eningiomas are !enign, slo(?gro(ing tumors that typically occur in older females* Ho(ever, they may

present in pregnancy due to their usually rapid increase in si4e* Often ophthalmic symptoms of decreased vision or visual field loss are the first manifestations* Since most of these tumors regress in si4e postpartum, those patients(ho are asymptomatic or (ith mild symptoms can !e o!served and left untreated* %or those patients (ho re2uiretreatment, it is usually surgical since these tumors are not radiation or chemotherapy sensitive* .ndications for timingand type of intervention re2uire individual case analysis*

+*eal melanomaUveal melanoma is a rare occurrence among pregnant patients, as they usually occur in the older

population* %rom the limited case reports that e)ist, it appears that uveal melanomas !ehave no differently inpregnancy, and those that have !een treated sho( similar <?year survival rates to the nonpregnant treatedpopulation* 'o increased ris of metastases is apparent (ith pregnancy, and no case reports of placental or fetalmetastases e)ist*

Miscellaneousase reports e)ist of other intracranial tumors occurring during pregnancy, such as lymphocytic

hypophysitis, (hich may mimic a pituitary adenoma* Other uncommon intracranial masses include choroidalhemangiomas, craniopharyngiomas, and or!ital hemangiomas*

+*eitis and in lammator% conditions

Vo!t&Ko%ana!i& arada s%ndromeVogt?/oyanagi?Harada syndrome is a !ilateral panuveitis (ith central nervous system and cutaneous

involvement* "eports e)ist of improvement and even complete remission during pregnancy and postpartum*

Sarcoidosis, ank%losin! spond%litis, and -u*enile rheumatoid arthritis &mple case reports e)ist of improvement in !oth ocular and systemic manifestations of the a!ove diseases

during pregnancy* This improvement may perhaps !e due to the increased amount of endogenous corticosteroidsduring pregnancy* #ostpartum recurrence or flare?ups are not uncommon*

.o#oplasmosisToxoplasma gondii is a parasite that can !e ac2uired congenitally via an acutely infected mother or ingestion

of infected meat* ongenital infection occurs through transplacental transmission from a mother infected +ust !eforeor during pregnancy to the developing fetus* The severity of congenital infection is highest (hen ac2uired during thefirst trimester of pregnancy, although the fre2uency of transmission to the fetus is greatest during the third trimester (hen contact of the maternal and fetal circulations is more li ely to occur* Once maternal immunity has developed, itis !elieved that all future fetuses are protected from the development of congenital to)oplasmosis*

Latent ocular to)oplasmosis may reactivate during pregnancy in the mother* These patients usually aretreated in a similar fashion to patients (ho are not pregnant* Ho(ever, since pyrimethamine is potentially teratogenic,

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spiramycin has !een recommended as a safer and e2ually effective alternative* The ris to the fetus of ac2uiringcongenital to)oplasmosis in these cases is almost negligi!le*

Miscellaneous conditions

/ra*es disease &n e)acer!ation of Braves disease may occur during the first trimester of pregnancy or even postpartum*The disease usually is 2uiescent during the latter portion of the pregnancy* #atients (ith Braves or!itopathy aretreated in a similar fashion to patients (ho are not pregnant* The ophthalmologist should !e a(are of the symptomsof thyroto)icosis 0ie, tachycardic, (eight loss, la!ile emotions, tremor, diaphoretic1 !ecause it represents anendocrinological emergency to !oth the mother and the fetus*

Retinitis pi!mentosa & fe( case reports of progression of retinitis pigmentosa during pregnancy e)ist* These reports are

anecdotal and do not suggest a clear mechanism*

Multiple sclerosis$uch li e the inflammatory conditions, multiple sclerosis has !een no(n to sta!ili4e or even improve during

pregnancy* Ho(ever, an increased ris of relapse postpartum e)ists* #regnancy does not appear to affect the overallcourse of multiple sclerosis and vice versa*

i!h m%opia.n the past, there has !een concern of retinal tears and detachments in patients (ith high myopia

undergoing spontaneous vaginal delivery* Ho(ever, one study of (omen (ith ?7*< D to ?6< D and various pree)istingretinal pathology 0eg, lattice degeneration, treated retinal tears or detachments1 has demonstrated no deleteriouseffects on the retina (ith spontaneous vaginal delivery*

Ophthalmic Medications in PregnancyLittle is no(n of the effect of ophthalmic medications on pregnancy, fetal (ell?!eing, and !reast mil

contamination* Ho(ever, the 'ational "egistry of Drug?.nduced Ocular Side Affects pu!lished a comprehensiverevie( of their findings* Their findings and recommendations are summari4ed !elo(*

/laucoma medications@eta?!loc ers 0eg, timolol, levo!unolol, !eta)olol, carteolol1 should !e avoided or used in the lo(est possi!le

dose in the first trimester of pregnancy and !e discontinued :? days prior to delivery to avoid !eta?!loc ade in theinfant* Due to case reports of !eta?!loc ers !eing concentrated in !reast mil , they should !e avoided in mothers (hoare !reastfeeding* Ho(ever, timolol has !een reported to !e compati!le (ith lactation according to the &merican

&cademy of #ediatrics*Topical and systemic car!onic anhydrase inhi!itors 0eg, aceta4olamide, dor4olamide, !rin4olamide1 are

contraindicated during pregnancy !ecause of potential teratogenic effects* They should !e avoided in mothers (hoare !reastfeeding !ecause of the potential hepatic and renal effects to the infant* Ho(ever, aceta4olamide has !eenreported to !e compati!le (ith lactation according to the &merican &cademy of #ediatrics*

$iotics 0eg, pilocarpine, echothiophate, car!achol1 appear to !e safe during pregnancy* The to)icity duringlactation is un no(n* One e)ception is demecarium, (hich is to)ic and is contraindicated in pregnancy and mothers(ho are !reastfeeding*

#rostaglandin analogs 0eg, latanoprost1 are not (ell studied, and the reports that do e)ist are conflicting*#rostaglandins are used systemically for la!or induction and termination, and as such, the topical use for glaucoma

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during pregnancy raises natural concern* Therefore, caution should !e e)ercised (hen latanoprost is administered in(omen (ho are pregnant or !reastfeeding*

.n animal studies, adrenergic agonists 0eg, !rimonidine1 have not demonstrated any fetal ris * &lthough nostudies (ere conducted in pregnant patients, it may !e used if necessary* Whether !rimonidine is e)creted in humanmil is not no(n* Therefore, caution should !e e)ercised since topical !rimonidine given to human infants aged

younger than : months has !een reported to cause !radycardia, hypertension, hypothermia, and apnea*

M%driaticsUse of occasional dilating drops during pregnancy for the purposes of ocular e)amination is safe* Ho(ever,

repeated use is contraindicated !ecause of potential teratogenic effects of !oth parasympatholytics 0eg, atropine1 andsympathomimetics 0eg, epinephrine1* Due to either the anticholinergic or hypertensive effects on the fetus, use of mydriatics is contraindicated in mothers (ho are !reastfeeding*

Corticosteroids &lthough systemic corticosteroids are contraindicated in pregnancy, there are no no(n teratogenic effects

of topical steroids* @ecause little is no(n a!out the ris of topical corticosteroids during lactation, it should !eavoided in mothers (ho are !reastfeeding*

Antibiotics &nti!iotics that are no(n to !e safe during pregnancy include erythromycin, polymy)in @, and the

2uinolones* During lactation, polymy)in @ and sulfonamides have !een sho(n to !e safe* /no(n anti!iotics thatshould !e avoided during pregnancy include the follo(ing3

• hloramphenicol• Bentamicin• 'eomycin• "ifampin• Tetracycline• To!ramycin

Anti*irals &ll antivirals should !e avoided during pregnancy !ecause of teratogenic effects* $oreover, they should !e

avoided in mothers (ho are !reastfeeding !ecause of tumorigenicity* Ho(ever, acyclovir has !een reported to !ecompati!le (ith lactation according to the &merican &cademy of #ediatrics*

Fluorescein'o no(n teratogenic effects of fluorescein during pregnancy e)ist* Ho(ever, the effect of fluorescein in

mothers (ho are !reastfeeding is un no(n*

.opical anesthetic'o no(n contraindications e)ist to the use of topical anesthetic drops in pregnancy or in mothers (ho are

!reastfeeding*

Medication use

&s descri!ed a!ove, patients (ho are pregnant may re2uire the use of medication to supplement their treatment* Ho(ever, to ensure a decreased incidence of systemic a!sorption and to)icity t(o simple measures have!een used* %irst, prescri!ing the patient the lo(est recommended dose reduces the total amount of availa!le drug*Secondly, patients are instructed (hen using topical medications to provide nasolacrimal duct and punctual occlusionthus reducing the amount of medication a!sor!ed !y the nasal mucosa*

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Ophthalmology Unclassified

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