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Sohel Somani, MD, FRCSC, Lecturer, Department of Ophthalmology and Vision Sciences, University of Toronto; Staff
Ophthalmologist, William Osler Health Centre, Humber River Regional Hospital, and Princess Margaret Hospital
Adil Bhatti, BSc, University of Toronto Faculty of Medicine;
Iqbal Ike K Ahmed, MD, FRCSC, Clinical Assistant Professor, Department of Ophthalmology, University of Utah
Introduction
Numerous physiologic effects occur within the body during pregnancy, and the eye is no exception. This
article outlines both normal physiologic changes and pathological changes in the eye that can occur from pregnancy.
Moreover, a brief discussion of ocular medications and their potential effects on the fetus are reviewed.
Another common external result of pregnancy is changes to the skin called chloasma. Due to increased
hormone levels (ie, progesterone), some pregnant women experience increased pigmentation around the eyes and
cheeks. The pigmentation changes tend to fade slowly postpartum.
imaging. It typically occurs in obese females in their third decade of life. Interestingly, pregnancy does not increase
the risk of developing BIH. If BIH does occur, it usually presents in the first trimester but may occur later.
BIH does not carry any fetal consequences and carries the same visual outcome in nonpregnant patients.
Treatment for BIH in pregnancy is similar to that in nonpregnant patients with a few considerations. First, intense
weight loss is not recommended because of risk to fetal viability. Second, carbonic anhydrase inhibitors are
contraindicated during pregnancy due to the potential fetal teratogenic effects. Thirdly, the use of diuretics poses the
risk of electrolyte and placental blood flow changes. Reports exist of spontaneous improvement with no treatment
and very close follow-up care of optic nerve function. However, with visual compromise, interventions, such as bed
rest, lumbar puncture, optic nerve sheath decompression, and lumboperitoneal shunting, have been reported.
Occlusive vascular disorders
It is well appreciated that pregnancy represents a hypercoagulable state, through various changes that
occur with platelets, clotting factors, and arteriovenous flow dynamics. Such changes may be related to the
development of retinal artery and vein occlusions, disseminated intravascular coagulopathy (DIC), thrombotic
thrombocytopenic purpura (TTP), amniotic fluid embolism, and cerebral venous thrombosis.
Both branch and central retinal artery occlusions have been reported to occur in pregnancy. Although a
hypercoagulable workup may detect an abnormality, routine hematological workup may be unremarkable. A case
report exists of bilateral central retinal artery occlusion from amniotic fluid embolism, which in and of itself is a
potentially fatal condition. Retinal vein occlusions are less common than arterial occlusions.
DIC is characterized by widespread small vessel thrombosis often associated with hemorrhage and tissue
necrosis. It may occur with complications in pregnancy, such as abruptio placentae, severe preeclampsia,
complicated abortion, and intrauterine death. The choroid is the most common location in the eye for DIC to manifest.
Patients often complain of visual loss from choroidal infarction or hemorrhage, retinal pigment epithelial, or serous
detachments usually located in the posterior pole. Visual recovery usually occurs once the DIC resolves; however,
mild pigmentary changes may persist.
TTP is a rare disorder characterized by small vessel thrombosis, thrombocytopenia, microangiopathic
hemolytic anemia, neurologic and renal dysfunction, and fever. Visual symptoms may occur due to serous retinal
detachment, retinal artery narrowing, retinal hemorrhage, and optic nerve head edema. The central nervous system
may be involved, and the most common visual complaint is a homonymous hemianopia.
Antiphospholipid antibody syndrome is another condition that warrants consideration. In this syndrome,
patients are in a thrombophilic state and are prone to recurrent arterial and/or venous thrombosis. Diagnostic criteria
include clinical evidence of recurrent pregnancy loss or thrombosis in any organ or tissue as well as laboratory
evidence of circulating antiphospholipid antibodies or lupus anticoagulant. Ophthalmic manifestations may present in
the form of vascular thrombosis of the retina, the choroid, the optic nerve and visual pathway, and ocular motor
nerves.
Miscellaneous disorders
Ptosis has been reported to occur during and after normal pregnancy and usually is unilateral. The
mechanism is thought to be due to defects that develop in the levator aponeurosis from fluid, hormonal, and other
changes due to the stress of labor and delivery.
Endogenous candidal endophthalmitis, although rare, has been associated with pregnant or postpartum
women with indwelling intravenous catheters, systemic antibiotic use, and surgery. However, postpartum candidal
endophthalmitis has also been reported in an otherwise uncomplicated labor and delivery.
obstetrician, neurosurgeon, and endocrinologist to decide upon the appropriate medical, surgical, or radiation
treatment.
One potentially visual-threatening complication of pituitary adenomas is the sudden increase in pituitary size
from infarction or hemorrhage referred to as pituitary apoplexy. This condition may present as a sudden onset of
headache, visual loss, and/or ophthalmoplegia. Pregnancy is one of several potential risk factors for its occurrence.
The management of such patients includes a neurosurgical opinion for potential surgical decompression.
Endocrinological coverage also is warranted because of the risk of hypopituitarism (Sheehan syndrome).
Meningiomas
Meningiomas are benign, slow-growing tumors that typically occur in older females. However, they may
present in pregnancy due to their usually rapid increase in size. Often ophthalmic symptoms of decreased vision or
visual field loss are the first manifestations. Since most of these tumors regress in size postpartum, those patients
who are asymptomatic or with mild symptoms can be observed and left untreated. For those patients who require
treatment, it is usually surgical since these tumors are not radiation or chemotherapy sensitive. Indications for timing
and type of intervention require individual case analysis.
Uveal melanoma
Uveal melanoma is a rare occurrence among pregnant patients, as they usually occur in the older
population. From the limited case reports that exist, it appears that uveal melanomas behave no differently in
pregnancy, and those that have been treated show similar 5-year survival rates to the nonpregnant treated
population. No increased risk of metastases is apparent with pregnancy, and no case reports of placental or fetal
metastases exist.
Miscellaneous
Case reports exist of other intracranial tumors occurring during pregnancy, such as lymphocytic
hypophysitis, which may mimic a pituitary adenoma. Other uncommon intracranial masses include choroidal
hemangiomas, craniopharyngiomas, and orbital hemangiomas.
spiramycin has been recommended as a safer and equally effective alternative. The risk to the fetus of acquiring
congenital toxoplasmosis in these cases is almost negligible.
Miscellaneous conditions
Graves disease
An exacerbation of Graves disease may occur during the first trimester of pregnancy or even postpartum.
The disease usually is quiescent during the latter portion of the pregnancy. Patients with Graves orbitopathy are
treated in a similar fashion to patients who are not pregnant. The ophthalmologist should be aware of the symptoms
of thyrotoxicosis (ie, tachycardic, weight loss, labile emotions, tremor, diaphoretic) because it represents an
endocrinological emergency to both the mother and the fetus.
Retinitis pigmentosa
A few case reports of progression of retinitis pigmentosa during pregnancy exist. These reports are
anecdotal and do not suggest a clear mechanism.
Multiple sclerosis
Much like the inflammatory conditions, multiple sclerosis has been known to stabilize or even improve during
pregnancy. However, an increased risk of relapse postpartum exists. Pregnancy does not appear to affect the overall
course of multiple sclerosis and vice versa.
High myopia
In the past, there has been concern of retinal tears and detachments in patients with high myopia
undergoing spontaneous vaginal delivery. However, one study of women with -4.5 D to -15 D and various preexisting
retinal pathology (eg, lattice degeneration, treated retinal tears or detachments) has demonstrated no deleterious
effects on the retina with spontaneous vaginal delivery.
during pregnancy raises natural concern. Therefore, caution should be exercised when latanoprost is administered in
women who are pregnant or breastfeeding.
In animal studies, adrenergic agonists (eg, brimonidine) have not demonstrated any fetal risk. Although no
studies were conducted in pregnant patients, it may be used if necessary. Whether brimonidine is excreted in human
milk is not known. Therefore, caution should be exercised since topical brimonidine given to human infants aged
younger than 2 months has been reported to cause bradycardia, hypertension, hypothermia, and apnea.
Mydriatics
Use of occasional dilating drops during pregnancy for the purposes of ocular examination is safe. However,
repeated use is contraindicated because of potential teratogenic effects of both parasympatholytics (eg, atropine) and
sympathomimetics (eg, epinephrine). Due to either the anticholinergic or hypertensive effects on the fetus, use of
mydriatics is contraindicated in mothers who are breastfeeding.
Corticosteroids
Although systemic corticosteroids are contraindicated in pregnancy, there are no known teratogenic effects
of topical steroids. Because little is known about the risk of topical corticosteroids during lactation, it should be
avoided in mothers who are breastfeeding.
Antibiotics
Antibiotics that are known to be safe during pregnancy include erythromycin, polymyxin B, and the
quinolones. During lactation, polymyxin B and sulfonamides have been shown to be safe. Known antibiotics that
should be avoided during pregnancy include the following:
Chloramphenicol
Gentamicin
Neomycin
Rifampin
Tetracycline
Tobramycin
Antivirals
All antivirals should be avoided during pregnancy because of teratogenic effects. Moreover, they should be
avoided in mothers who are breastfeeding because of tumorigenicity. However, acyclovir has been reported to be
compatible with lactation according to the American Academy of Pediatrics.
Fluorescein
No known teratogenic effects of fluorescein during pregnancy exist. However, the effect of fluorescein in
mothers who are breastfeeding is unknown.
Topical anesthetic
No known contraindications exist to the use of topical anesthetic drops in pregnancy or in mothers who are
breastfeeding.
Medication use
As described above, patients who are pregnant may require the use of medication to supplement their
treatment. However, to ensure a decreased incidence of systemic absorption and toxicity two simple measures have
been used. First, prescribing the patient the lowest recommended dose reduces the total amount of available drug.
Secondly, patients are instructed when using topical medications to provide nasolacrimal duct and punctual occlusion
thus reducing the amount of medication absorbed by the nasal mucosa.