Eye conditions and care during pregnancy

Does pregnancy affect the eye?

Yes! ocular changes occur commonly during pregnancy. Although most of are physiologic responses to the metabolic, hormonal, and immunologic modifications to adopt the gestational product, there is some serious pathology that may develop, exacerbate, or even resolve over the course of pregnancy which requires prompt diagnosis and management. The pathological eye conditions can be classified into preexisting pathologies and emerging ocular diseases.

While up to 15% of these pregnancy-induced changes are benign, a few pathological conditions might affect the eyes. On the other hand, the severity of these ocular changes is largely affected by the health status of the pregnant women, e.g., in a diabetic or hypertensive pregnancy

Ocular symptoms in pregnancy

  • Grittiness of eye
  • Blurring of vision
  • Diminution of vision
  • Floaters and flashes
  • Scotomas
  • Photopsia

Pregnancy and its impact on the eyes

Physiologic changes during pregnancy (May worsen during pregnancy but resolves spontaneously post delivery
  • Chloasma – hyper melanosis of eyelids
  • Refractive change – Increasing in central and thinnest corneal thicknesses in the second and third trimesters of pregnancy due to water retention.
  • Contact lens intolerance -As cornea becomes sensitive
  • Dry eye – This condition is caused by disruption of lacrimal acinar cells which farms tears components.
  • Krukenberg spindles (mild inflammation)-Develop early in pregnancy and usually tend to decrease in size during the third trimester and postpartum.
  • Ptosis – drooping eyelid, due to fluid and hormonal effect on levator aponeurosis which helps in opening eyelids properly
Intraocular pressure changes during pregnancy

IOP has been proclaimed to drop 2–3 mmHg during pregnancy mainly under the influence of progesterone hormone. This drop reaches to a 10% value, notably in the third trimester. Although the underlying mechanism in pregnancy that decreases the IOP, proposed factor to explain reduction in IOP during pregnancy are increased aqueous outflow, lower scleral rigidity as a result of increased tissue elasticity, lower episcleral venous pressure due to decreased systemic vascular resistance, and general acidosis during pregnancy.

Pathologic changes during pregnancy

Systemic pathologic changes during pregnancy with possible ocular effect.

  • Preeclampsia (high blood pressure after 20 weeks of pregnancy) and eclampsia (seizures in preeclampsia pt) As a constrictive vasculopathy, preeclampsia is considered to be a major cause of maternal and neonatal morbidity and mortality. It has been estimated that the visual system is affected in 30%–100% of pregnant women with an established diagnosis of preeclampsia. Preeclampsia occurs in about 5% of pregnant women and ocular complications have been reported in one-third of these patients. Blurred vision is the most frequent complaint in these patients, however, photopsia, scotoma, and diplopia is not uncommon. Most of these findings return to normal following the resolution of preeclampsia. The only definitive treatment for preeclampsia and eclampsia is delivery. However, anticonvulsant medications such as magnesium sulfate and antihypertensive therapy like administration of nifedipine or labetalol may be useful in treatment of these patients.
  • Occlusive vascular disorders Purtscher-like retinopathy has been reported in the immediate postpartum period. It is associated with preeclampsia, pancreatitis, hypercoagulability state, and amniotic fluid emboli, experience severe bilateral vision loss with widespread cotton-wool spots with or without intraretinal hemorrhage shortly after delivery. Visual symptoms and retinal changes may resolve spontaneously. Less common findings such as branch and central retinal artery occlusions and retinal vein occlusions have been reported in pregnancy, probably secondary to or a hypercoagulable state or amniotic fluid emboli.
  • Antiphospholipid syndrome (APS) is autoimmune disorder characterized by either a history of vascular thrombosis or pregnancy morbidity in association with the presence of antiphospholipid antibodies. Both anterior and posterior segments of the eye are involved in APS. These complications in the anterior segment include episcleritis, iritis, conjunctival telangiectasia or conjunctival microaneurysms, and limbal or filamentary keratitis, and in the posterior segment include vitritis, retinal detachment, retinal hemorrhages, cottonwool spots, central serous type chorioretinopathy, posterior scleritis, branch or central retinal vein occlusion, bilateral choroidal infarction, cilioretinal artery occlusion, and venous tortuosity.
  • Central Serous Chorioretinopathy (CSCR) is classified as a type of retinopathy characterized by neuroepithelium detachment with subretinal fluid accumulation at the posterior part of the fundus. Pregnancy has been shown to increase the risk of CSCR up to 9 times.71 It is mostly observed in the third trimester of pregnancy. The main cause of this condition is attributed to the high concentration of cortisol level.
  • Disseminated Intravascular Coagulation (DIC) is an acquired syndrome characterized by the systemic intravascular activation of coagulation. The most common intraocular structure involved in DIC is choroid. Occlusion of the choriocapillaris by a thrombus leads to disruption of the overlying retinal pigment epithelium, causing serous retinal detachment.
  • Sheehan’s Syndrome or Pituitary Apoplexy is an enlargement of pituitary gland due to infarct and severe postpartum hemorrhage in pituitary adenoma. Pregnancy is a risk factor associated with this condition. This vision-threatening condition is accompanying with sudden headache, vision and visual field loss, and/or ophthalmoplegia.
  • Idiopathic Intracranial Hypertension (IIH) also known as benign intracranial hypertension (BIH) or pseudotumor cerebri is a disease of unknown etiology associated with increased intracranial pressure. Obese females of childbearing age are at increased risk of developing IIH. The most common symptoms of papilledema are transient visual obscuration, loss of peripheral vision, and a decrease in visual acuity. Medical treatment of IIH includes symptoms alleviation and preservation of visual function. Moreover, weight loss is recommended after pregnancy.
  • Graves’ disease is the most common cause of hyperthyroidism in pregnancy. It is an important cause of unilateral and bilateral proptosis. Graves’ disease tends to exacerbate in the first trimester, remit in the second and third trimesters, and relapse postpartum. Eye stare, eyelid lag, proptosis, and extraocular muscle palsy are common abnormal eye findings in Graves’ diseases. Mild cases may be monitored, but moderate to severe cases need treatment

Preexisting ocular diseases

  • Diabetic retinopathycan progress quickly during pregnancy. Hyperglycemia, duration of diabetes before pregnancy, degree of retinopathy in the beginning of pregnancy, glycemic control, and comorbid hypertension are several factors associated with the progression of retinopathy during pregnancy.
    For women with preexisting diabetic retinopathy or at risk of developing a hypertensive crisis, the frequency of this screening approach should be increased to a level to assure prompt detection of minimal retinal changes in order to prevent further damage or decelerate its progression. 10% of patients without diabetic retinopathy at the beginning of pregnancy developed non-proliferative change, while only less than 0.2% developed proliferation. Therefore, in the absence of visual symptoms, a baseline examination during first trimester is sufficient.
    The standard treatment for diabetic retinopathy is pan retinal photocoagulation that may be safely administered during pregnancy. However, regression of diabetic retinopathy after delivery may occur with uncertain rate and timing.
    Diabetic macular edema is observed with proteinuria or hypertension and may worsen during pregnancy. Macular edema may spontaneously resolve postpartum, but in some cases may remain and cause long-term visual loss. Laser treatment is recommended in patients with clinically significant disease.
    The injection of anti-vascular endothelial growth factor (anti-VEGF) agents is accepted as the main method for treatment of retinal vascular disorders and neovascularization in proliferative diabetic retinopathy in patients of child-bearing age. Bevacizumab and ranibizumab are category C, and pegaptanib is category B. Bevacizumab is preferred over ranibizumab because its high molecular weight prevents it from crossing the placenta. However, theoretically, they can affect placental vasculature. Therefore, the decision whether to treat with VEGF inhibitors should be made individually by a well-informed patient and her physician during a carefully monitored pregnancy.
  • Glaucoma As a physiologic change during pregnancy IOP has been proclaimed to drop 2–3 mmHg mainly under the influence of progesterone hormone. The drop in IOP has the potential benefit of avoiding anti-glaucoma medications in pregnancy, as glaucoma management may pose a challenge in pregnant women. Considering the decrease in IOP with an increase in gestational age and the possible birth defects and patient’s apprehension, the ophthalmologists may be tempted to put the anti-glaucoma medications on hold in pregnant women. Most of the glaucoma medications are in the B or C pregnancy category and are therefore contraindicated or should be used only on limited indications. However, patients with planning for pregnancy can benefit from laser trabeculoplasty, cyclophotocoagulation, trabeculectomy, or shunt tube surgery.

Ophthalmic medication and its impact on foetus

Self-medication is a strict no. FDA categorizes medications according to its use in pregnancy rating system as proven safety, presumed safety, uncertain safety, unsafe and contraindicated. During the gestational period, all medications have to be after consultation with your doctor. There are number of antibiotics, Anaesthetics, antifungal treatments, allergy medications, NSAID’s Steroids, Beta-blockers which may have a varied effect on the ocular health of the mother and foetus.

FDA Category according to its use in pregnancy rating system

A- Medication have proven safety

B- Drugs have presumed safety

C-Drugs have uncertain safety

D- Unsafe

X- contraindicated

Drugs FDA rating Remarks
Anaesthetics C Use with cautions
Mydriatics/ cycloplegics:Tropicamide,cyclopentolate Atropine C
Antibiotics: gatifloxacin, moxifloxacin, levofloxacin, ofloxacin, norfloxacin, ciprofloxacin, gentamicin, sulfacetamide, trimethoprim/ polymyxin B, bacitracin, neomycin C Discontinue drug or nursing
Antibiotics: erythromycin B Good safety in pregnancy
Antibiotics: tobramycin D Discontinue
Anifungals: natamycin C Use with caution/Infant risk cannot be ruled out
Allergy mediciations: antazoline, naphazoline, pheniramine, oxymetazoline, tetrahyrdozoline, zinc sulfate, olopatadine, pemirolast, ketotifen, epinastine, azelastine C Use with caution
NSAIDs: Ketorolac tromethamine, diclofenac, Nevanac (nepafenac 0.1%, Alcon), Xibrom (bromfenac 0.09%, Ista) C Use with caution/Avoid during late pregnancy (third trimester) due to potential effects on fetal cardiovascular system
NSAIDs: Ketorolac tromethamine, diclofenac, Nevanac (nepafenac 0.1%, Alcon), Xibrom (bromfenac 0.09%, Ista) C Use with caution/Avoid during late pregnancy (third trimester) due to potential effects on fetal cardiovascular system
Steroids: rimexolone, loteprednol, prednisolone, fluorometholone, dexamethasone C Use with caution/Best to discontinue drug or nursing
Glaucoma (beta-blockers): timolol, betaxolol, levobunolol C Use with caution/It is best to avoid beta-blockers during the first trimester. If necessary
Travoprost, Pilocarpine, dorzolamide, brinzolamide C Use with caution/It is best to avoid beta-blockers during the first trimester. If necessary

Eye care during pregnancy and after child birth

The body tends to go through physiological and immunological changes. The eye being a very sensitive organ needs to be taken care of. Inclusion of dark green leafy vegetables, vitamin A enriched foods, supplements and Omega Oils in the diet helps in improving ocular health in pregnant women. However they need to avoid any form of self-medication, prolonged screen time, salty food and carbonated drinks.

Regardless of the different mechanisms by which these ocular changes occur, the key point is the establishment of an effective perinatal screening program to monitor the new development or successive progression of these ocular abnormalities. Irrespective of the visual health status of the pregnant women, regular perinatal eye examination should be scheduled in order to assure continuous surveillance of healthy eyes.

Discriminating pathological eye disease from physiologic ocular changes is important in order to establish an individualized treatment or preventive plan and constitutes the mainstay of obstetric ophthalmology. This individualized approach should always weigh the ocular benefits of treatment to the mother against the potential harms to the fetus.

What to avoid
  • Self medication
  • Prolonged screen time
  • Salty food
  • Carbonated drinks
Food that help to improve ocular health
  • Dark green leafy vegetables-Vitamin A rich
  • Omega oils

Author

Posted on by Chouriya Prabha