Ophthalmology – Pregnancy and Ophthalmic Disease

Basics

Description

Pregnancy produces physiologic, vascular, hormonal, metabolic, and immunologic changes that may:

• Alter normal ocular physiology
• Exacerbate preexisting eye disease
• Produce pregnancy-specific retinal or neuro-ophthalmic manifestations
• Modify the safety and timing of ophthalmic investigations and treatment

Important ophthalmic disorders associated with pregnancy include:

• Preeclampsia/eclampsia and posterior reversible encephalopathy syndrome (PRES)
• Diabetic retinopathy
• Central serous chorioretinopathy
• Retinal vascular occlusion
• Purtscher-like retinopathy
• Pituitary enlargement/apoplexy
• Meningioma enlargement
• Hypercoagulability-related disease

Visual symptoms during pregnancy may occasionally signal a:

Potentially life-threatening obstetric or neurologic emergency.

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Physiologic Ocular Changes in Pregnancy

Normal pregnancy can produce several reversible ocular changes.

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Corneal Changes

Pregnancy may cause:

• Increased corneal thickness
• Mild corneal edema
• Increased corneal curvature
• Reduced corneal sensitivity
• Contact lens intolerance

These changes can produce:

• Temporary refractive fluctuation
• Blurred vision

They generally resolve postpartum.

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Refractive Changes

Transient shifts may occur because of:

• Corneal hydration
• Curvature changes
• Lens changes

Therefore:

Avoid prescribing a major new permanent spectacle correction solely for a pregnancy-related refractive shift when possible.

Stable refraction can be reassessed several weeks to months postpartum.

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Refractive Surgery

Elective refractive surgery is generally deferred during:

• Pregnancy
• Early postpartum period
• Often lactation until refraction stabilizes

because corneal and refractive parameters may fluctuate.

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Accommodation

Some patients experience:

• Transient accommodative insufficiency
• Difficulty with near vision

Symptoms generally resolve postpartum.

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Intraocular Pressure

IOP commonly:

Falls during pregnancy

particularly in the second and third trimesters.

Possible mechanisms include:

• Increased aqueous outflow
• Hormonal effects
• Reduced episcleral venous pressure

IOP usually returns toward baseline after delivery.

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Dry Eye

Pregnancy can alter the tear film and meibomian gland function, producing:

• Dry eye
• Contact lens intolerance
• Burning or foreign-body sensation

Treatment generally includes:

• Preservative-free artificial tears
• Lid hygiene when appropriate

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Preeclampsia

Modern Definition

Preeclampsia develops after approximately:

20 weeks of gestation

and is characterized by new-onset hypertension plus either:

• Proteinuria

or evidence of maternal organ dysfunction such as:

• Thrombocytopenia
• Renal impairment
• Liver dysfunction
• Pulmonary edema
• Cerebral or visual symptoms

Therefore:

Proteinuria is not required for the diagnosis if other severe features are present.

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Eclampsia

Eclampsia refers to:

Preeclampsia associated with:

New-onset generalized seizures not attributable to another cause.

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Ophthalmic Importance of Preeclampsia

Visual symptoms are important because they may represent:

• Severe hypertensive retinopathy
• Choroidal ischemia
• Serous retinal detachment
• Optic neuropathy
• PRES
• Stroke

Any pregnant patient with:

• New blurred vision
• Scotoma
• Photopsia
• Diplopia
• Severe headache

in the setting of hypertension requires urgent obstetric and medical evaluation.

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Ocular Findings in Preeclampsia

Possible findings include:

• Retinal arteriolar narrowing
• Arteriolar vasospasm
• Retinal hemorrhages
• Cotton-wool spots
• Hard exudates
• Optic disc edema
• Choroidal ischemia
• Serous retinal detachment

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Serous Retinal Detachment

Serous retinal detachment is an uncommon but classic severe manifestation of:

• Preeclampsia
• Eclampsia
• HELLP syndrome

It is caused primarily by:

Choroidal vascular compromise → RPE dysfunction → subretinal fluid accumulation

It is often:

• Bilateral
• Bullous in severe cases

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Prognosis of Preeclamptic Serous Detachment

Most cases improve after:

• Blood pressure stabilization
• Treatment of preeclampsia
• Delivery when indicated

Subretinal fluid frequently resolves over:

• Days to weeks

Persistent RPE pigmentary changes may remain.

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Hypertensive Choroidopathy

Findings may include:

• Elschnig spots
• Siegrist streaks
• Serous retinal detachment

These result from:

Choroidal ischemia

rather than primary retinal disease.

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Posterior Reversible Encephalopathy Syndrome

The older term “preeclampsia/eclampsia hypertensive posterior encephalopathy syndrome” is now generally encompassed by:

Posterior reversible encephalopathy syndrome (PRES)

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PRES

PRES may occur with:

• Preeclampsia
• Eclampsia
• Severe hypertension

Symptoms include:

• Headache
• Seizures
• Altered mental status
• Visual disturbance
• Cortical blindness

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Visual Findings in PRES

Patients may experience:

• Bilateral blurred vision
• Homonymous field defects
• Visual neglect
• Cortical blindness

The pupils and ocular examination may remain:

Normal

because the visual deficit is retrochiasmal.

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MRI in PRES

MRI typically demonstrates:

• Vasogenic edema

predominantly involving:

• Parieto-occipital white matter

although other regions may be involved.

MRI is preferred when clinically feasible.

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Cortical Blindness in Preeclampsia

Visual loss can result from:

• PRES
• Occipital ischemia or infarction

In reversible PRES:

• Visual recovery can be excellent

after maternal stabilization.

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HELLP Syndrome

HELLP stands for:

• Hemolysis
• ELevated liver enzymes
• LP low platelet count

It is a severe pregnancy-related hypertensive disorder.

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Ocular Findings in HELLP

Reported manifestations include:

• Serous retinal detachment
• Choroidal ischemia
• Retinal hemorrhage
• Cotton-wool spots
• Vitreous hemorrhage
• Purtscher-like retinopathy

Visual symptoms require urgent systemic assessment.

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Diabetic Retinopathy and Pregnancy

Pregnancy can accelerate progression of:

Preexisting diabetic retinopathy

particularly in patients with:

• Type 1 diabetes
• Type 2 diabetes

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Gestational Diabetes

Gestational diabetes that begins during pregnancy:

Does not itself cause diabetic retinopathy during that pregnancy

because the duration of hyperglycemia is too short.

However, if diabetes may have existed before pregnancy:

• A retinal examination is appropriate

because previously undiagnosed pregestational diabetes may already have caused retinopathy.

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Risk Factors for Diabetic Retinopathy Progression

Progression is more likely with:

• More severe retinopathy at conception
• Longer duration of diabetes
• Poor preconception glycemic control
• Rapid improvement of markedly elevated glucose
• Hypertension
• Renal disease
• Poor glycemic control during pregnancy

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Rapid Glycemic Improvement

Rapid normalization of severe hyperglycemia can produce:

Transient early worsening of diabetic retinopathy

This is not a reason to avoid appropriate glucose control, but patients with significant baseline retinopathy require close ophthalmic surveillance.

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Screening Before or During Pregnancy

Women with known pregestational diabetes should ideally receive a dilated retinal examination:

• Before conception

or:

• Early in the first trimester

if not evaluated preconception.

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Follow-Up in Diabetic Retinopathy

Follow-up frequency is based on baseline disease severity.

No or Minimal Retinopathy

May require:

• One or more examinations during pregnancy

depending on systemic control and guideline used.

Mild–Moderate NPDR

Usually requires:

• Closer surveillance during pregnancy

Severe NPDR or PDR

Requires:

• Frequent retina follow-up
• Often every 1–3 months or more frequently depending on activity

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Diabetic Retinopathy Postpartum

Pregnancy-related progression may partially regress postpartum.

However:

Postpartum regression should not be assumed.

Patients with significant retinopathy require continued follow-up after delivery.

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Proliferative Diabetic Retinopathy

PDR can worsen rapidly during pregnancy.

Treatment of active high-risk PDR is usually:

Panretinal photocoagulation (PRP)

Because pregnancy may accelerate disease, PRP is often performed:

• Promptly
• Sometimes earlier than in a comparable nonpregnant patient

when significant proliferative disease is present.

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Anti-VEGF in Pregnancy

Intravitreal anti-VEGF therapy is generally:

Avoided when an effective alternative exists

because systemic VEGF signaling is important for:

• Placental development
• Fetal vascular development

and pregnancy safety data remain limited.

When sight is threatened and alternatives are inadequate, treatment requires individualized discussion with:

• Retina specialist
• Obstetrician
• Maternal-fetal medicine specialist

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Diabetic Macular Edema

DME may:

• Develop
• Worsen
• Occasionally regress postpartum

Management depends on severity.

Options may include:

• Observation for mild cases
• Focal/grid laser in selected cases
• Intravitreal corticosteroid in carefully selected sight-threatening cases

Anti-VEGF is generally avoided when possible during pregnancy.

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Delivery and Diabetic Retinopathy

An important modern correction:

Diabetic retinopathy or PDR alone is not usually an indication for cesarean delivery.

Normal vaginal delivery is generally acceptable.

A cesarean section should be based on:

Obstetric indications, not simply concern about Valsalva-induced vitreous hemorrhage.

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Valsalva Retinopathy

Pregnancy and labor can occasionally produce:

Valsalva retinopathy

from sudden increased intrathoracic pressure.

Findings include:

• Preretinal hemorrhage
• Subhyaloid hemorrhage
• Sudden painless visual loss

Most cases resolve spontaneously.

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Central Serous Chorioretinopathy

Pregnancy is a recognized risk factor for:

Central serous chorioretinopathy (CSCR)

probably related to:

• Elevated endogenous corticosteroid levels
• Choroidal vascular changes

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Timing of Pregnancy-Associated CSCR

CSCR occurs most commonly in:

Late pregnancy, especially the third trimester

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Clinical Findings

Patients may report:

• Central blur
• Metamorphopsia
• Micropsia
• Relative scotoma

OCT demonstrates:

Serous neurosensory retinal detachment

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Subretinal Fibrin

Pregnancy-associated CSCR may show:

• Subretinal fibrinous material

more often than typical CSCR outside pregnancy.

This can sometimes mimic:

• Inflammatory disease
• Choroidal neovascularization

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Treatment of Pregnancy-Associated CSCR

Most cases are:

Observed

because spontaneous resolution commonly occurs:

• Near delivery
• During the postpartum period

Avoid exogenous corticosteroids when clinically feasible.

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Retinal Vascular Occlusion

Pregnancy creates a relatively:

Hypercoagulable state

which can contribute to:

• Retinal artery occlusion
• Retinal vein occlusion
• Cerebral venous thrombosis

especially in patients with additional thrombotic risk factors.

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Hypercoagulability

Pregnancy physiologically increases:

• Several clotting factors

while reducing some anticoagulant and fibrinolytic activity.

This protects against obstetric hemorrhage but increases thrombotic risk.

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Retinal Artery Occlusion

Acute monocular visual loss from retinal artery occlusion requires urgent investigation for:

• Embolic disease
• Thrombophilia
• Cardiac disease
• Preeclampsia
• Systemic vascular disease

Pregnancy alone should not automatically be assumed to be the cause.

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Retinal Vein Occlusion

Retinal vein occlusion is uncommon but may occur with:

• Hypercoagulability
• Hypertension
• Preeclampsia
• Thrombophilic disorders

Management is individualized because usual intravitreal anti-VEGF therapy raises pregnancy-specific concerns.

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Disseminated Intravascular Coagulation

DIC may occur with:

• Placental abruption
• Severe preeclampsia
• Amniotic fluid embolism
• Sepsis
• Retained fetal demise
• Major obstetric hemorrhage

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Ocular DIC

Ocular manifestations may include:

• Retinal hemorrhage
• Cotton-wool spots
• Choroidal vascular occlusion
• Serous retinal detachment
• RPE changes

Systemic management is the priority.

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Thrombotic Thrombocytopenic Purpura

TTP is characterized by:

• Microangiopathic hemolytic anemia
• Thrombocytopenia

with variable:

• Neurologic dysfunction
• Renal involvement
• Fever

Pregnancy can trigger or exacerbate TTP.

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Ocular Findings in TTP

Possible manifestations include:

• Retinal hemorrhages
• Cotton-wool spots
• Retinal vascular occlusion
• Purtscher-like retinopathy
• Serous retinal detachment

TTP is a:

Medical emergency

requiring urgent hematologic management.

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Purtscher-Like Retinopathy

Purtscher-like retinopathy may occur with:

• Preeclampsia
• HELLP
• TTP
• Pancreatitis
• Renal failure
• Other severe systemic conditions

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Clinical Findings

Typical fundus findings include:

• Purtscher flecken
• Cotton-wool spots
• Retinal hemorrhages

usually clustered around the:

• Optic disc
• Posterior pole

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Amniotic Fluid Embolism

Amniotic fluid embolism is a rare but catastrophic obstetric emergency characterized by sudden:

• Hypoxia
• Hypotension
• Cardiovascular collapse
• DIC

Ocular vascular occlusions may occur but are not the defining manifestation.

Modern survival is substantially better than the extreme mortality rates quoted in older literature, although the condition remains highly dangerous.

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Pituitary Enlargement During Pregnancy

The pituitary normally enlarges during pregnancy because of:

Lactotroph hyperplasia

This physiologic enlargement is usually asymptomatic.

Preexisting pituitary tumors, especially macroadenomas, may enlarge sufficiently to affect:

• Optic chiasm
• Cavernous sinus

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Pituitary Apoplexy

Pituitary apoplexy is:

Acute hemorrhage or infarction within the pituitary, usually in an adenoma

and is an endocrine and neuro-ophthalmic emergency.

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Symptoms of Pituitary Apoplexy

Classic symptoms include:

• Sudden severe headache
• Nausea/vomiting
• Reduced vision
• Bitemporal visual field loss
• Ophthalmoplegia
• Ptosis

Cranial nerves:

• III
• IV
• VI

may be affected within the cavernous sinus.

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Pituitary Apoplexy Examination

Assess urgently:

• Visual acuity
• Pupils
• Color vision
• Visual fields
• Ocular motility
• Optic nerves

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MRI in Pituitary Apoplexy

Preferred imaging is:

Urgent MRI of the pituitary/sella

when available.

CT may be used when MRI is unavailable or contraindicated.

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Systemic Management of Pituitary Apoplexy

Immediate management includes:

• Hemodynamic stabilization
• Electrolyte assessment
• Endocrine testing
• Stress-dose corticosteroids when adrenal insufficiency is suspected
• Neurosurgical and endocrinologic consultation

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Pituitary Surgery

Transsphenoidal decompression may be required when there is:

• Severe or progressive visual impairment
• Significant visual field loss
• Progressive ophthalmoplegia
• Neurologic deterioration

Some stable cases can be managed conservatively under close multidisciplinary supervision.

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Sheehan Syndrome

An important correction:

Sheehan syndrome is not simply postpartum pituitary apoplexy.

It is postpartum ischemic necrosis of the enlarged anterior pituitary, typically following:

• Severe postpartum hemorrhage
• Profound hypotension

Clinical manifestations may include:

• Failure to lactate
• Amenorrhea
• Hypothyroidism
• Adrenal insufficiency

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Meningioma and Pregnancy

Some meningiomas enlarge during pregnancy because of:

• Hormonal influences
• Increased vascularity
• Fluid shifts

Symptoms may include:

• Visual loss
• Optic neuropathy
• Visual field defects
• Proptosis with orbital lesions
• Cranial neuropathies

Some tumors decrease in size postpartum.

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Idiopathic Intracranial Hypertension

IIH may occur during pregnancy but pregnancy itself is not considered a primary cause.

Management principles remain centered on:

• Visual preservation
• Optic nerve monitoring

Acetazolamide may be considered when benefits justify use, especially after discussion with obstetric specialists.

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Multiple Sclerosis and Optic Neuritis

MS relapse rates generally:

• Decrease during late pregnancy
• Increase during the early postpartum period

Acute optic neuritis during pregnancy is evaluated similarly to nonpregnant patients, with imaging and treatment individualized.

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Graves Orbitopathy

Autoimmune thyroid disease may:

• Improve during pregnancy because of relative immunosuppression
• Flare postpartum

Thyroid status requires coordinated endocrine and obstetric management.

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Keratoconus and Ectasia

Hormonal changes may alter corneal biomechanics.

Some patients with keratoconus may demonstrate:

• Increased steepening
• Progression

during pregnancy.

Patients with known ectasia who report visual change may benefit from:

• Topography/tomography

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Diagnostic Evaluation of Visual Symptoms

Evaluation should be determined by the suspected disorder but may include:

• Visual acuity
• Pupils
• Color vision
• Visual fields
• IOP
• Slit-lamp examination
• Dilated fundus examination
• OCT

Check systemic status when appropriate, especially:

Blood pressure

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OCT

OCT is:

• Noninvasive
• Nonionizing

and is considered safe during pregnancy.

It is particularly useful for:

• DME
• CSCR
• Serous retinal detachment
• Optic nerve disease

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OCT Angiography

OCTA avoids intravenous dye and can be useful for evaluating:

• Retinal vasculature
• Choroidal neovascularization

It is noninvasive and particularly attractive during pregnancy when conventional angiography can be avoided.

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Fluorescein Angiography

Fluorescein:

• Crosses the placenta
• Enters breast milk

No strong evidence proves major teratogenicity, but pregnancy safety data are limited.

Therefore FA is usually:

Avoided unless the diagnostic information is important for sight-threatening disease.

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Indocyanine Green Angiography

Pregnancy data for ICG are limited.

ICG should generally be:

• Avoided if unnecessary
• Used when clinically important and benefits outweigh uncertainty

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MRI

MRI without contrast is generally the preferred cross-sectional imaging modality when:

• Neuro-ophthalmic disease
• Pituitary disease
• PRES
• Intracranial mass

is suspected.

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Gadolinium

Gadolinium crosses the placenta.

It is generally:

Avoided during pregnancy unless essential for diagnosis and expected to materially alter management.

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CT

CT is not absolutely contraindicated when urgently needed.

For:

• Stroke
• Hemorrhage
• Trauma
• Other emergencies

necessary maternal imaging should not be withheld solely because of pregnancy.

Radiation exposure should be minimized appropriately.

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Ophthalmic Medications in Pregnancy

General principles include:

• Use medication only when clinically indicated
• Use the lowest effective dose
• Prefer topical over systemic therapy when appropriate
• Reduce systemic absorption with punctal occlusion

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Punctal Occlusion

After instilling an eye drop:

• Close the eyelids
• Apply gentle nasolacrimal pressure for approximately 1–2 minutes

This can reduce:

Systemic drug absorption

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Topical Beta-Blockers

Timolol can cross systemically.

Potential fetal/neonatal concerns include:

• Bradycardia
• Hypotension
• Respiratory depression

When required:

• Use the lowest effective dose
• Consider gel formulations
• Use punctal occlusion

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Brimonidine

Brimonidine has historically been considered relatively acceptable during pregnancy, but should generally be:

Avoided near delivery and during breastfeeding

because it can cause:

• CNS depression
• Apnea

in neonates and young infants.

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Topical Carbonic Anhydrase Inhibitors

Dorzolamide and brinzolamide may be considered when necessary.

Systemic exposure is substantially lower than with oral therapy.

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Acetazolamide

Systemic acetazolamide has traditionally been avoided during early pregnancy when alternatives exist.

However, human evidence has not demonstrated a strong teratogenic signal, and it may be used when:

Maternal visual benefit outweighs theoretical fetal risk

after multidisciplinary discussion.

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Prostaglandin Analogs

Prostaglandin analogs have theoretical concerns related to:

• Uterine smooth-muscle activity

Systemic exposure from ophthalmic dosing is very low, but they are commonly avoided when satisfactory alternatives are available.

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Miotics

Pilocarpine has relatively limited systemic exposure with topical use and may be considered when clinically necessary.

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Topical Corticosteroids

Topical ophthalmic corticosteroids are generally usable when indicated because systemic exposure is low.

Monitor usual ocular adverse effects:

• IOP elevation
• Cataract
• Infection

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Anti-VEGF Therapy

Intravitreal:

• Bevacizumab
• Ranibizumab
• Aflibercept
• Faricimab

are generally avoided during pregnancy when other reasonable treatments exist.

The concern is systemic VEGF suppression during:

• Placental vascular development
• Fetal organogenesis

Treatment of vision-threatening disease requires individualized risk–benefit discussion.

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Laser Treatment

Ophthalmic laser procedures such as:

• PRP
• Focal retinal laser
• Laser retinopexy
• YAG capsulotomy

do not expose the fetus to ionizing radiation and can be performed when clinically required.

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Surgery During Pregnancy

Urgent sight-saving ocular surgery should:

Not be withheld solely because the patient is pregnant.

When possible:

• Coordinate with obstetrics
• Prefer local/regional anesthesia
• Minimize unnecessary medications
• Consider gestational age and positioning

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Preeclampsia Treatment

Ophthalmic manifestations improve primarily by treating the:

Systemic obstetric disease

Management includes:

• Maternal stabilization
• Blood pressure control
• Seizure prophylaxis when indicated
• Delivery according to obstetric criteria

The ophthalmologist’s role is often:

• Recognition
• Documentation
• Exclusion of competing causes of visual loss

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Follow-Up

Follow-up depends on the condition.

Urgent evaluation is required for:

• Sudden visual loss
• New field defect
• Diplopia
• Severe headache
• Seizure
• New flashes/floaters
• Hypertension with visual symptoms

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Patient Education

Pregnant patients should seek urgent medical assessment for:

• New persistent blurred vision
• Scintillating or missing areas of vision
• Sudden visual loss
• Diplopia
• Severe headache
• Neurologic symptoms
• Seizure

These symptoms should not automatically be attributed to normal pregnancy.

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Prognosis

Most physiologic pregnancy-related ocular changes resolve:

After delivery

Preeclampsia-associated:

• Retinal vasospasm
• Choroidal abnormalities
• Serous retinal detachment
• PRES

often improve markedly after systemic stabilization and delivery.

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Diabetic Retinopathy Prognosis

Pregnancy-related worsening may partly regress postpartum, but:

• Permanent progression can occur
• PDR and DME require continued surveillance

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CSCR Prognosis

Pregnancy-associated CSCR usually:

• Resolves spontaneously
• Has good visual prognosis

but may recur:

• In subsequent pregnancies
• Outside pregnancy

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Complications

Potential ocular and neurologic complications include:

• Permanent retinal ischemia
• Vitreous hemorrhage
• Tractional retinal detachment
• Neovascular glaucoma
• Optic neuropathy
• Cortical blindness
• Stroke
• Persistent visual field loss

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Ophthalmology Pearls

• Pregnancy causes reversible refractive, corneal, and IOP changes; permanent spectacle or refractive surgery decisions are best deferred until postpartum stability.
• New visual symptoms in a pregnant patient can be the first clue to preeclampsia, eclampsia, PRES, retinal vascular disease, or pituitary apoplexy.
• Preeclampsia no longer requires proteinuria if hypertension is accompanied by other maternal end-organ dysfunction, including visual or cerebral symptoms.
• Preeclampsia may produce hypertensive retinopathy, choroidal ischemia, serous retinal detachment, and PRES.
• Bilateral serous retinal detachment in preeclampsia/HELLP usually resolves after maternal stabilization and delivery.
• PRES commonly causes headache, seizures, altered mental status, and cortical visual loss, with parieto-occipital vasogenic edema on MRI.
• Pregnancy can significantly accelerate preexisting diabetic retinopathy, especially when disease is already advanced at conception.
• Gestational diabetes itself does not cause diabetic retinopathy during the pregnancy, but suspected preexisting diabetes warrants retinal evaluation.
• Perform diabetic retinal examination before conception or early in the first trimester and increase surveillance according to baseline retinopathy severity.
• PRP remains the preferred treatment for proliferative diabetic retinopathy during pregnancy.
• Diabetic retinopathy alone is not an indication for cesarean delivery; mode of delivery should usually be based on obstetric factors.
• Intravitreal anti-VEGF is generally avoided when effective alternatives exist because pregnancy safety data are limited and VEGF is important in fetal/placental development.
• Pregnancy-associated CSCR usually occurs in late pregnancy and often resolves postpartum.
• Pituitary apoplexy is an endocrine and neuro-ophthalmic emergency presenting with sudden headache, visual loss, field defects, and/or ophthalmoplegia.
• Sheehan syndrome is postpartum ischemic pituitary necrosis after severe hemorrhage/hypotension, not simply pituitary apoplexy.
• OCT and OCTA are useful noninvasive tests during pregnancy; fluorescein and ICG angiography are generally reserved for cases in which they are clinically necessary.
• MRI without gadolinium is preferred for many neuro-ophthalmic indications; gadolinium is avoided unless essential.
• For topical ophthalmic drugs, use the lowest effective dose and punctal occlusion to reduce systemic exposure.
• Urgent sight- or life-saving ophthalmic treatment should not be delayed solely because of pregnancy.