Dr. Aditi Rao1, Dr. Radhika Sharma2 and Dr. Divya Sharma*3
1Dr. Aditi Rao, MS Ophthalmology, MO Specialist, Government of Himachal Pradesh, India
2Dr. Radhika Sharma, MD Anesthesiology, MO Specialist, Government of Himachal Pradesh, India
*3Dr. Divya Sharma, MS Ophthalmology, MO Specialist, Government of Himachal Pradesh, India
Dr. Divya Sharma
Abstract: The effects of pre-existing diabetic retinopathy can worsen during pregnancy. Pregnant diabetic women who also had proteinuria and high blood pressure have been linked to macular edema. The degree of diabetic retinopathy at the beginning of pregnancy has been demonstrated to be a weaker predictor of the health of the foetus than glycemic control during pregnancy. In this review we have described the effect of pregnancy on preexisting ocular disorders.
Keywords: Pregnancy, Ocular Disorders.
Pregnancy can exacerbate the effects of pre-existing diabetic retinopathy. The severity of retinopathy at conception, the duration of diabetes, glycemic management, and the existence of concomitant hypertension are all factors that influence disease progression. The chance of developing retinopathy from gestational diabetes is quite low.1
According to studies on patients who did not have diabetic retinopathy at the start, about 10% of diabetic pregnant women develop some background retinopathy alterations. However, only about 0.2 percent of diabetic pregnant women developed proliferative illness. Unless visual complaints develop, a single baseline ophthalmologic examination may be sufficient in the first trimester.2
Furthermore, research in patients with nonproliferative diabetic retinopathy revealed that up to 50% of them may have an increase in nonproliferative retinopathy, which usually improves by the third trimester and postpartum.3 Proliferative alterations occur in about 5-20% of individuals, with the risk being higher in those who had significant nonproliferative retinopathy at the start of their pregnancy. Patients with nonproliferative diabetic retinopathy should have an ophthalmologic examination at least once every trimester.4
Patients with proliferative diabetic retinopathy may see disease progression in as many as 45 percent of cases, according to research. The probability of advancement was lowered by 50% in patients who received laser treatment before becoming pregnant. Furthermore, if total regression of proliferative alterations occurred before to the commencement of pregnancy, no cases of recurrence during pregnancy have been observed.5 As a result, laser photocoagulation should be started before to pregnancy, if not during the first trimester, if serious nonproliferative or proliferative alterations are present. Without therapy, proliferative retinopathy may regress at the end of the third trimester or after delivery. Monthly ophthalmologic evaluations are recommended for people with proliferative diabetic retinopathy.6
During pregnancy, macular edema can develop or worsen. Macular edema has been connected to pregnant women with diabetes who also had proteinuria and high blood pressure.7 There have been no studies done on the onset of treatment during pregnancy. It may not be unreasonable to keep such patients under observation until they reach postpartum, especially because studies have shown that the majority of instances resolve on their own following birth.8
Glycemic management during pregnancy has been shown to be a stronger predictor of foetal well-being than the degree of diabetic retinopathy at the start of pregnancy. As a result, obstetrical and endocrinological follow-up treatment is crucial to the mother's and foetus' future health.
Intracerebral and other Tumors:
Adenomas of the pituitary gland:
Previously asymptomatic pituitary adenomas or microadenomas may increase during pregnancy, causing ocular symptoms such as headaches, visual field changes, and/or vision loss. As a result, before starting pro-ovulation drugs, patients with amenorrhea are frequently examined to rule out pathological causes (e.g., a pituitary tumour). Although the majority of pituitary adenomas are asymptomatic during pregnancy, a small percentage of them may require radiation or surgery if vision is jeopardised. Radiation and surgical therapy are both effective and have no prenatal side effects.9
Bromocriptine is an alternate medication for prolactinoma patients that has been demonstrated to have no higher risk to the foetus. Corticosteroid therapy has been mentioned as a possible treatment. Pituitary adenomas shrink in size after pregnancy and usually have no visible consequences. Monthly ocular follow-up treatment with visual field testing is indicated for pregnant individuals with pituitary adenomas and microadenomas to rule out enlargement. An ophthalmologist, obstetrician, neurosurgeon, and endocrinologist may collaborate to determine the best medicinal, surgical, or radiation treatment for symptomatic pituitary adenomas.
Pituitary apoplexy, a sudden rise in pituitary size caused by infarction or bleeding, is a potentially vision-threatening consequence of pituitary adenomas. A quick onset of headache, visual loss, and/or ophthalmoplegia may be symptoms of this illness. One of several potential risk factors for its occurrence is pregnancy. A neurosurgical opinion is sought for possible surgical decompression in such patients. Because of the potential of hypopituitarism, endocrinological coverage is also recommended (Sheehan syndrome).10
Meningiomas are slow-growing benign tumours that usually affect older women. They may, however, be present during pregnancy because to their rapid growth. The earliest signs and symptoms are frequently ocular problems such as blurred vision or loss of visual field. Patients who are asymptomatic or have minimal symptoms can be examined and left untreated because most of these tumours shrink in size after birth. Because these tumours are not susceptible to radiation or chemotherapy, surgical treatment is usually the best option for individuals who need it. Individual case analysis is required to determine the timing and type of intervention.11
Melanoma of the Uvea:
Uveal melanoma is a rare occurrence in pregnant women, as it is more common in the elderly. According to the few case studies that exist, uveal melanomas behave similarly to nonpregnant uveal melanomas during pregnancy, and those who have been treated have similar 5-year survival rates. There is no evidence that pregnancy increases the incidence of metastases, and there are no case reports of placental or foetal metastases.
Other brain tumours that can form during pregnancy, such as lymphocytic hypophysitis, can mimic a pituitary adenoma, according to case studies. Choroidal hemangiomas, craniopharyngiomas, and orbital hemangiomas are all uncommon intracranial tumours.
Uveitis and Inflammatory Conditions:
Syndrome of Vogt-Koyanagi-Harada:
A bilateral panuveitis with central nervous system and cutaneous involvement is known as Vogt-Koyanagi-Harada syndrome. Improvement and even complete remission have been reported throughout pregnancy and postpartum.12
Sarcoidosis, ankylosing spondylitis, and juvenile rheumatoid arthritis are all examples of rheumatoid arthritis.
There are several case reports of improvement in both the ocular and systemic symptoms of the disorders mentioned above during pregnancy. This improvement could be attributed to the elevated levels of endogenous corticosteroids that occur during pregnancy. Recurrences or flare-ups after childbirth are not rare.
Toxoplasma gondii is a parasite that can be passed along from a mother who is acutely infected or by eating infected meat. Congenital infection is transmitted to the developing baby through transplacental transmission from a mother who was infected soon before or during pregnancy. Congenital infection is most severe in the first trimester of pregnancy, while the frequency of transmission to the foetus is highest in the third trimester, when the maternal and foetal circulations are most likely to come into touch. It is thought that once maternal immunity develops, all future foetuses are protected from developing congenital toxoplasmosis.
The mother's latent ocular toxoplasmosis may reactivate during pregnancy. These individuals are normally handled in the same way that non-pregnant patients are. Spiramycin has been recommended as a safer and equally effective alternative to pyrimethamine because it is potentially teratogenic. In these instances, the risk of congenital toxoplasmosis to the foetus is essentially non-existent.13
Graves disease can worsen throughout the first trimester of pregnancy or even after the baby is born. During the last trimester of pregnancy, the condition is normally dormant. Patients with Graves orbitopathy are treated in the same way that non-pregnant patients are. The signs of thyrotoxicosis (tachycardia, weight loss, labile emotions, tremor, diaphoresis) should be recognised by the ophthalmologist since they indicate an endocrinological emergency for both the mother and the foetus.
There are a few case reports of retinitis pigmentosa progression during pregnancy. These reports are based on anecdotal evidence and do not point to a specific mechanism.
Multiple sclerosis (MS):
Multiple sclerosis has been reported to stabilise or even improve during pregnancy, similar to inflammatory disorders. However, there is a higher chance of recurrence after childbirth. The overall course of multiple sclerosis does not appear to be affected by pregnancy, and vice versa.
In the past, individuals with extreme myopia who had a spontaneous vaginal delivery were concerned about retinal tears and detachments. However, one research of women with -4.5 D to -15 D vision and varied previous retinal disease (e.g., lattice degeneration, treated retinal tears or detachments) found that spontaneous vaginal delivery had no negative consequences on the retina.
Mackensen F, Paulus WE, Max R, Ness T. Ocular changes during pregnancy. Deutsches Ärzteblatt International. 2014 Aug;111(33-34):567–575.
Weinreb RN, Lu A, Beeson C. Maternal corneal thickness during pregnancy. American journal of ophthalmology. 1988 Mar 1;105(3):258-60.
Naderan M, Jahanrad A. Topographic, tomographic and biomechanical corneal changes during pregnancy in patients with keratoconus: a cohort study. Acta ophthalmologica. 2017 Jun;95(4):e291-6.
Goldich Y, Cooper M, Barkana Y, Tovbin J, Ovadia KL, Avni I, Zadok D. Ocular anterior segment changes in pregnancy. Journal of Cataract & Refractive Surgery. 2014 Nov 1;40(11):1868-71.
Roth LW, Alvero R. Pregnancy in a woman with premature ovarian insufficiency associated with blepharophimosis, ptosis, epicanthus inversus syndrome type I. A case report. The Journal of reproductive medicine. 2014 Jan 1;59(1-2):87-9.
Sanke RF. Blepharoptosis as a complication of pregnancy. Annals of ophthalmology. 1984 Aug 1;16(8):720-2.
Lee HR, Song JE, Lee KY. Developed diplopia and ptosis due to a nonfunctioning pituitary macroadenoma during pregnancy. Obstetrics & gynecology science. 2014 Jan 16;57(1):66-9.
Sharma S, Rekha W, Sharma T, Downey G. Refractive issues in pregnancy. Australian and New Zealand journal of obstetrics and gynaecology. 2006 Jun;46(3):186-8.
Omoti AE, Waziri-Erameh JM, Okeigbemen VW. A review of the changes in the ophthalmic and visual system in pregnancy. African Journal of reproductive health. 2008;12(3),185–196.
Davison JM, Lindheimer MD. 8 Volume homeostasis and osmoregulation in human pregnancy. Baillière's clinical endocrinology and metabolism. 1989 Aug 1;3(2):451-72.
Matias DS, Costa RF, Matias BS, Cláudio Lemos Correia L. Doppler velocimetry of the orbital vessels in pregnancies complicated by preeclampsia. Journal of Clinical Ultrasound. 2012 Nov;40(9):576-85.
Schultz KL, Birnbaum AD, Goldstein DA. Ocular disease in pregnancy. Current opinion in ophthalmology. 2005 Oct 1;16(5):308-14.
Grant AD, Chung SM. The eye in pregnancy: ophthalmologic and neuro-ophthalmologic changes. Clinical obstetrics and gynecology. 2013 Jun 1;56(2):397-412.
Samra KA. The eye and visual system in pregnancy, what to expect? An in-depth review. Oman journal of ophthalmology. 2013 May;6(2):87–91.