THIEME 32 Review Article Ocular Changes During Pregnancy Alterações oftalmológicas na gravidez Pedro Marcos-Figueiredo1 Ana Marcos-Figueiredo2 Pedro Menéres2,3 Jorge Braga3,4 1 Hospital Senhora da Oliveira (HSO), Guimarães, Portugal Address for correspondence Pedro Figueiredo, MD, Hospital Senhora 2 Centro Hospitalar do Porto (CHP), Porto, Portugal da Oliveira (HSO), Rua dos Cutileiros, Creixomil 4835-044, Guimarães, 3 Instituto de Ciências Biomédicas de Abel Salazar da Universidade do Portugal (e-mail: pedrofigueiredofi[email protected]). Porto (ICBAS-UP), Porto, Portugal 4 Centro Materno-Infantil do Norte (CMIN), CHP, Porto, Portugal Rev Bras Ginecol Obstet 2018;40:32–42. Abstract Pregnancy is needed for the perpetuation of the human species, and it leads to physiological adaptations of the various maternal organs and systems. The eye, although a closed space, also undergoes some modifications, most of which are relatively innocuous, but they may occasionally become pathological. For women, pregnancy is a susceptibility period; however, for many obstetricians, their knowledge Keywords of the ocular changes that occur during pregnancy tends to be limited. For this reason, ► pregnancy this is a important area of study as is necessary the development of guidelines to ► ophthalmology approach those changes. Of equal importance are the knowledge of the possible ► eye medication therapies for ophthalmological problems in this period and the evaluation of the mode ► ocular physiology of delivery in particular conditions. For this article, an extensive review of the literature ► ocular pathology was performed, and a summary of the findings is presented. Resumo A gravidez é necessária à perpetuação da espécie humana, levando a adaptações fisiológicas dos diversos órgãos e sistemas maternos. O olho, apesar de uma cavidade fechada, sofre também algumas modificações, a maioria relativamente inócuas, que pontualmente poderão se tornar patológicas. A gravidez assume-se como um período particular de suscetibilidade para a mulher; no entanto, muitos obstetras têm Palvras-chave conhecimento limitado sobre as alterações oftalmológicas na gravidez. Por conse- ► gravidez guinte, impõe-se o seu estudo, bem como a elaboração de diretrizes para lidar com ► oftalmologia essas mudanças. De igual importância são o conhecimento da eventual terapêutica ► medicação ocular para problemas oftalmológicos neste período e a avaliação do tipo do parto em ► fisiologia ocular condições particulares. Desta forma, foi efetuada uma revisão bibliográfica extensa e ► patologia ocular apresentada uma síntese do tema. Introduction sive vascular diseases, in addition to the evolution of preex- Physiological changes during pregnancy involve changes to isting pathologies. Likewise, the administration of ocular the interior of the eye and to the outer ocular surface. Among drugs, depending on the route, may undergo adaptations, the pathological alterations, several are related to gestational justifying individualized decision-making. The timing of hypertension, such as, central serous retinopathy and occlu- delivery and its potential interference in this balance also received DOI https://doi.org/ Copyright © 2018 by Thieme Revinter March 31, 2017 10.1055/s-0037-1605366. Publicações Ltda, Rio de Janeiro, Brazil accepted ISSN 0100-7203. June 30, 2017 published online August 7, 2017 Ocular Changes During Pregnancy Marcos-Figueiredo et al. 33 reveal remarkable interest. We performed an extensive edema), and an increase in curvature during pregnancy,1,2,8 review and summarized the existing evidence on ophthal- causing temporary refractive changes.2,9 All of these factors mology and pregnancy. may contribute to contact lens intolerance (or the need to use more flat lenses).4 This is common in pregnant women, even 2 Methods if the lenses have been used for several years. This occurs mainly in the second and third trimesters,10 and pregnancy is We performed various literature searches on the PubMed considered a contraindication to ophthalmic surgery.1 Post- database looking for articles published in English, French, partum, these physiological changes tend to reverse, usually Spanish and Portuguese. We used the terms ophthalmology in the first two months, and it is advised to only consider lens and pregnancy; eye and pregnancy; ocular changes in preg- upgrade or refractive surgery after this period.2,4,9 nancy; ocular physiology and pregnancy; ocular diseases and pregnancy; eye and birth; ocular diseases and delivery;and Lens eye and delivery. The inclusion criteria were studies about: A transient loss of accommodation may occur during preg- the changes in ophthalmology conditions caused by preg- nancy and lactation,4 and any potential surgery should be nancy, including physiological or pathological changes; the postponed until stable refraction is achieved (if the pregnan- ocular prescription in this period; and the relationship cy is anticipated).2 between ocular diseases and delivery. Individual studies were considered when they presented a new piece of infor- Iris mation. We excluded from our search works regarding A Krukenberg spindle (pigment deposit on the posterior genetic or molecular studies. cornea) can be observed in pregnant women (3%).3 This appears to decrease in size during the third trimester until 4 Results the postpartum period, mainly due to hormonal changes and aqueous humor dynamics.4 More than 1,500 articles were evaluated, and 46 fulfilled the inclusion criteria. The information was analyzed for: the Intraocular Pressure consistency of the theoretical and experimental data, if It is accepted that there is a decrease in intraocular pressure applied; the year of publication (which was not an exclusion (IOP) in the second half of pregnancy,1,11 mainly in the third criterion); and the quality of the study. trimester,1,2 with a decrease in its diurnal variation compared with pre-pregnancy values4 (probably due to an increase in Physiological Changes uveoscleral drainage and hormonal changes, decreasing the Most ocular changes during pregnancy have hormonal, aqueous humor production).1,3 It varies in adults, being lower metabolic, immunological, hematological and cardiovascu- in the sitting position and higher in the supine position, with lar origin.1 an inverse variation in ocular perfusion pressure.12 There is an improvement in preexisting glaucoma, with glaucomatous Eyebrows/Chloasma symptoms during gestation rarely occurring. The IOP regresses Increased periocular pigmentation is one of the most com- to baseline values about two months postpartum.1 Applana- mon physiological changes, known as melasma or tion tonometry or alternative methods such as Tono-pen chloasma.2 Increased skin pigmentation occurs in 90% of (Reichert Technologies, Depew, NY, US) and iCare (ICare pregnant women, with the proportion of chloasma (“preg- Finland Oy, Vantaa, Finland) are all valid diagnostic tools in nancy mask”)variable(5–70%).3 It is usually limited to the pregnancy.3 Dynamic tonometry has already been suggested malar region, but it may include the eyebrows.4 They are by some authors as a diagnostic test for pregnancy.4 reversible, and decrease gradually after delivery (and are rarely associated with thyroid disease). Choroid The choroidal thickness seems to be higher in pregnant – Tear Film women,13 16 mainly in the first trimester,17 with the excep- Pregnancy conditions a modification in the physiology of the tion of preeclampsia (PE) (equal or slightly higher than non- tear film, due to hormonal changes and disruption of acinar pregnant women).14,16 The macula appears to be cells, producing dry eye syndrome.2,4 unchanged.15 Pupil Visual Field The photopic and mesopic diameters of the pupil appear to There are visual field changes reported in pregnancy, but increase during pregnancy (not increasing wavelength aber- their etiology is unknown.2 There is a physiological increase rations), mainly in the third trimester. It has been postulated of the pituitary gland, but this is insufficient by itself to cause that this is due to increased sympathetic activity.5 a defect in the visual field, unless it is accompanied by an abnormal relationship between the optic chiasm and the Cornea pituitary gland.4 These asymptomatic changes are complete- The cornea, which acts as a barrier, may show a decrease in ly reversible postpartum.2 If symptomatic, the existence of – sensitivity,1,2,6 8 an increase in thickness8 (minimal, due to masked tumors should be investigated.4 Rev Bras Ginecol Obstet Vol. 40 No. 1/2018 34 Ocular Changes During Pregnancy Marcos-Figueiredo et al. Hemeralopia the degree of retinopathy, the severity of PE, maternal blood Hemeralopia (difficulty to see in bright light; daytime blind- pressure and fetal mortality.4 The use of magnesium sulfate ness) may also be more frequent in this period. Both the in the prevention and treatment of seizures has been shown modification of the tear film and the hemeralopia may also to significantly decrease this index in the posterior retinal be due to vitamin A deficiency, but supplementation does not and ciliary arteries. Observation of the ocular fundus has prevent all cases, and this is controversial in pregnancy. been shown to be of increasing importance, seeming to even predict the fetal prognosis.18 In cases of PE, the retinopathy Postpartum severity appears to be linked to the level of placental insuffi- Conjunctival hemorrhage (hyposphagma) is present in 10% ciency and fetal growth restriction.19,20 In the hemolysis, of pregnant and postpartum