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The Eye and Visual System in Pregnancy, What to Expect? an In‑Depth Review

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The Eye and Visual System in Pregnancy, What to Expect? an In‑Depth Review [Downloaded free from http://www.ojoonline.org on Tuesday, April 22, 2014, IP: 197.35.182.178] || Click here to download free Android application for this journal Review Article The eye and visual system in pregnancy, what to expect? An in‑depth review Khawla Abu Samra Department of Ophthalmology, Ross Eye Institute, Buffalo, NY, USA Pregnancy represents a real challenge to all body pregnancy can affect vision through systemic disease systems. Physiological changes can involve any of the that are either specific to the pregnant state itself such as body organs including the eye and visual system. The the pre‑eclampsia/eclampsia and Sheehan’s syndrome, ocular effect of pregnancy involves a wide spectrum of or systemic diseases that occur more frequently in physiologic and pathologic changes. The latter might be relation to pregnancy such as Graves’ disease, idiopathic presenting for the first time during pregnancy such as intracranial hypertension, anti‑phospholipid syndrome, corneal melting and corneal ectasia, or an already existing and disseminated intravascular coagulation. ocular pathologies that are modified by pregnancy such as diabetic retinopathy and glaucoma. In addition, Keywords: Complications, eye, ocular effect, pregnancy Introduction • Ocular complications of systemic diseases. These are either pregnancy specific diseases such as pre‑eclampsia/eclampsia Pregnancy represents a serious challenge to all body systems. The syndrome and Sheehan syndrome, or diseases that occur more progressive physiological changes that occur are essential to support frequently during pregnancy such as idiopathic intracranial and protect the developing fetus in addition to prepare the mother hypertension (IIH), Graves’ disease, Antiphospholipid for parturition.[1] These physiologic changes involve cardiovascular, syndrome (APS) and disseminated intravascular coagulation [3] renal, pulmonary, hormonal, metabolic, hematologic, immunologic, (DIC). and visual systems.[1] In the presence of clinical or sub‑clinical pathology, the normal physiologic changes of pregnancy can place Although, most of pregnancy ocular complications are mild, significant strain on already compromised systems.[1,2] transient and require no treatment, some are occasionally serious, permanent and require prompt ophthalmic referral. In Ocular complications are common during pregnancy.[3] In general, addition, some ocular complications occurring during pregnancy the ocular effect of pregnancy can be divided in to physiologic and may provide a direct insight in to the pathophysiology of many pathologic changes. The pathologic changes are further divided in systemic diseases. to the following: • Ocular changes occurring for the first time during pregnancy This article provides a review of the physiologic changes of • An already existing ocular pathology that is modified pregnancy, the effect of pregnancy on pre‑existing ocular disease by pregnancy and the ocular manifestations of systemic diseases in pregnant women. The ocular complications of pre‑eclampsia/eclampsia syndrome will be discussed in part 2 of this review. Access this article online Quick Response Code: Website: Physiologic Changes www.ojoonline.org Eyelids DOI: One of the most common ocular physiologic changes includes 10.4103/0974-620X.116626 increased pigmentations around the eye.[4] These pigmentations, known as melasma or chloasma, are reversible and fade slowly Copyright: 2013 Samra K. A., et al. This is an open‑access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Correspondence: Dr. Khawla Abu Samra, 911 Harvest Lane, Apt 3, Lansing/MI, USA 48917. E‑mail: [email protected] Oman Journal of Ophthalmology, Vol. 6, No. 2, 2013 87 [Downloaded free from http://www.ojoonline.org on Tuesday, April 22, 2014, IP: 197.35.182.178] || Click here to download free Android application for this journal Samra: Eye and visual system in pregnancy after pregnancy. It is postulated that hormonal variations of changes. In one study that was conducted in healthy pregnant pregnancy increase melanin as a result of an increase in both women, Akar et al.[17] found that the VF mean threshold sensitivity melanogenesis and melanocytosis.[4] increased significantly in the third trimester. These asymptomatic VF changes were shown to be completely reversible postpartum.[17] Tear Pregnancy affects the physiology of the tear film resulting in Ocular Diseases Modified by Pregnancy dry eye syndrome.[5] This may occur as a result of the direct disruption of lacrimal acinar cells through pregnancy enhanced Diabetic retinopathy immune‑reactivity of prolactin, transforming growth factor beta 1, The number of women with diabetes in pregnancy is increasing, and epidermal growth factor in ductal cells.[5,6] partly as a reflection of increasing obesity in women of child‑bearing age.[18] DR is the most common ocular condition modified by Cornea pregnancy and pregnancy is associated with an increased risk of Cornea may show changes in sensitivity, thickness or curvature. development and progression of DR.[18‑21] Corneal sensitivity tends to decrease, with most changes occur late in pregnancy.[7] A measurable increase in corneal thickness DR developing during pregnancy may show a high‑rate of due to edema has been reported to occur during pregnancy.[8] An spontaneous regression after delivery. In a study of patients increase in corneal curvature also has been reported.[9] Park et al. with no DR at onset who then developed mild non‑proliferative showed that there was a statistically significant increase in corneal DR (NPDR) during pregnancy, 50% had complete regression, and curvature during the second and third trimesters which resolved 30% had partial regression of DR after delivery.[22] completely after delivery or after the cessation of breast feeding.[9] Factors that have been shown to influence the progression of DR in Changes in thickness may alter the refractive index of the cornea; pregnancy include, the pregnant state itself, duration of diabetes, thereby changing refraction.[10] Many women develop contact degree of retinopathy at time of conception, metabolic control of lens intolerance while pregnant despite a previous success. This diabetes, and the presence of co‑existing hypertension.[23] intolerance may be due to the increase in either corneal curvature or thickness.[10,11] It is advisable that pregnant women wait until at The exact pathogenesis for the progression of DR during pregnancy least several weeks postpartum before obtaining a new spectacle remains controversial. Some studies demonstrated a decrease in prescription or new contact lens fitting.[10,11] retinal venous diameter and volumetric blood flow in diabetic patients during pregnancy and hypothesized that this may exacerbate Lens retinal ischemia and hypoxia.[24,25] On the other hand, several Transient loss of accommodation has been reported previously studies have reported an increase in retinal blood flow in diabetic both with pregnancy and lactation.[3] The timing for refractive patients during pregnancy and suggested that this hyper‑perfusion surgery in a pregnant woman or in a woman planning to become causes an added stress to an already compromised retinal circulation pregnant can be a difficult decision. It is better to delay refractive leading to the progression of Diabetic retinopathy (DR).[26] surgery during pregnancy and wait until stability of refraction is clear postpartum.[11] Several studies have shown that higher glycosylated hemoglobin (HbA1C) levels at conception and the rapid tightening of glycemic Intraocular pressure control during pregnancy have been associated with a higher risk IOP decreases during pregnancy.[12,13] Studies in healthy women of DR progression. The diabetes in early pregnancy study showed have shown a statistically significant decrease in IOP during all that elevated HbA1C at baseline was associated with a higher risk trimesters of pregnancy compared with non‑pregnant women.[14] of retinopathy progression and the rates of progression almost IOP declines as pregnancy advances, with statistically significant doubled in women with HbA1C levels greater than 6 standard decrease in IOP from the first to the third trimesters.[13] deviation above the control mean.[19,26] Immunity Diabetic women in child‑bearing age should be counseled Pregnancy is associated with immune suppression, an essential regarding the risk of development and progression of DR. The risk physiologic element for the implantation of the embryo.[15] It of retinopathy progression during pregnancy is higher in patients is associated with lower rates of flare‑ups of non‑infectious with inadequate glycemic control, thus, whenever possible, tight uveitis compared to the non‑pregnant state.[14] Pregnancy has glycemic control should be attained before conception.[27] a beneficial effect on number of uveitis syndromes including Vogt‑Koyanagi‑harada syndrome, Behcet disease and the Patients with severe NPDR or proliferative DR (PDR) are at a idiopathic uveitis syndrome.[14,16] higher risk of progression during pregnancy thus, it is advisable to postpone conception until stabilization of their ocular disease.[27] Visual field VF changes have been reported in pregnant women.[17] Wide Diabetic patients with PDR during pregnancy should be managed speculation exists about the degree and mechanism of these
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