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NCOS 2019 What to Expect When Your Patient Is Expecting .Pptx 5/28/19 Congratulations, you’re Disclosures What to Expect When pregnant!.... Your Patients Expecting • None Cecelia Koetting, OD FAAO Virginia Eye Consultants Norfolk, VA Now, here’s a list of all the New FDA Pregnancy and But why are we worried things to worry about . Lactation Categories • Spontaneous abortion of the pregnancy • 8.1 Pregnancy includes labor and delivery • Transference of medication both during pregnancy • 8.2 Lactation including nursing mothers and during breastfeeding • Causing complications during pregnancy for both • 8.3 Females and males of reproductive Potential mother and child • Birth defect rates from medication use • Topical vs Oral Old FDA Pregnancy and Lactation Categories Optometrist Prescribing • Category A • Category D • The safest drugs to take during pregnancy. Controlled studies • There is positive evidence of potential fetal risk, but the for Pregnant Patients show no risk or find no evidence of harm benefits from use in pregnant women may be acceptable despite the risk (i.e. life threatening • Category B condition to mother). • Animal Studies show no risks but there are no controlled studies on pregnant women • Category X • Category C • Studies in animals or human beings have demonstrated fetal abnormalities, or there is evidence of fetal risk. • Animal studies have shown risk to the fetus, there are no The drug is contraindicated in women who are or may controlled studies in women, or studies in women and become pregnant. animals are not available. 1 5/28/19 When in doubt….. Oral Medication Oral Medication • Can NOT be prescribed • CAN be prescribed • Antibiotic • Antivirals Contact the patients OB/GYN • Oral Acyclovir, Valcyclovir and Famcyclovir • Chloramphenicol, neomycin, ciprofloxacin, doxycycline, • Category B tetracycline, sulfonamides, trimethoprim • Oral Acyclovir is OK for lactating women • Systemic tobramycin is category D • Antibiotics • Pain relief • Often needed for skin and soft tissue infections • Augmentin, erythromycin, azithromycin, amoxicillin • Codeine, ibuprofen/Motrin • Category B • Steroids • Pain relief • Category C • Tylenol • Contraindicated due to their teratogenic effect and role in CSR • Tylenol #3 (short term) • Call OB/GYN • In breastfeeding patients Hydrocodone is preferred • Alternative therapy: meditation and acupuncture during certain trimesters Topical Medications Topical Medications Topical Medications • Dilation drops • Allergy drops • Antibiotics drops • Occasional is acceptable: risk vs benefit • All except Lastacaft are category C • Similar to oral • Alternative: consider shorter acting agents and not recommended • Fluoroquinolones used when benefits>risk, consult OB/ • Tropicamide 0.5% GYN • Category C • SE shown in studies to fetus • Anesthetic • NO phenylephrine • Tobramycin category B, safe for use • Proparicaine is Category C • May cause fetus heart to beat to slowly or cause birth • Less severe bacterial infection defects • Erythromycin, polymyxin B, topical azithromycin • Minor fetal malformations reported with use of systemic phenylephrine, atropine and homatropine • Severe ulcers or bacterial keratitis • Fortified cephalosporin's category B Topical Medications Misc • Glaucoma drops • Steroids • Anti-VEGF • Most are category C • Unlike oral, no known teratogenic effect however is • Systemic absorption is low • Prostaglandins have concern for induction of labor and category C miscarriage • Bevacizumab can’t cross the placenta barrier but is • Beta blockers caution in first trimester and discontinued • Restasis category C shortly before birth to prevent neonatal beta blockade • Could still affect placental vasculature • Category C • CAI has teratogenic and hepatorenal effects • Ranibizumab is category C • Miotic appear to be safe but are still category C • Decrease systemic absorption • pegaptanib (Macugen) is category B • Alphagan is category B • • DO NOT use in lactation, can cause sleep apnea and CNS Punctal occlusion? depression in infant • Punctal plugs? • No oral diamox 2 5/28/19 Ocular and Systemic Refractive Shifts Refractive Shifts Changes During • Studies show approximately 40-75% of pregnant women • Hormonal changes during first trimester causes changes in experience a change in their distance vision Pregnancy thickness of the cornea • Mehdizadehkashi et al. • Water retention • Second trimester • 51% DVA OU affected • Increase in lens curvature • 11% NVA OU affected • Third trimester • Accommodation loss and insufficiency • 74.7% DVA OU affected • Resolve shortly after breastfeeding discontinued • 20..2% NVA OU affected • Other less common causes • Postnatal 8.2% DVA and 4% NVA still affected at • Shifts in cataracts, DM, accommodative spasm • Most studies found women's vision returned to pre- • Usually a myopic shift but hyperopic can also occur pregnancy refractive error shortly after birth and cessation of breast feeding Dry Eye Disease Dry Eye Disease IOP Variations • Changes to cornea and lacrimal system can lead to • Safe treatments during pregnancy • Studies have found IOP tends to decrease during pressure DED or worsening of pre-existing DED • Punctal Plugs • 19.6% reduction in patients with normal IOP • Changes have been noted in tear film physiology • Artificial tears • 24.4% reduction for OHTN patients • Possible immune reaction to the lacrimal duct cells and • Omega 3 and 6 Fatty Acids • Possible Explanation: destruction of acinar cells by prolactine • Steroids? • Increased aqueous outflow • Physical dehydration from nausea and vomiting • Category C • Lower episcleral venous pressure due to decreased systemic • Restasis? vascular resistance • Secondary contact lens intolerance • Category C • Lower scleral rigidity resultant of increased tissue elasticity • Xiidra? • General acidosis during pregnancy • Decrease in corneal sensitivity in third trimester • No category assigned, data not available • Returns to normal approx 2 months post partum Whats this? Adnexa Changes Whats this? • Increased pigmentation around the eyes may occur • “pregnancy mask”, Cloasma, or melasma • Caused by increased estrogen, progesterone and melanocyte stimulating hormone • Occasional unilateral ptosis occurs • Returns to prior position after delivery • Thought to be result of fluid and hormonal effects on the levator aponeurosis 3 5/28/19 Gestational Diabetes Diabetic Retinopathy AOA Practice Guidelines • Like other types of diabetes, gestational affects how • Patients who already have DM and diabetic • Gestational Diabetes your body uses glucose retinopathy may note quick progression • Occurs in second to third trimester and glucose • Pt with NPDR show 50% progression during tolerance usually returns to normal within 6 weeks after • Gestational DM has a small risk of developing pregnancy pregnancy ends retinopathy • 5-20% pts with serve NPDR progress to PDR • Since it is relatively short and temporary it does not • 10% pt without DR prior to pregnancy develop NPDR • Up to 45% progression can be seen in pts who already have a high likelihood they will develop retinopathy during pregnancy have PDR • Retinal evaluation for diabetic retinopathy in these • Baseline examination in first trimester is usually patients is not indicated sufficient when pt is absent of visual symptoms AOA Practice Guideline Whats this? Preeclampsia/Eclampsia • Diabetes Mellitus Type I and II • Preeclampsia triad in a normotensive pregnant woman • Women with pre-existing diabetes who are planning on • BP > 140/90mmHg being pregnant or become pregnant • Edema • Should have a comprehensive eye exam prior to planned • Proteinuria after week 20 of pregnancy pregnancy or during first trimester • Should have a follow-up each trimester of pregnancy • This triad plus contractions without any other cause is eclampsia Idiopathic Intracranial Preeclampsia/Eclampsia Multiple Sclerosis Hypertension • • Increased intracranial pressure with no known cause • Preeclampsia incidence is 5% Patients with MS may note a decrease in attacks during pregnancy causing bilateral edematous ONH • Ocular sequelae in 1 out of 3 • Visual field defects, OCTG elevation • Blurred vision • Will possibly increase the first 3 months postpartum • Photopsia • Diplopia and photopsia less often • Optic Neuritis may occur as a result of immune • Scotoma • Headaches and tinitis medicated changes • Diplopia • Caused by increase in weight during pregnancy that • Signs of retinopathy mimic HTN retinopathy triggers and overproduction of CSF • Most common finding retinal arteriolar narrowing • Will return to normal after patient is post partum 4 5/28/19 IIH Treatment • Diagnosis with MRI without contrast of brain and orbit followed by LP to confirm diagnosis • Based on exclusion • Pts are usually monitored with no treatement given the possible side effects to the fetus from Diamox and Topamax • Serial LP throughout pregnancy and sometimes a tube shunt or OHN fenestration if vision is at high risk What’s causing this? Pituitary Adenoma Pituitary Gland • Previously asymptomatic PA or microadenomas • Patients without a pituitary adenoma can also may grow during pregnancy experience visual field defects when the pituitary • Headaches, gland grows during pregnancy • visual field changes (bitemporal) • Can mimic PA VF defects with a bitemporal defect • Decreased VA • After pregnancy will usually shrink • If patient is known to have this prior to pregnancy, should monitor with visual fields for tumor growth What's this? Graves disease Whats this? • Most common cause of hyperthyroidism during pregnancy • May exacerbate
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