CLINICAL Ophthalmic associations in pregnancy Queena Qin, Celia Chen, Sudha Cugati PREGNANCY RESULTS in various physiological variation in pregnancy.2 It normally changes in the female body, including in fades slowly after pregnancy and does the eyes. A typical pregnancy results in not need active intervention. Background A range of ocular pathology exists cardiovascular, pulmonary, metabolic, • Cornea – corneal thickness, curvature during pregnancy. Some pre-existing eye hormonal and immunological changes. and sensitivity may be altered during conditions, such as diabetic retinopathy, Hormonal changes occur, with a rise of pregnancy. Corneal thickness and can be exacerbated during pregnancy. oestrogen and progesterone levels to curvature can increase in pregnancy, Other conditions manifest for the first suppress the menstrual cycle.1 especially in the second and third time during pregnancy as a result of The eye, an end organ, undergoes trimesters, and return to normal in complications such as pre-eclampsia changes during pregnancy. Some of the postpartum period.3 Patients who and eclampsia. Early recognition and understanding of the management of these changes exacerbate pre-existing wear contact lenses may experience ophthalmic conditions is crucial. eye conditions, while other conditions intolerance to the use of contact lenses. manifest for the first time during Pregnant women should be advised Objective pregnancy. Early recognition and to delay obtaining a new prescription The aim of this article is to discuss the understanding of management of for glasses or undergoing a contact physiological and pathological changes in the eyes of pregnant women. ophthalmic conditions during pregnancy lens fitting until after delivery. Laser Pathological changes are sub-divided is crucial for the primary care physician. refractive surgery is contraindicated into: 1) pre-existing eye conditions The aim of this article is to summarise the during pregnancy and is not modified during pregnancy, 2) pathological physiological and pathological ophthalmic recommended until stable postpartum conditions occurring for the first time and changes that can occur during pregnancy refraction is achieved, because the 3) ophthalmic associations due to (Table 1). A guide to the ophthalmic majority of the cornea is made up of complications in pregnancy. assessment of a pregnant woman collagen in the stromal layer, which can Discussion presenting to general practice is also be affected by pregnancy hormones. This article reviews the ophthalmic presented (Figure 1 and Table 2). Corneal sensitivity can be reduced conditions that can manifest during in pregnancy, and this in turn can pregnancy and discusses their increase susceptibility to serious corneal pathophysiology and clinical implications. Physiological ocular changes 4 Recognition, history and examination of infections including post–laser surgery. ophthalmic conditions and a diagnostic in pregnancy • Lens – a myopic shift in the lens framework for referral are provided. Physiological changes in pregnancy can results from increased lens curvature Fundamental multidisciplinary care affect various eye structures, including: in pregnancy, resulting in a change in principles involving the primary care • Eyelids – melasma is a condition refraction. Furthermore, a temporary physician, ophthalmologist, characterised by increased pigmentation loss of accommodation can be seen rheumatologist or haematologist and around the eye and cheeks. It is in the immediate postpartum period. obstetrician in the care of the pregnant patient are discussed. commonly seen during pregnancy and These lenticular changes also indicate results from increased melanocytosis that new glasses or refractive surgeries and melanogenesis due to hormonal should be avoided during pregnancy. © The Royal Australian College of General Practitioners 2020 REPRINTED FROM AJGP VOL. 49, NO. 10, OCTOBER 2020 | 673 CLINICAL OPHTHALMIC ASSOCIATIONS IN PREGNANCY Pathological ocular changes (RANZCO) recommends referral to an (Figure 2B). The safety of intravitreal in pregnancy ophthalmologist within four weeks of anti–vascular endothelial growth factor Pre-existing eye conditions modified the initial ophthalmic exam.12 Diabetic treatment is not established and hence during pregnancy macular oedema, a hallmark of severe best avoided;13 intravitreal triamcinolone Diabetic retinopathy diabetic retinopathy that leads to vision is a safe alternative. Crucially, eyes with Diabetic retinopathy is a common ocular loss, may develop during pregnancy existing or worsening diabetes sequalae condition, and progression of diabetic retinopathy during pregnancy is seen in both types 1 and 2 diabetes, especially Table 2. Vision change in a pregnant woman: A guide for patient during the second and third trimesters symptomatology49,50 (Figure 2). The prevalence of diabetic Symptoms to guide urgency of retinopathy in patients with type 2 referral to ophthalmologist Associated eye condition diabetes is 14% during pregnancy.5 The degree of diabetic retinopathy at the start Urgent of pregnancy, glycosylated haemoglobin Transient vision loss (vision returns to Papilloedema, amarosis fugax control, duration of diabetes and presence normal <24 hours) of hypertension are known risk factors for Sudden painless vision loss (>24 hours) Retinal artery or vein occlusion, serous retinal worsening of diabetic retinopathy during detachment, vitreous hemorrhage, optic disc pregnancy.6,7 Regression of diabetic ischaemia retinopathy and spontaneous recovery Sudden painful vision loss Acute angle closure glaucoma, optic disc of vision often occur in the postpartum neuritis (pain with eye movement in >50% of period. Gestational diabetes carries cases), intraocular infection a very small risk (<1%) of developing retinopathy, and ophthalmologic Sudden loss of visual field Optic neuritis, meningioma, branch retinal artery or vein occlusion, occipital lobe examination is not necessary.8 pathology, optic tract lesion, glaucoma An early discussion about pregnancy with patients who have diabetes may Diplopia monocular (symptom can be Refractive error, cornea disease, iris pathology be advisable.9 Good prognostic factors elicited from one eye only) include tight glycaemic control prior to Diplopia binocular (symptoms present Cranial nerve palsies – 3rd/4th/5th/6th conception and recent onset of diabetes when both eyes are open) at the time of pregnancy. Controlling Intermediate urgency risk factors such as blood sugar levels and hypertension is crucial for women Gradual painless loss of vision (over Refractive error, glaucoma, diabetic retinopathy with diabetes.10,11 Ocular examination months or years) or associated diabetic macular oedema is recommended before conception and Non-urgent again during the first trimester for women with diabetes. The Royal Australian and Burning/itching/tearing without pain Blepharitis, dry-eye syndrome, conjunctivitis, contact lens–related problems New Zealand College of Ophthalmologists Table 1. Ophthalmic associations in pregnancy Pathological pre-existing Pathological eye conditions Pathological systemic pregnancy Physiological ocular eye conditions worsening occurring for the first time complications leading to eye changes in pregnancy during pregnancy during pregnancy conditions • Melasma • Diabetic retinopathy • Central serous • Pre-eclampsia and eclampsia • Cornea thickness and • Glaucoma* chorioretinopathy • Disseminated intravascular curvature • Idiopathic intracranial • Uveal melanoma coagulopathy • Myopic shift hypertension • Antiphospholipid antibody syndrome • Meningiomas • HELLP (haemolysis, elevated liver enzymes, low platelets) syndrome • Pituitary adenoma • Thrombocytopenic purpura • Grave’s disease *Pregnancy-related physiological changes may protect against glaucoma, with reduced intraocular pressure during pregnancy. 674 | REPRINTED FROM AJGP VOL. 49, NO. 10, OCTOBER 2020 © The Royal Australian College of General Practitioners 2020 OPHTHALMIC ASSOCIATIONS IN PREGNANCY CLINICAL such as non-clearing vitreous haemorrhage primary open angle glaucoma include also protects the optic nerve. These and tractional retinal detachments may be age, family history, previous trauma and physiological effects and IOP return to considered for surgical intervention.14 myopia. Glaucoma may become more baseline three months postpartum.15 prevalent in women who are choosing In patients with pre-existing Glaucoma to start families later, and may have glaucoma, preconception counselling Glaucoma is a condition in which there pre-existing glaucoma while pregnant. is important to assess the safety of is an elevated intraocular pressure (IOP), Physiological changes during pregnancy IOP-lowering medication (Table 3). Laser which can damage the optic nerve and are protective against glaucoma. The level trabeculoplasty is a safe option during cause visual field loss. Risk factors for of female sex hormones during pregnancy pregnancy for refractive elevated IOP not Patient presentation Refer to Table 2 General practice Diagnosis Condition not sight- Sight-threatening Diagnosis uncertain threatening* condition identified Conditions that are normally sight- threatening (and should therefore be managed in secondary care) include: GP/optometrist Common conditions that • pre-eclampsia and eclampsia are not normally sight- • HELLP (haemolysis, elevated liver threatening (and can Management, advice If there is concern, Urgent referral enzymes, low platelets) syndrome therefore