So, a pregnant lady walks into your office …

That’s not the opening line to a joke, but it could be the beginning of a conundrum.

By Karen Auge, Contributing Editor

Pregnancy alone should not prompt a woman’s visit to an ophthalmologist beyond the routine annual checkup. But, changes in hormones, blood flow and even fluid retention that accompany pregnancy can cause several ocular changes. Some are normal and benign, but some are not. For ophthalmologists the trick is identifying which is which, and knowing how to safely treat them.

Physicians should consider the following when treating these patients’ ocular problems.

Avoid changes if possible

It’s generally not a good idea to do LASIK procedures on a pregnant woman, or to modify an eyeglass or contact lens prescription for minor vision changes, says Natasha Herz, MD. That’s because fluid retention can cause refractive changes, but those usually resolve after the pregnancy, says Dr. Herz, clinical spokesperson for the American Academy of Ophthalmology. Of course, if the vision changes are so extreme that they put the woman in danger when she drives, then new eyeglasses would be in order, she says.

In addition, women on medication for ocular hypertension who stop taking that medication during pregnancy should be closely monitored, says Ingrid U. Scott, MD, MPH, professor of ophthalmology and public health at Penn State University College of Medicine. Dr. Scott says that the second half of pregnancy is associated with decreased IOP. Among patients with ocular hypertension, the IOP decrease that often accompanies pregnancy may be even greater. IOP changes typically return to pre-pregnancy levels approximately two months post-delivery, she says.

Common ocular issues

The vast majority of ocular symptoms that occur during pregnancy can annoy patients but are not cause for alarm. Dr. Herz says most of the concerns of pregnant women who come to her Maryland practice involve changes in vision. Many women experience dry eyes or new or worsened contact-lens intolerance. Most of the time, these conditions resolve once the pregnancy ends.

While pregnancy itself should not trigger additional monitoring by ophthalmologists, women with uncontrolled hypertension or pre-pregnancy diabetes are exceptions, says Kathleen Digre, MD, professor of neurology and ophthalmology at the University of Utah. The AAO guidelines recommend that if possible, women with diabetes undergo a dilated funduscopic eye exam before becoming pregnant, in order to establish baseline retinopathy, says Dr. Scott.

Diagnosis

Often, relatively minor conditions share symptoms with much more serious concerns. “Women often report seeing spots on the eye — that can indicate pre-eclampsia, but it can also be a symptom of migraine,” says Dr. Digre, a specialist in neuro-ophthalmology and headache. “So it’s important to check blood pressure.”

That overlap of symptoms requires careful testing and diagnosis. “The message I take to every group I speak to is: get the right diagnosis. Use whatever test you need to use to make the right diagnosis,” Dr. Digre says.

Some routine diagnostic procedures might give physicians pause when the patient is expecting. But most procedures are safe. And, any risk associated with a procedure has to be weighed against the risk to both mother and child of making an incorrect diagnosis, Dr. Digre says. “You’ve got to find out what’s going on,” and communicate openly and often with the patient’s obstetrician.

Rare but noteworthy

Ophthalmologists should be on the lookout for other more serious conditions associated with pregnancy, says Dr. Digre. For example, pituitary edemas could enlarge during pregnancy because of hormonal changes, says Dr. Scott.

Pre-eclampsia and eclampsia, potentially serious conditions that occur in roughly 3% to 5% of pregnant women, can cause a number of ocular complications, according to a 2013 article in the Saudi Journal of Ophthalmology.¹ Roughly 25% of women with severe pre-eclampsia report vision symptoms. Among women with eclampsia, the number jumps to 50%. Those symptoms include blurred vision, focal or generalized arteriolar narrowing, cotton wool spots, Elschnig spots and, in rare cases, retinal detachment.

Yet another potential complication for pregnant women is central serous chorioretinopathy (CSCR). This typically occurs more frequently in men, “but in women the condition may be associated with pregnancy,” Dr. Scott says. Patients with CSCR generally complain of reduced visual acuity and may exhibit metamorphopsia. In most cases, the condition will resolve itself without treatment a few months after delivery, she says.

In addition, idiopathic intracranial hypertension, (IIH) which is associated with females and with weight gain, can cause papilledema during pregnancy. Ordinarily, a recommended treatment for IIH is weight loss, but that is hardly practical or advisable for pregnant women, Dr. Herz says. The common drug therapy, acetazolamide, (Diamox, Duramed) is a category C medication, and therefore not advisable for pregnant women. That leaves close monitoring in cooperation with the patient’s obstetrician as the best course of action, Dr. Herz says.

Treatment options

Physicians may be understandably reluctant to prescribe medications and interventions to pregnant women that are otherwise used commonly and successfully. Caution is always the wise course, but many medications can be used safely, Dr. Digre says. Still, consult the FDA’s drug classification system and the patient’s obstetrician, she says.

Fortunately, eye drops are almost always safe to use. These are particularly helpful in treating dry eye, which doesn’t, like many other conditions, necessarily resolve itself after the pregnancy, Dr. Herz says. In fact, it can briefly get worse due to post-pregnancy hormonal surges and lack of sleep.

Keep in mind that pregnant women may feel they have plenty to worry about, and ophthalmologists don’t want to needlessly contribute to stress, says Dr. Scott. “There is a balance. You want people to be vigilant, but you don’t want to create undue anxiety.” OM

REFERENCES

*Formerly Lighthouse International.