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Original Article

Eye Changes and Risk of Ocular Medications
During Pregnancy and Their Management

Jagdish Bhatia, Mohammad Naqaish Sadiq, Taqdees Anwar Chaudhary, Agdish Bhatia
Pak J Ophthalmol 2007, Vol. 23 No. 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . See end of article for Purpose: To review various eye changes during pregnancy and potential risks of
eye medications to the mother and her fetus. Methods and Materials: We performed a literature search through internet
using the medical search headings, effect of pregnancy in eyes, ocular changes in pregnancy, eye medication in pregnancy. We also performed a manual search using references from these articles, review articles and standard text books and Data extraction: All relevant articles including the original articles, review
Rustaq Hospital, PO Box: 421 PC: 329, Rustaq papers, case studies, and relevant book chapters were extracted and reviewed. Conclusion: Little has been published to evaluate the eye changes in pregnancy.
Eye changes in pregnancy are a well established entity in the field of ophthalmology. The risk of giving ophthalmic medicines to pregnant woman is low. The effects of pregnancy on the eyes and there management are reviewed Key words: fetus, ocular changes, ophthalmic medications, physiological eye
changes, pathological eye changes, pregnancy.
uring pregnancy, various physiological The physiological changes in eyes include the
changes take place in body due to the following:
D hormonal effects of the placenta. These The Intra-ocular Pressure: The normal intra-ocular
hormones have effects on most organ systems, pressure (the fluid pressure within the eye) may including the eyes. This article outlines both normal decrease slightly due to certain hormonal and physiological changes in eye during pregnancy and circulatory change1,2. The decrease in intra ocular pathological changes in the eye that can occur from pressure may persist for several months post-partum. pregnancy. Moreover a brief discussion of ocular This could be advantageous to patients suffering from medications and their potential effects on the fetus are Glaucoma, a condition where the raised intra-ocular reviewed. Through this article we review the pressure damages the optic nerve that transmits visual • The physiological changes in eyes during Contact Lens intolerance: The sensitivity of the
pregnant mother’s cornea also decreases significantly • Pathological effects of pregnancy in eyes. due to the associated fluid retention of ocular tissues (especially during the last trimester of pregnancy) (1,2) Effect of Ophthalmic medications in pregnancy. This may cause problems for contact lens wearers who may traumatize their corneas more than usual, recommended prior to pregnancy. In patients with resulting in red, irritated eye and relative contact lens proliferatve diabetic retinopathy, monthly ophthalmic examinations are warranted. Proliferative diabetic Change in refraction: The tendency of fluid retention
retinopathy may regress at the end of the third affects your refraction. This means that your current trimester or postpartum. Pan retinal laser spectacles or contact lenses may be temporarily either photocoagulation is effective during pregnancy in too weak or too strong, depending upon your specific inducing regression of proliferative retinopathy. refractive error. It is usually a temporary change, and Almost all retinal specialists would aggressively treat you need not get your eyes re-tested during the later patients with high-risk characteristics of proliferative stages of pregnancy and for at least the first 6 weeks retinopathy as defined by the Diabetic Retinopathy after child birth. Unless the patient is insisting, it is study. In patients with proliferative diabetic best to defer prescribing new glasses until several retinopathy that does not meet the high risk criteria, some would treat one or both eyes, given the fact that some patients have progressed rapidly during Dry Eyes: Some women experience dry eyes during
pregnancy. Patients with proliferative diabetic retino- pregnancy. This is usually temporary and goes away pathy cesarean section should be considered to after delivery. Lubricating eye drops which are safe to prevent vitreous hemorrhage due to Valsalva use during pregnancy can lessen the discomfort of dry maneuver used during labor. Proliferative diabetic retinopathy are definitely not an indication to Pathological effects of pregnancy on eyes include the
Diabetic macular edema may develop or worsen following
during pregnancy. It may be reasonable to observe Diabetic Patients: Pregnancy can have an adverse such patients until they reach postpartum, especially
outcome on the state of pre-existing diabetic given that studies have shown that most cases have
retinopathy. The worsening of the disease depends on
resolved spontaneously after delivery1,2. the severity of diabetic retinopathy before pregnancy. It is therefore important for woman with Early stages of diabetic retinopathy usually stay quite advanced diabetic eye disease to seriously take their stable, but the more advanced stages (especially the visual future into consideration when planning their proliferative diabetic retinopathy stages) tend to pregnancy and these decisions should only be made after consultation with their ophthalmologist. The Gestational diabetes poses a very low risk for the
proliferative or advanced diabetic eye changes should development of retinopathy. Usually eye examination be treated and stabilized before planned pregnancy. is not required for pregnant woman who had Pregnancy Induced Hypertension (Pre-eclampsia):
The onset of hypertension in an otherwise normoten- In patients who had nonproliferative diabetic sive pregnant woman, with generalized edema and/or retinopathy, studies demonstrated that as many as 50 proteinurea is termed pregnancy induced hyperten- % of them may show an increase in their sion (PIH) or pre-eclampsia. If these changes are nonproliferative retinopathy, which often improves by associated with seizures, then the disorder is classified the third trimester and postpartum. Approximately 5- as eclampsia.The incidence of PIH in otherwise 20 % of these patients develop proliferative changes, healthy women is approximately 5% and is more the risk being higher in those patients who had severe common in primigravidas. The onset of this disorder nonproliferative retinopathy at beginning of their usually is after 20th week of gestation. PIH has various pregnancy. An ophthalmologic examination at least maternal and fetal consequences, including ocular sequelae in up to one third of cases. The most common Studies on patients with proliferative diabetic ocular complaint is visual blurring; however other retinopathy have shown that a progression of disease symptoms have been reported, including photopsias, may occur in as many as 45 % of them. However, in scotomas, and diplopia. The protean ocular those patients who had laser treatment before manifestations include retinopathy, optic neuropathy, pregnancy, the risk of progression was reduced by 50 serous retinal detachment and occipital cortical %. Hence; initiation of laser photocoagulation is changes. The changes that occur in PIH induced retinopathy are similar to changes from hypertensive retinopathy. The most common finding is focal such patients includes a neurosurgical opinion for arteriole narrowing, which also may be diffuse. Other changes may include retinal hemorrhages, retinal Meningioma of Pregnancy: Meningiomas are benign,
edema, cotton wool spots, nerve fiber layer infarcts slow growing tumors. Meningiomas may have a very and vitreous hemorrhage and papilledema. A positive aggressive growth pattern during pregnancy that is correlation exists between the severity of PIH and difficult to manage. They may regress postpartum but degree of retinopathy, however most changes are may regrow during subsequent pregnancy. Often ophthalmic symptoms of decreased vision or visual Cortical blindness has also been seen in association
field loss are the first manifestations. Since most of with severe preeclamsia/eclampsia around the time of these tumors regress in size postpartum, those patients who are asymptomatic or with mild symptoms can be In the past, changes in retinal vessels were observed and left untreated. For those patients who considered a risk factor for placental insufficiency and require it, treatment usually is surgical. Indications for fetal mortality and induction for delivery3. Both an old timing and type of intervention require individual and a recent study of patients with pre-eclampsia and eclampsia, found that those patients with retinal Occlusive vascular disorders: It is well appreciated
hemorrhages and cotton wool spots had a higher rate
that pregnancy represents a hypercoagulable state in of fetal mortality4.
which both clotting factors and clotting activity are increased, through various changes that occur with Central serous retinopathy (CSR): although not platelets, clotting factors, and arterio-venous flow
typical, CSR has been reported to occur during dynamics. Such changes may be related to the
pregnancy5. Although more common in third development of central retinal artery and vein
trimester, it has been reported to occur in the first and
occlusion in eye. Both branch and central retinal artery second trimesters. The diagnosis is clinical one. occlusions have been reported to occur in pregnancy. Observation is the treatment of choice as the condition Retinal vein occlusions are less common than arterial resolves spontaneously in first few months occlusions. postpartum and has been known to occur in future Toxoplasmic Retinochoroiditis: Pregnant patients
pregnancies. A weak plus lens (hyperopic correction) with old toxoplasmic retinochoroiditis are usually may provide temporary visual assistance. concerned about the possibility of transmitting toxoplasmosis to the fetus, but in general they need Intracerebral and other tumors:
not to be concerned. Congenital toxoplasmosis in the Pituitary adenomas: With pregnancy, previously fetus generally results only from active infection of the
asymptomatic pituitary adenomas or micro adenomas
mother that develops during that pregnancy. The may enlarge and result in various ophthalmic presence of toxoplasmic retinochoroiditis or choriore-symptoms, such as headache, visual field change, and tinal scars in the mother is regarded as evidence of / or visual acuity loss. It is recommended that congenital infection of the mother herself, and does pregnant patients with pituitary adenomas and micro not indicate a new active infection of the mother. In adenomas have monthly ophthalmic follow up with recurrent disease, there are usually pre-existing visual field assessment to rule out enlargement. maternal antibodies that are believed to protect the Symptomatic pituitary adenomas may require the fetus. Therefore, the fetus should not be at risk for combined efforts of an ophthalmologist, obstetrician, contracting congenital toxoplasmosis and its related neurosurgeon, and endocrinologist to decide upon birth defects from a mother with toxoplasmic medical, surgical, or radiation treatment. One retinochoroiditis or chorio-retinal scars. These patients potentially visual threatening complication of usually are treated in a similar fashion to patients who pituitary adenomas is the sudden increase in pituitary are not pregnant. However spiramycin has been size from infarction or hemorrhage referred to as recommended as a safer effective alternative. pituitary apoplexy. This condition may present as a sudden onset of headache, visual loss, and / or Miscellaneous disorders:
ophthalmoplegia. Pregnancy is one of several potential
Ptosis (drooping of upper eyelid) has been reported to
risk factors for its occurrence. The management of occur during and after normal pregnancy and is usually unilateral. The mechanism is thought to be due to defects that develop in levator aponeurosis Prostaglandin analogs (eg, latanoprost) FDA risk
from fluid, hormonal, and other changes from the category C. Not well studied, and the reports that do
exist are conflicting. The use of latanoprost / trvoprost Uveitis: The immunosuppressive effects and high is generally contraindicated in pregnant women8,9.
steroid levels present in pregnant women may cause
Mydriatics (Dilating Drops): Use of occasional
improvement in uveitis during pregnancy, with dilating drops during pregnancy for the purposes of exacerbation after delivery. This has been noted in ocular examination is safe. However, repeated use is patients with sarcoidosus6 and Vogt koyanagi-harada contraindicated because of potential teratogenic effects of both parasympatholytics (eg, atropine) and Conjunctival Blood Vessels: Changes in conjunctival
blood vessels have been described toward the end of Topical Corticosteroids: (Prednisolone) FDA risk
pregnancy. These changes include a granularity of category B. Although systemic corticosteroids are
conjunctival venules, mild spasm of conjunctival contraindicated in pregnancy, topical steroids have arterioles, and decreased visualization of conjunctival not been reported to have an adverse effect on capillaries. Excessive vomiting during pregnancy can pregnancy (10), but the safety of their use has not absolutely been established. Therefore, use with care during pregnancy. Avoid their prolong use in Ophthalmic medications in pregnancy
“Doctor, I am pregnant. Can I still use this eye
drops?” This is probably one of the most common
Anti-infection preparations:
questions asked by pregnant women when they visit Topical chloramphenicol: FDA risk category is not
not only to their ophthalmologist, but also their available. It is used widely to treat superficial eye
obstetrician or even family physician. Perhaps it is also
infection because of its spectrum and low cost. Many one of the few questions that even ophthalmologist concerns, however, have been documented about this and other doctors of various specialties might have drug’s serious side effects-namely aplastic anemia and difficulty in answering, especially when they have to ‘grey baby syndrome’. A review article in 2002 present evidence to convince their patients. Limited concluded that the risk of these serious side effects is data have been published regarding the potential risk low and they are unlikely to occur if patients adhere to of eye medications to the mother and fetus. When one wishes to administer ophthalmic pharmacologic treatment.Chloramphenicol if given to mother shortly agents during pregnancy, there should be a clear before labor may cause “grey baby syndrome” with indication for them. Although most ophthalmic cyanosis and hypothermia.Chloramphenicol treatment medications, in the doses used and the topical mode of should be avoided during the last week of pregnancy administration, have not been implicated in an and breast feeding. adverse fetal outcome, thought should go into using Gentamicin eye drops: FDA risk Category C. Should
drugs only as necessary. However recommendations be avoided in pregnancy. Drug should be given only if are summarized as per the FDA guide lines below for the potential benefit outweighs the potential risk8,9. Ciprofloxacin eye drops: FDA risk category C.
Anti-Glaucoma medications:
Should be used only if the potential benefit outweighs the potential risk8,9. Topical Beta blockers: (e.g., timolol eye drops) FDA
risk category C in first trimester while D in 2
Tetracycline eye ointment: FDA risk category D.
trimester. B blockers can cause intrauterine growth Positive evidence of human fetal risk exists8,9. retardation if used in 2nd and 3rd trimester and Topical Erythromycin: FDA risk Category B.
persistent neonatal blockade if used near term. Should
Controlled studies done on animals does not indicate risk to fetus. However no adequate and well Topical and systemic carbonic anhydrase inhibitors
controlled studies done on pregnant women. (eg, acetazolamide, dorzolamide) are contraindicated Generally considered safe to use in pregnancy8-10. during pregnancy because of potential teratogenic Antibiotics which are safe during pregnancy are effects10.
amoxicillin, ampicilline, benzylpenicilline, cabenicilline, cloxacilline, Erythromycine and ophthalmologists, and family physicians are essential vancomycin. Antibiotics which should be avoided during pregnancy are, gentamycin, streptomycin, neomycin, Author’s affiliation
and kenamycin, Flourinated quinolones like Dr.Jagdish Bhatia norfloxacilline and ciprofloxacilline are not considered Rustaq Hospital, PO Box: 421, PC: 329, Rustaq Antiviral eye preparations (Acyclovir eye ointment):
FDA risk category B. Topical acyclovir has not been
studied in pregnant woman. However this medicine has not been shown to cause birth defects or other problems in animal studies. So it is considered Rustaq Hospital, Sultanate of Oman generally safe for eye application. Systemic acyclovir should only be used during pregnancy if potential benefit justifies the potential risk to fetus8,9. Fluorescein dye: FDA risk category B. No known
teratogenic effects of fluorescein during pregnancy Sultanate of Oman exist. Most of the retinal specialist avoids fluorescein angiography during pregnancy, especially first Consultant Gynaecologist Topical anesthetic: No known contraindications exist
to use of topical anesthetic drops in pregnancy10. Anti-allergic eye drops: Sodium cromoglycate 2% REFERENCES
(FDA risk category B) eye drop is safe to use in pregnancy while antihistaminic eye drops containing Somani S, Iqbal Ike K Ahmed. Pregnancy, Special
considerations. www.e-medicine.com/oph, 2005; November 7.
naphazoline (FDA category C) are better avoided8,9. Janet S. Sunness, Arturo Santos. Pregnancy and the mother’s
eye. Duane’s clinical ophthalmology. 1997; 32: 1-19. Sadowsky A, Serr DM, Landau J. Retinal changes and fetal
CONCLUSION
prognosis in the toxemias of pregnancy. Obstet Gynecol. 1956; Little has been published to evaluate the true risk in Uto M, Uemura A. Retinochoroidopathy and systemic state in
the use of eye medication during pregnancy The toxemia of pregnancy. Acta Soc Ophthalmol. 1991; 95: 1016. overall level of evidence for risk giving ophthalmic Bedrossian RH. Central serous retinopathy and pregnancy.
drugs to pregnant women is low. Most of the available evidence is based on only individual case reports and Chumbley LC, Kearns TP. Retinopathy of sarcoidosis. Am J
Ophthalmol. 1972; 73: 123.
Steahly LP. Vogt-Koyanagi-Harada syndrome and pregnancy.
The topic of this article provides a practical Chung CY, Kwok AKH, Chung KL. Use of ophthalmic
overview for pregnant women and their treating medications during pregnancy. Hong Kong Med J. 2004; 10: doctors. Little has been published to evaluate the eye changes in pregnancy; however most of the 9. Drugs in Pregnancy and Lactation: www.safefetus.com physiological eye changes are reversible and doesn’t 10. Samples JR, Meyer SM. Use of ophthalmic medications in
pregnant and nursing women. Am J Ophthalmol 1988; 106 : warrant urgent ophthalmic help. Fortunately the pathological eye changes during pregnancy discussed above are extremely rare and occasionally seen in daily ophthalmic practice. Opinions from obstetrician,

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