Topical timolol therapy in pregnancy: is it safe for the fetus?

Pregnancy and the eye: What do we need to watch out for? A review

Pregnancy causes changes in all body systems, including the eye. The eye can undergo physiological and pathological changes in pregnancy. Some changes exacerbate pre-existing eye conditions while other conditions manifest for the first-time during pregnancy. Early recognition and management are essential to prevent sight threatening complications. In addition, some obstetric complications can be associated with ophthalmic signs. Prompt recognition of these eye findings may be life saving for both the mother and the foetus. The aim of this article is to present potential ocular complications in pregnancy and outline the appropriate management to preserve sight and maintain maternal and foetal safety. The safety of the use of common ophthalmological medications will also be discussed.

Pregnancy Loss Signal from Prostaglandin Eye Drop Use in Pregnancy: A Disproportionality Analysis Using Japanese and US Spontaneous Reporting Databases

Background

There is limited research regarding the use of glaucoma medicines during pregnancy. Prostaglandins contract uterine smooth muscle; however, it is not clear whether prostaglandin eye drops are associated with pregnancy loss in pregnant women.

Objectives

We conducted a pharmacovigilance study using spontaneous report databases from Japan and the USA to evaluate the association between pregnancy loss and the use of prostaglandin eye drops during pregnancy.

Methods

The Japanese Adverse Drug Event Report database and the Food and Drug Administration Adverse Event Reporting System were used for analysis. Disproportionality analyses and a review of individual case safety reports were conducted.

Results

As for prostaglandin eye drops in pregnancy-related reports, there were eight reports involving latanoprost in the Japanese Adverse Drug Event Report database and no reports of pregnant women using other prostaglandin eye drops. In the Food and Drug Administration Adverse Event Reporting System, there were 25 reports involving latanoprost, 23 involving bimatoprost, 13 involving travoprost, and three involving tafluprost. The drug safety signal was detected during latanoprost usage and pregnancy loss. In the Japanese Adverse Drug Event Report database, there were five reports of pregnancy loss related to latanoprost, with a reporting odds ratio of 12.84 (95% confidence interval 3.06–53.86), and in the Food and Drug Administration Adverse Event Reporting System, pregnancy loss was reported in 12 cases of latanoprost usage with a reporting odds ratio of 4.35 (95% confidence interval 1.98–9.54). Uterine contractions were observed as concomitant adverse events in one case.

Conclusions

Although a disproportionality analysis cannot determine causality, we need to keep an eye on the signal detected in this study. This signal should be validated using a causal design study.

Pregnancy and the eye

PURPOSE OF REVIEW

The aim of this study was to summarize common eye changes that may occur during pregnancy, and how pregnancy may affect preexisting eye conditions such as glaucoma and diabetic retinopathy. Challenges and complexities surrounding the treatment of these eye conditions during pregnancy are also highlighted.

RECENT FINDINGS

Refractive changes are common and may persist in the postpartum in patients with keratoconus. Although new medical and surgical glaucoma treatments are available, their safety in pregnancy is unknown. Limited use of topical and systemic glaucoma therapies is recommended, with a preference for selective laser trabeculoplasty as first line treatment in appropriate cases. The impact of pregnancy on diabetic retinopathy remains unclear. Although anti-vascular endothelial growth factor agents are first-line treatment for sight-threatening diabetic retinopathy, their effect on the developing foetus remains unknown and are therefore best avoided in the first and second trimesters. Noninfectious uveitis tends to become less active during pregnancy, allowing the potential tapering of systemic therapy and the use of local topical or injected corticosteroid treatment for active disease as required.

SUMMARY

Significant changes can occur to the eye during pregnancy, wherein the optimal treatment for many ocular conditions remains uncertain, highlighting the need for further research to develop clear recommendations that best balance the need to preserve the mother's sight, and the health of the developing foetus. The need for preconception planning, and collaborative multidisciplinary care between the obstetrician, physician, ophthalmologist and paediatrician is paramount.

Systemic side effects of glaucoma medications

Glaucoma is a progressive loss of retinal ganglion cells leading to visual field loss. Lowering intraocular pressure is currently the only modifiable risk factor to slow glaucoma progression. Intraocular pressure-lowering options include topical and systemic medications, lasers, and surgical procedures. Glaucoma eye drops play a major role in treating this blinding disease. Similar to all medications, the glaucoma medications have their own adverse effects. The majority of glaucoma medications work by stimulating or inhibiting adrenergic, cholinergic, and prostaglandin receptors, which are distributed all over the body. Therefore, the glaucoma medications can affect organs other than the eye. This review will discuss the systemic adverse effects of carbonic anhydrase inhibitors, sympathomimetics, para-sympathomimetics, beta blockers, prostaglandin analogs, hyperosmotic agents, and novel glaucoma medications with a stress on pregnant patients, breastfeeding mothers, and paediatric patients.

Motherhood: What every ophthalmologist needs to know

The aim of this review article is to summarize the available literature on physiologic and pathologic ocular changes during pregnancy and the effect of diseases in pregnancy. A literature search was conducted using PUBMED, MEDLINE, and Cochrane library in English. In addition, the cited references in the published articles were manually reviewed for the relevant results. Pregnancy encompasses a multitude of changes in all body systems, including the visual system of the female. The changes can be physiological, i.e., changes occurring in the lids and adnexa, cornea, conjunctiva, changes in tear film composition and intraocular pressure, retina, choroid, and visual field. Pathological changes in a pregnant woman's eye include changes related to preeclampsia and eclampsia, central serous chorioretinopathy, retinal artery or vein occlusions, and disseminated intravascular coagulation. Preexisting diseases like diabetic retinopathy, Graves' disease, idiopathic intracranial hypertension, various inflammatory conditions can undergo changes in their course during pregnancy. Ophthalmic medications can have an effect on both mother and the baby and hence should be used cautiously. In addition, intrauterine infections play a major role in causing inflammation in the eye of the baby. Hence, vaccination of the mother prior to pregnancy plays an important role in preventing intrauterine infections in the neonate. A regular eye examination in the perinatal period plays a vital role in recognizing ophthalmic pathologies which might require a prompt medical intervention. Pathological ocular diseases should be discriminated from physiologic changes to establish an individualized treatment or preventive plan. This approach to ocular benefits of treatment to the mother should always weigh against the potential harm to the fetus.

Management of glaucoma in pregnancy - balancing safety with efficacy

Glaucoma and pregnancy is an uncommon combination, but it constitutes a very challenging situation for the treating doctor. The challenge is not only controlling the intraocular pressure and preventing glaucoma progression in the mother, but also having to deal with her mental stress and anxiety regarding the safety of her child. The situation is further worsened by the lack of definite guidelines as to how to deal with such patients. Relative rarity of glaucoma in this population restricts any large prospective randomized clinical trials or any large systematic studies. Moreover, none of the existing anti-glaucoma medications is absolutely safe in pregnancy. Current practice patterns depend on some case reports, a few observational studies and a few animal studies that attempt at determining the safety and efficacy of the available medicines. These are then prescribed on the basis of their relative safety in any particular stage of pregnancy or lactation. Newer medications that were released recently in 2018, such as Vyzulta and Rhopressa, presently have limited data to support their safety for use during pregnancy. Laser trabeculoplasty, conventional filtration surgery (of course without anti-metabolites), and minimally invasive glaucoma surgery represent a few non-pharmacological management options. Surgical procedures such as trabeculectomy and tube-shunts or collagen matrix implants, and newer minimally invasive glaucoma surgery procedures such as the gelatin stents are currently being explored and may prove to be viable solutions for severe glaucoma during pregnancy, although they too have their own inherent drawbacks. Management of glaucoma during pregnancy and lactation requires careful consideration of the disease status, gestational stage, US Food and Drug Administration classification and guidelines, and potential benefits and limitations of the various therapeutic modalities. This review focuses on the importance of a multidisciplinary team approach, starting with preconception planning and counseling, determining the treatment options depending on the stage of glaucoma and of pregnancy, and emphasizes the involvement of the patients, their obstetrician, and pediatrician through active discussion regarding the various medical, laser, or surgical modalities currently available or under exploration for use during pregnancy and lactation. The ultimate aim is to achieve an optimal balance between the risks and benefits of any type of intervention, and to customize treatment on an individual basis in order to achieve the best outcomes for both mother and fetus.

Intraocular pressure-lowering medications during pregnancy and risk of neonatal adverse outcomes: a propensity score analysis using a large database

BACKGROUND/AIMS

To investigate the association between exposure to intraocular pressure (IOP)-lowering medications during pregnancy and neonatal adverse outcomes.

METHODS

This retrospective, cohort study used the JMDC Claims Database (JMDC, Tokyo, Japan), 2005-2018. We extracted data on pregnant women with glaucoma, including dispensation of (1) any IOP-lowering medications, (2) only prostaglandin analogues (PGs) and 3) only beta-blockers, during the first trimester. We compared frequency of congenital anomalies (CA), preterm birth (PB), low birth weight (LBW) and the composite outcome of these three measures, between the women with and without IOP-lowering medications. We calculated propensity scores (PSs) using logistic regression in which use of IOP-lowering medications was regressed against known confounders (disorders during pregnancy and other chronic comorbidities). We then conducted logistic regression in which neonatal adverse outcomes were regressed against use of IOP-lowering medications with adjustment for the PS.

RESULTS

We identified 826 eligible women, 91 (11%) of whom had received any IOP-lowering medications. CA occurred in 9.9% and 6.4%, PB in 2.2% and 4.5%, LBW in 9.9% and 6.0% and composite outcome in 17.6% and 13.3% of mothers with and without IOP-lowering medications, respectively. After adjustment for PS, IOP-lowering medications were not significantly associated with more frequent CA (adjusted OR (aOR), 1.43; 95% CI, 0.66 to 3.12), PB (aOR, 0.45; 95% CI, 0.10 to 1.97), LBW (aOR, 2.11; 95% CI, 0.98 to 4.57) or composite outcome (aOR, 1.40; 95% CI, 0.78 to 2.53). Results were similar regarding PGs only and beta-blockers only.

CONCLUSIONS

IOP-lowering medications during the first trimester were not significantly associated with increase in CA, PB or LBW.

Management of Glaucoma in Pregnancy

Management of glaucoma during pregnancy represents a challenge for the physician. Important disease and patients' health decisions begin even before conception and continue throughout pregnancy and breastfeeding. The data on this topic is limited due to ethical and legal constraints and challenges of conducting large, prospective, and randomized clinical trials on this patient population. Our review suggests that individually, intraocular pressure is lower in a pregnant woman when compared with a nonpregnant woman. Importantly, the medical management of glaucoma during pregnancy poses special challenges due to the possibility of adverse effects of medications on the fetus and newborn. Laser trabeculoplasty and traditional filtration surgery, and minimally invasive glaucoma surgery, represent nondrug management options. Thus, managing glaucoma in pregnancy is a delicate balance between treatment to prevent damage to the optic nerve in the mother and avoidance of interventions potentially harmful to the fetus. This literature review of published individual and population-based studies was performed to explore current knowledge and guidelines in the management of glaucoma in pregnancy.

Glaucoma medications in pregnancy

Glaucoma is a chronic, progressive disease of the optic nerve which is relatively uncommon in childbearing age; however, its management is a real challenge. Although the intraocular pressure decreases in pregnancy, many glaucoma patients continue to require treatment. In addition to the side effects, antiglaucoma medications on the mother, the possible side effects of drugs on the fetus must be taken into account. The only antiglaucoma medication categorized in Category B is brimonidine, and all others are in Category C. Most evidence on glaucoma medications in pregnancy comes from single case reports or animal studies with the limitations that these impose. Theoretically, glaucoma medications may damage the fetus; however, they may not have substantial clinical significance with routine dosages and no topical antiglaucoma agents have strong evidence of safety to the fetus based on the human studies. When discussing possible options for glaucoma management with the pregnant patient, it is important to emphasize the lack of definitive studies and the patient may be involved in the therapeutic decision-making process.

Evidence-Based Approaches to Glaucoma Management During Pregnancy and Lactation

With increasing maternal age in this decade, there is a parallel rise in the number of pregnant and lactating women affected by glaucoma worldwide. Understanding the diagnosis and management of glaucoma during pregnancy and lactation is essential to preventing blindness from glaucoma in this vulnerable population. This report provides a review of the current literature and offers effective strategies that will overcome the challenges in managing glaucoma during pregnancy and lactation. Practically, glaucoma management during pregnancy and lactation presents a unique challenge for the physician, as the benefit of any treatment must be weighed against the potential risks to the fetus. Prior to initiating or continuing treatment, the physician should be familiar with the various treatment options to manage intraocular pressure during pregnancy and lactation, including the safety of various anti-glaucoma medications as supported by the existing literature and based on the food and drug administration guidelines. A collaborative team effort between the ophthalmologist, obstetrician, and neonatologist in high-risk pregnancies is recommended to optimize care for the mother and fetus.

Cardiac safety of ophthalmic timolol

INTRODUCTION

It is generally believed that topical administration of eye drops safeguards against harmful systemic effects. However, about 80% of the drug in the ophthalmic products is systemically absorbed and the first-pass metabolism is avoided. Ophthalmic timolol is widely prescribed in the treatment of glaucoma either alone or in the combination eye drop products, many of which have been launched fairly recently. Ophthalmic timolol may cause serious adverse effects such as symptomatic bradycardia, various conduction disorders in the heart, orthostatic hypotension, syncope and falls. Areas covered: In this review we document a number of factors associated with the properties of ophthalmic timolol and specific features of a patient, which may jeopardize patient's cardiac safety even after topical treatment. Expert opinion: Plasma timolol levels are correlated with cardiovascular adverse effects in patients, since timolol is mainly metabolized by cytochrome P450 2D6 (CYP2D6) enzyme in the liver. Patients who are lacking the functional CYP2D6 or who are concomitantly using potent CYP2D6 inhibitor drugs (e.g. paroxetine or fluoxetine) or verapamil or other beta-blockers are at risk of getting serious cardiac adverse effects. Prior to treatment initiation, ECG should be always performed and CYP2D6 genotyping should be considered, if routinely available.

Ocular changes during pregnancy

BACKGROUND

Most ocular changes in pregnancy are harmless. For example, 14% of pregnant women need a new eyeglass prescription. Some changes, however, are serious, such as retinal effects of hypertension, which can be a sign of pre-eclampsia. Ocular changes may give rise to uncertainty about the administration of ophthalmological drugs or the optimal method of childbirth.

METHOD

This review is based on pertinent literature retrieved by a selective search in Medline and on guidelines from Germany and abroad. Recommendations about drugs were taken from the Embryotox and Reprotox databases, the German Red List, and the United States Food and Drug Administration (FDA).

RESULTS

40% to 100% of pregnant women with high blood pressure have retinal changes whose severity is correlated with the severity of pre-eclampsia or eclampsia. Diabetic women should undergo ocular examination before and during pregnancy. Pre-existing retinal changes worsen during pregnancy in 55% of cases. Most ocular diseases can be treated with the usual drugs in pregnant women and nursing mothers, although the evidence for drug safety is derived from case series and the treatment is usually provided off label. Ocular conditions that are present before pregnancy are irrelevant to the choice of a method of childbirth.

CONCLUSION

Pregnant women and nursing mothers can undergo most types of ophthalmological examination and treatment. Recommendations about drug treatment should be checked against current information that can be found on the embryotox.de and reprotox.de websites.

Topical intraocular pressure therapy effects on pregnancy

Purpose

To assess the course of intraocular pressure (IOP), visual field progression, and adverse effects of antiglaucoma medication used during pregnancy.

Methods

Thirteen eyes of eight patients with glaucoma were examined. Their clinical records were reviewed to compare IOP, number of medications, and visual field indices (VFI) before, during, and after pregnancy using a two-tailed paired t-test.

Results

In seven (87.5%) of the eight patients, no disease progression was observed. IOP (mmHg) remained stable (baseline 17.3 ± 3.6; first trimester 17.4 ± 5.2, P = 0.930; second trimester 18.1 ± 4.7, P = 0.519; third trimester 20.2 ± 8.7, P = 0.344; and postpartum 21.5 ± 7.6, P = 0.136). The mean number of glaucoma treatments fell from 1.7 ± 0.52 before pregnancy to 0.83 ± 0.75 (P = 0.04) in the second and third trimesters. In one patient, IOP increased during pregnancy and there was further visual field loss. In the only patient kept on fixed combination timolol–dorzolamide therapy throughout pregnancy, labor was induced because of delayed intrauterine growth.

Conclusions

No changes in IOP and VFI were detected in most patients despite a reduction in the number of hypotensive agents required. Delayed intrauterine growth in one patient under fixed combination timolol–dorzolamide treatment was observed whereas no other adverse effects were detected.

[Ophthalmic agents during pregnancy and breastfeeding]

Ocular therapy is necessary even during pregnancy but the use of pharmaceutical substances bears the risk of side effects on mother and child. The article reflects current knowledge on how to treat the most important eye diseases during pregnancy and breastfeeding. The review covers the diagnostics (tonometry, mydriasis, angiography) as well as treatment of infections of the eyes, glaucoma, allergies, diabetic retinopathy, pain and inflammation.

Cardiovascular and respiratory considerations with pharmacotherapy of glaucoma and ocular hypertension

Glaucoma and ocular hypertension are highly prevalent conditions in individuals over the age of 40 and are commonly seen together in patients with cardiovascular disease. Many of the antiglaucoma medications, when systemically absorbed, affect the sympathetic and parasympathetic nervous systems of patients and can cause cardiovascular toxicity. Such adverse effects are frequently associated with the long-term use of potentially toxic agents in elderly people, who are most prone to chronic eye disease. Moreover, patients may not associate their symptoms with the topical eye medications, and consequently may not report adverse drug effects. Drug-drug interactions can also occur when patients are taking medications for both cardiovascular disease and glaucoma. In this review, the systemic toxicity of these agents is reviewed, along with possible drug-drug interactions. Mention is made of other antiglaucoma medications used alone and in combination with topical beta-blockers. Identification of genetic loci-a bold new step toward glaucoma treatment-is mentioned briefly at the end of the article.

Ocular disease in pregnancy

PURPOSE OF REVIEW

Pregnancy may cause ocular changes, both physiologic and pathologic, and may be associated with the development of new disease or may alter the course of preexisting disease. This paper discusses these changes and reviews diabetic retinopathy, uveitis, preeclampsia, cortical blindness and central serous chorioretinopathy.

RECENT FINDINGS

Recent reports have contributed to our understanding of the pathophysiology of diabetic retinopathy and cortical blindness associated with preeclampsia, the impact of pregnancy on the course of inflammatory eye disease, and the use of optical coherence tomography in following central serous chorioretinopathy in pregnant women.

SUMMARY

This improved understanding of the pathophysiology of ocular disease in pregnancy and the impact of pregnancy on the course of preexisting ocular disease offers the opportunity for meaningful counseling of women who are pregnant or planning to become pregnant.

Glaucoma management in pregnancy: a questionnaire survey

BACKGROUND

The management of glaucoma in a pregnant woman can pose a challenge for the ophthalmologist. The risks and benefits to the mother and foetus must be weighed. When it is decided that treatment is necessary, there is no consensus as to the safest treatment. This study was designed to garner the experiences and views of UK ophthalmologists with regard to this scenario.

METHODS

All consultant ophthalmologists in the UK were sent a questionnaire. They were asked if they had previous experience treating pregnant women with glaucoma, what management they had used, what management they would currently employ, and, if they were to use medical treatment, what would their first choice agent be.

RESULTS

A total of 282 out of 605 questionnaires were returned. Of the respondents, 26% had previously treated pregnant women with glaucoma. Most (71%) had continued with the therapy that the women were already on. In all, 34% had observed the situation and had not needed to treat. When asked what they would currently do in this scenario, 31% were unsure. A total of 40% would simply continue the prepregnancy treatment. A total of 45% of respondents, if they were to use medical treatment, would use beta-blockers, compared to 33% who would use prostaglandins.

CONCLUSION

Although it is thought to be a relatively rare clinical situation, over a quarter of our respondents had first hand experience of the management of glaucoma in pregnancy. Our results indicate some uncertainty about the optimal strategy. It is unlikely that trials will be performed and we suggest guidelines be produced using current knowledge and modified as evidence appears.

Migraine during pregnancy: options for therapy

Migraine is common during pregnancy, but fortunately this combination of conditions obviously exists for only a finite period. The greatest frequency of migraine attacks occurs during the first trimester. Accurate diagnosis is a sine qua non in this setting as in any headache patient. It is in the first trimester that the fetus is at greatest risk from abortifacient and teratogenic drugs, and when very early pregnancy may be undiagnosed. Ergot alkaloids (including methysergide) should be avoided during pregnancy because of their teratogenicity, and most other drug classes should be used only when unavoidable. The use of prophylactic agents during pregnancy should be the exception, not the rule, and preferably only during the second and third trimesters; propranolol is probably safest in this situation. De novo headache during pregnancy usually requires expert review of the patient. Treatment tactics for uncomplicated migraine in pregnancy depend on the concurrent clinical situation. Paracetamol (acetaminophen) is the mainstay for the patient whose typical attacks continue into the first trimester. If paracetamol is insufficient, then partial agonist opioids may be used if typical migraine attacks persist in the second and third trimesters (which is uncommon). 'Chronic migraine' in pregnancy, i.e. >or=15 headache days per month, is rare, and is the greatest therapeutic challenge. Co-morbidities such as depression or epilepsy require specialised approaches. The complexities associated with these tactics are discussed in this article, and it is emphasised that none has the specific approval of regulatory authorities. Heightened pharmacovigilance will better inform the future pregnant migraineur. However, this type of information is less likely to be available for novel classes of neuropharmacological agents than for existing ones.

The effect of antihypertensive drugs on the fetus

A critical review of the literature on the effects of antihypertensive drugs on the fetus in pregnant women is presented. The survey covers the alpha-adrenergic receptor agonists, beta-blockers including topical eye medications, alpha-beta blockers, calcium antagonists, diuretics, and angiotensin-converting enzyme (ACE) inhibitors. The lack of data on angiotensin II receptor blockers is noted although effects are considered to be similar to those reported with ACE inhibitors and therefore to be avoided. Analysis of the literature underscores that some antihypertensive drugs can be used safely at certain stages of pregnancy, while others are suspect and to be avoided at all costs. The lack of placebo-controlled studies on the treatment of severe hypertension in pregnancy due to ethical considerations is discussed against the background of the pressing need to treat these women despite the possible deleterious effects of antihypertensive drugs.

Cardiovascular considerations in using topical, oral, and intravenous drugs for the treatment of glaucoma and ocular hypertension: focus on beta-adrenergic blockade

Glaucoma and ocular hypertension are highly prevalent conditions in individuals over the age of 40 and are commonly seen together in patients with cardiovascular disease. Many of the antiglaucoma medications, when systemically absorbed, affect the sympathetic and parasympathetic nervous systems of patients and can cause cardiovascular toxicity. Such adverse effects are frequently associated with the long-term use of potentially toxic agents in elderly people, who are most prone to chronic eye disease. Moreover, patients may not associate their symptoms with the topical eye medications, and consequently may not report adverse drug effects. Drug-drug interactions can also occur when patients are taking medications for both cardiovascular disease and glaucoma. This review focuses on beta-adrenergic blockers as topical antiglaucoma medications and other topical antiglaucoma drugs. The systemic toxicity of these agents is reviewed, along with the possible drug interactions. Brief mention is also made of other antiglaucoma medications used alone and in combination with topical beta-blockers.