The management of labor in high myopic patients

RATES OF RECURRENT RETINAL DETACHMENT AFTER VAGINAL VERSUS CESAREAN DELIVERIES: A Retrospective Analysis and Review of the Literature

PURPOSE

To evaluate the risk of a retinal redetachment in women after vaginal delivery versus cesarean delivery.

METHODS

Retrospective cohort analysis of patients diagnosed with retinal detachment (RD) who had later delivered in one tertiary medical center. Recurrence rates of RD were obtained from medical charts.

RESULTS

A total of 967 women with RDs were evaluated, and 66 patients met the inclusion criteria. The mean age at the time of RD was 22.64 ± 5.81 SD years and 21.75 ± 5.47 SD years in the vaginal delivery group and the cesarean section group, respectively. None of the patients had a history of eye surgery or traumatic eye injury before the event of RD. In all patients, the detached retina was surgically reattached. Retinal detachment was not recorded in the fellow eye during follow-up. We report four cases of redetachment after birth in four women. In our study, there was a 5% rate (n = 2) of RD after a vaginal delivery as compared with a 7.5% (n = 2) redetachment rate for patients after a cesarean delivery ( P = 0.654).

CONCLUSION

The risk of a redetachment of the retina in women is not increased after a vaginal delivery as compared with a cesarean delivery. Therefore, in our opinion, there is no ophthalmic benefit in a cesarean section for a woman with prior RD.

INTRAVITREAL RANIBIZUMAB IN PREGNANT PATIENT WITH MYOPIC CHOROIDAL NEOVASCULAR MEMBRANE. A CASE REPORT

AIM

To present the case of a patient with myopic choroidal neovascular membrane (mCNV) in the 3rd trimester of pregnancy, who was treated with intravitreal ranibizumab.

CASE REPORT

The 34-year-old patient was referred to the Department of Ophthalmology of the University Hospital Kralovske Vinohrady in January 2020 for mCNV on her right eye (RE). The patient was in the 34th week of pregnancy. Initial best corrected visual acuity (BCVA) was 68 ETDRS letters. Spherical equivalent of the RE was -11.5 dioptres, axial length of the RE was 27.7 mm. Pigmented CNV with small haemorrhage was present on the retina of the RE. Optical coherence tomography (OCT) of the RE showed a hyperreflective mass above the retinal pigment epithelium, central retinal thickness (CRT) was 310 µm. OCT angiography confirmed the presence of a classic CNV in the macula of the RE. Two weeks later, the hyperreflective lesion and oedema in the macula of the RE increased, the CRT was 329 µm, BCVA remained stable. After discussion with the patient and the treating gynaecologist, intravitreal ranibizumab was administered in the RE in the 36th week of pregnancy. On check-up 3 weeks later, we observed the decrease of macular oedema to 276 µm and the improvement of BCVA to 78 ETDRS letters. The patient delivered a healthy baby girl in the 39th week of pregnancy via caesarean section, postnatal adaptation of the newborn was normal. During further visits, the BCVA improved to 83 ETDRS letters and the macular oedema disappeared completely. 8 months after the first ranibizumab injection, the CNV reactivated, BCVA decreased to 72 ETDRS letters, oedema was present in the macula and the CRT was 309 µm. Another ranibizumab was administered into the RE. The patient then discovered that she was pregnant; according to calculations, she was in the 3rd week of pregnancy at the time of the second ranibizumab injection. After the second injection, BCVA improved to 79 ETDRS letters, macular oedema on the OCT disappeared and CRT decreased to 264 µm. The pregnancy was terminated per patients request.

CONCLUSION

Intravitreal administration of ranibizumab in the 3rd trimester of pregnancy led to the improvement of BCVA and decrease of macular oedema in the patient with mCNV. The injection had no adverse effect on the pregnancy or the postnatal adaptation of the newborn. However, it is always necessary to consider the risk/benefit ratio when administering intravitreal antiVEGF drugs in pregnant patients. Thorough discussion with the patient is necessary.

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.

Immediate post partum macular subretinal bleeding in a highly myopic patient: a case report

BACKGROUND

Pathologic myopia is a major cause of visual impairment and blindness.

CASE PRESENTATION

We report a case of an immediate post partum macular subretinal bleeding observed in a highly myopic patient. A 30-years-old woman presented two days after childbirth for sudden loss of vision in her right eye. Multimodal imaging showed macular hemorrhage masking a subtle yellowish linear lesion corresponding to lacker crack. Due to the lack of evidence for choroidal neovascularization, a simple clinical and imaging monitoring was recommended. Six weeks later, we noted an improvement in her best-corrected visual acuity and a decreased in size of the macular hemorrhage.

CONCLUSIONS

This is the first case reporting a macular subretinal bleeding on macular lacquer cracks in a highly myopic patient in immediate post partum. Valsalva maneuver associated with vaginal delivery could explain the occurrence of the hemorrhage associated with lacquer crack. However, natural history of pathological myopia could not be excluded.

IS VAGINAL DELIVERY HARMFUL TO PATIENTS WITH PSEUDOXANTHOMA ELASTICUM?

BACKGROUND/PURPOSE

To investigate the effect of a vaginal delivery (VD) on retinal pathology in patients with pseudoxanthoma elasticum.

METHODS

Retrospective case series. All 14 consecutive women with pseudoxanthoma elasticum who visited the ophthalmology department during pregnancy and after delivery between 2010 and 2018 were included. Prepartum and postpartum imaging consisted of color imaging, near-infrared imaging, and optical coherence tomography and was assessed on occurrence of (sub)retinal hemorrhages and change in angioid streaks.

RESULTS

Fourteen patients (15 deliveries) were included, of whom 11 patients (79%) had a VD and three patients (21%) a secondary caesarian section. Data of three patients with VD (four deliveries) could not be assessed for (sub)retinal hemorrhage within 10 weeks postpartum. The median age at delivery was 31 years (IQR 29-37). One patient with VD (9%) had a choroidal neovascularization and was treated with anti-VEGF injections before assisted delivery. All patients had angioid streaks in the central 5,500 µm of the posterior pole of both eyes. After delivery, no patient in the VD or caesarian section group presented with progression of angioid streaks or (sub)retinal hemorrhage.

CONCLUSION

Pushing during the expulsion phase of VD seems safe in pseudoxanthoma elasticum patients without active choroidal neovascularization, and the presence of angioid streaks alone should not be an indication for elective caesarian section.

Glaucoma in pregnancy: an update

PURPOSE OF REVIEW

Glaucoma management during pregnancy is a complex challenge, which requires balancing the clinical disease of the mother with the potential risks of therapy to the developing child. Because systematic studies are lacking in the pregnant population, this review aims to collect the array of available data from observational studies and case reports to provide the reader with guidance and context for the safety of glaucoma interventions during pregnancy.

RECENT FINDINGS

Surgical glaucoma is a rapidly expanding field with many new technologies and procedures. We review the surgical options for the gravid patient with reference to traditional procedures like trabeculectomy and tube-shunts, and newer MIGS procedures. When indicated, orphan trabeculectomy, or with collagen matrix implant may be a viable solution for severe glaucoma during pregnancy. Newer MIGS procedures such as the gelatin stent may also provide minimally invasive options for pregnant patients. Two new medications, Vyzulta and Rhopressa, were recently released in 2018 and have limited data to support their safety for use during pregnancy.

SUMMARY

The careful consideration of fetal health in the management of glaucoma during pregnancy is best done as a part of a multidisciplinary team including obstetrics and neonatology. When medication is necessary, steps to minimize systemic absorption should be employed. Surgical management should not be excluded for pregnant patients and may be considered before medical management in some cases to prevent fetal exposures and maternal harm.

Delivery in Myopic Women: A Comparison of Mode of Delivery in Years 1990, 2000, and 2010

BACKGROUND A belief has existed for many years that severe myopia is a direct indication for cesarean section or an instrumental vaginal delivery, although many academic papers negated this opinion. The aim of this study was to analyze the mode of delivery of myopic patients in the years 1990, 2000, and 2010. MATERIAL AND METHODS Medical records of 3027 women in labor from the 1st Department of Obstetrics and Gynecology, Medical University of Warsaw were analyzed in 3 time periods: year 1990 - group 1 (G1), year 2000 - group 2 (G2), and 2010 - group 3 (G3). Maternal age, severity and proportion of myopia, ophthalmological consultations, and mode of delivery were assessed. RESULTS In G1 there were 992 patients, in G2 there were 1010 patients, and in G3 there were 1025 patients. Myopic women in labor accounted for 20% of G1, 12% of G2, and 20% of G3. The mean maternal age was ±29.4 years in G1, ±30 years in G2, and ±31.5 years in G3. Myopia was divided into 3 levels of severity depending on the degree of refractive error: low myopia -6 DS. The number of ophthalmological examinations needed in myopic patients to decide on the mode of delivery showed an increasing tendency over the evaluated years, but the rates of referrals for cesarean section/assisted delivery decreased. CONCLUSIONS The proportion of myopic women in labor receiving ophthalmological consultations showed an increasing trend over time. Despite publication of the Ophthalmology-Obstetrics Consensus of the Polish Society of Ophthalmology guidelines, myopia still remains an indication for cesarean section (cesarian section), but not to shorten the second stage of delivery.

Delivery recommendations for pregnant females with risk factors for rhegmatogenous retinal detachment

OBJECTIVE

High-risk pathologies for rhegmatogenous retinal detachment (RRD) in otherwise healthy pregnant females are not contraindications for spontaneous vaginal delivery. However, 74% of European obstetrician-gynecologist (OBGYN) respondents in 2008 recommended operative delivery for females at risk for RRD. This discrepancy is likely due to an older study suggesting a causal relation between Valsalva-like manoeuvres and RRD. The purpose of this study is to determine current delivery recommendations for healthy pregnant females with high-risk pathologies for RRD among Canadian ophthalmologists and OBGYNs.

METHODS

Anonymous prospective cross-sectional survey sent via electronic link in 2013. χ(2) test of proportions was used to compare delivery recommendations between the 2 specialties. Multinomial logistic regression was used to identify predictors for recommendations.

RESULTS

A total of 356 participants responded including 92 ophthalmologists and 27 trainees, and 185 OBGYNs and 52 trainees. For healthy pregnant females with previously treated retinal hole/tear or treated RRD, significantly more OBGYNs recommended cesarean section and significantly more ophthalmologists recommended spontaneous vaginal delivery. Length of practice and type of practice setting were significant predictors among obstetricians in their delivery recommendations.

CONCLUSIONS

This study is the first to include obstetricians, ophthalmologists, and their trainees in a survey of the recommended mode of delivery for pregnant females with risk factors of RRD. Our results suggest that obstetricians concerned about potential RRD in pregnant patients may be unnecessarily recommending operative management. Educational sessions on the risk for RRD with spontaneous vaginal delivery may reconcile the current differences in recommendations between ophthalmologists and obstetricians.

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.

[Bilateral postpartum macular hole]

We report the case of a 30-year-old, -7 myopic woman presenting with visual acuity decreased to 3/10 P4 in her right eye and 8/10 P3 in her left eye one month after uncomplicated delivery. Optical coherence tomography (OCT) demonstrated a stage III macular hole (MH) measuring 100 μ with intraretinal cysts in her right eye and a 100 μ stage Ib MH in her left eye. The stage III MH grew to 440 μ, requiring surgery to close it at 3 months, while the stage Ib hole resolved spontaneously. While myopia is a well-known risk factor for MH, the bilateral nature of this case and the context implicate the role of delivery. Thus, MH may be a cause of visual loss in the postpartum period. Diagnosis may be facilitated by OCT.

[Influence of mode of delivery on pre-existing eye diseases]

Many ophthalmologists and obstetricians recommend either an assisted vaginal delivery with forceps or vacuum extraction, or a Caesarean section in cases of pre-existing eye diseases, such as myopia, retinal detachment, glaucoma or diabetic retinopathy. This is mainly based on the increase of intraocular pressure during the final stage of labor. These recommendations, however, are not evidence-based. None of the published trials have reported any retinal changes after vaginal delivery. This report provides information on the influence of physiological changes on eye diseases during the final stage of delivery. In general eye disease is not an indication for an instrumental or operative delivery provided regular eye examinations (once each trimester) have been performed.

Obstetric opinions regarding the method of delivery in women that have had surgery for retinal detachment

Objectives

We sought to determine international obstetric opinions regarding the influence of a history of rhegmatogenous retinal detachment on the management of labour and to review the evidence base.

Design

A questionnaire containing closed questions, with pre-coded response opinions, was designed to obtain a cross-section of the obstetric opinions.

Setting

Questionnaires were distributed at the 20th European Congress of Obstetrics and Gynaecology in Lisbon, Portugal.

Participants

One hundred questionnaires were distributed among obstetricians attending the congress and 74 agreed to participate.

Main outcome measures

Participants were asked to state their preferred method of delivery in such patients and the reasons for their recommendation. Furthermore, we questioned whether there was any difference in opinions depending on generation.

Results

The majority of respondents (76%) would recommend assisted delivery (either Caesarean section or instrumental delivery), whereas the remaining 24% would advise normal delivery. Generation is not a factor influencing this decision. The majority (58%) based their decision to alter the management of labour on their personal opinion of standard of care.

Conclusion

The literature shows that there is little evidence to support the belief that previous retinal surgery increases the risk of re-detachment of the retina during spontaneous vaginal delivery. This short survey shows that the majority of an international sample of obstetricians questioned does not share this viewpoint. Therefore, unnecessary interventions may be occurring in otherwise fit women with a history of retinal detachment.

[Understanding refraction disorders and oculomotor problems during pregnancy]

During pregnancy, hormonal and hemodynamic modifications can generate a number of organic consequences, specifically ocular, more or less regressive in systemic disease. Refraction disorders are marked by myopization, often not very significant and always regressive within six weeks after the childbirth. Pregnancy could cause a thickening of the cornea and a modification of its curvature. Likewise, contact lens intolerance is common, secondary to the modification of lacrimal film, but does not systematically contraindicate lens wearing. Photorefractive surgeries are ill-advised during pregnancy. Hemeralopia is the most common visual complaint of the pregnant woman. Oculomotor disorders are exceptional. Convergence insufficiency or accommodation disorders are the most common anomalies described. These disorders usually regress in the postpartum period. Oculomotor palsies could be the first symptoms of pre-eclampsia or an associated intracranial pathology. They are specific palsies such as in the abducens nerve and the oculomotor nerve in very unusual cases. Nevertheless, oculomotor paralysis in the pregnant woman should motivate neuroradiological exploration. Intensive labor can be rhegmatogenous in women with severe myopia. Examination of the retinal periphery is systematic before and during pregnancy in these cases. Systematic cesarean section is not formally indicated. It is nevertheless preferable to facilitate delivery with epidural anesthesia.

Refractive issues in pregnancy

Pregnancy is known to cause refractive changes as a result of various hormonal changes occurring during pregnancy. These changes may persist for a few weeks post-partum and during lactation. In this article we discuss various refractive issues in pregnancy that have an effect on contact lens use, myopia and the outcome of refractive surgery.

The effect of normal childbirth on eyes with abnormalities predisposing to rhegmatogenous retinal detachment

BACKGROUND

Pregnant women who have high myopia, a history of retinal detachment or retinal holes, or have known lattice degeneration are frequently referred to an ophthalmologist for advice concerning the management of pregnancy and labor, i.e. whether a spontaneous vaginal delivery can be allowed and whether prophylaxis for high-risk retinal pathology is indicated. Many obstetricians still believe that pregnant women with ocular abnormalities predisposing to rhegmatogenous retinal detachment should have an instrumental delivery, and a few even advocate cesarian section. Very little has been written about the management of pregnant women with high-risk retinal pathology, and opinions differ considerably. Patient data on this subject are scarce.

METHODS

We studied 10 women who had 19 deliveries (10 prospective and 9 retrospective) and who had a history of retinal detachment, had been diagnosed as having extensive lattice degeneration, or had been treated for symptomatic retinal holes or breaks. The women were followed from the third trimester of pregnancy through labor and delivery into the postpartum period, looking for changes in the retinal status.

RESULTS

We found no changes in the retinal status in the postpartum examination.

CONCLUSION

We conclude that prenatal treatment of asymptomatic retinal pathology is not indicated and that spontaneous vaginal delivery may be allowed to take place in women with high-risk retinal pathology.

The pregnant woman's eye

The effects of pregnancy on the eye fall into three categories. Nonpathological physiologic changes in pressures, corneal sensitivity and thickness, and visual function can occur. Pathologic conditions reported to develop during pregnancy include central serous chorioretinopathy, hypertensive and vascular disorders, and uveal melanoma. Pregnancy also can affect pre-existing ocular conditions, such as diabetic retinopathy, tumors, and a variety of immunological disorders and can have beneficial effects on such pre-existing conditions as glaucoma. This review covers ocular disorders in these three categories, and summarizes the systemic changes of pregnancy and the effects of ocular medications on the fetus.