Retinal detachment in association with pre-eclampsia, eclampsia, and HELLP syndrome

Bilateral Exudative Retinal Detachment in Preeclampsia: A Case Report and Literature Review

Preeclampsia, a complex multisystem disorder predominantly impacting the kidneys and liver, manifests through hypertension and organ dysfunction in expectant mothers. Preeclampsia can also cause ocular signs, but they are uncommon. Exudative retinal detachment (ERD) is one such unusual but dangerous consequence. A thorough clinical description and therapy of a patient who experienced exudative retinal detachment while experiencing preeclampsia are provided in this study. A 28-year-old Saudi female, with no medical or surgical history, underwent an emergency cesarean section (CS) due to severe preeclampsia and failed induction of labor. The patient complained of painless blurry vision, with central dark spot and decreased vision starting from labor daytime. The patient was admitted to the hospital for blood pressure monitoring and further investigations. The patient was started on hydralazine intravenous (IV) and labetalol PO to control BP. The patient was delivered by cesarean section for preeclampsia with severe features after the failure of labor induction, and she had improved her vision by four weeks postpartum. Retinal detachment as a consequence of preeclampsia is conservatively managed, with a generally favorable prognosis. Previous studies have consistently emphasized the critical importance of a multidisciplinary approach that fosters collaboration between obstetricians and ophthalmologists. This collaborative strategy not only ensures comprehensive care but also facilitates early detection, timely intervention, and improved management outcomes for conditions affecting both maternal health and ophthalmic well-being during pregnancy.

Preeclampsia and the Retina

PURPOSE OF REVIEW

This review summarizes key findings relating to the association between preeclampsia and retinal disorders.

RECENT FINDINGS

Preeclampsia is a major cause of maternal morbidity. Pregnant women with preeclampsia frequently describe having visual disturbances. Retinal changes can be identified on fundoscopy in most patients with preeclampsia. While retinal pathology secondary to preeclampsia usually resolves postpartum, there is growing evidence that women with preeclampsia have a higher long-term risk of developing retinal disorders after pregnancy. Pregnant women often experience visual changes. While these symptoms may be benign, careful attention should be paid to exclude retinal disorders secondary to preeclampsia. Pregnant women complaining of new-onset or worsening blurry vision, scotomata, diplopia, or photopsia require rapid and thorough evaluation to rule out hypertensive disorders. Management of preeclampsia, including administration of magnesium sulfate and delivery of the fetus, can reverse retinal pathologies in most cases.

A Case Report of Bilateral Exudative Retinal Detachment in Severe Pre-eclampsia

We report a case of a 31-year-old gravida 2 para 1 female presenting to the optician with a two-week history of blurred vision and persistent headaches at 29 weeks gestation. Visual acuity on presentation was 6/100 in the right eye and 6/24 in the left eye. Fundoscopy of both eyes revealed serous retinal detachment in the absence of background retinal changes. On urgent admission to the maternity assessment unit, blood pressure was 189/126 mmHg and urine dipstick revealed 4+ proteinuria. Due to recurrent poor foetal heart rate variability on cardiotocography monitoring, an emergency caesarean was conducted. Sixteen hours following delivery, visual symptoms had improved, and clinical examination revealed normal blood pressure. An optical coherence tomography scan performed three months later was dry bilaterally with minor retinal pigment epithelium clumping. Serous retinal detachment involves the separation of the neurosensory retinal layer from the underlying retinal pigment epithelium. It is rare in pre-eclampsia but can be seen in patients with severe disease. The presentation of serous retinal detachment includes acute visual loss, reduced visual acuity, floaters, and flashing lights appearing in the vision. Although alarming on initial presentation, resolution is commonly seen within a couple of days postpartum. The pathogenic mechanism for serous retinal detachment development is widely discussed and thought to include changes to the choroidal circulation. Overall, although often self-resolving, a move to thorough antenatal care and vigilant monitoring in pre-eclamptic women is vital to prevent complications like this from occurring.

Exudative Retinal Detachment and Ciliochoroidal Effusion in Preeclampsia

Purpose: To describe a novel case of focal exudative retinal detachment, choroidal effusion, and acute angle closure in preeclampsia. Methods: A case report is presented. Results: A 37-year-old woman at 38 weeks gestation presented with 2 weeks of progressive blurred vision in the left eye. She had a visual acuity (VA) of 20/800 and an intraocular pressure (IOP) of 26 mm Hg in the left eye (compared with 17 mm Hg in the right eye). Examination showed subretinal fluid in the posterior pole, ciliochoroidal effusion, and angle closure in the left eye without pathology in the right eye. She was found to have hypertension and proteinuria consistent with preeclampsia. The visual symptoms resolved after delivery. At the 1-month follow-up, she had a VA of 20/60 OS, symmetric IOPs, and resolved subretinal and choroidal effusions. Conclusions: To our knowledge, this is the first reported case of ciliochoroidal effusion in the setting of preeclampsia. It may aid in the diagnosis of preeclampsia's ocular manifestations and broaden pathophysiological understanding.

BILATERAL SEROUS RETINAL DETACHMENTS IN A PATIENT WITH PREECLAMPSIA WITHOUT HYPERTENSION

PURPOSE

To report a case of bilateral serous retinal detachments in a patient with preeclampsia without hypertension using multimodal ophthalmic imaging.

METHODS

Case report.

RESULTS

This case demonstrates the rare presentation of bilateral serous retinal detachment in a patient with preeclampsia without hypertension. Characteristic subretinal fluid was seen on examination and optical coherence tomography. No leakage was noted on fluorescein angiography. Treatment was deferred, and the subretinal fluid resolved within 3 weeks.

CONCLUSION

Practitioners should be aware of the rare presentation of serous retinal detachments in preeclampsia, even in the absence of hypertension. Long-term sequelae are uncommon and usually only seen in severe disease. Delivery should be considered once serous retinal detachment develops.

A algorithm for prediction of exudative retinal detachment risk of patients with pregnancy-induced hypertension

AIM

To investigate the risk of exudative retinal detachment (ERD) morbidity in patients with pregnancy-induced hypertension (PIH) by using the logistic regression combined with the receiver operating characteristic (ROC) curve.

METHODS

A total of 46 patients with ERD and 142 patients with non-ERD were diagnosed as PIH from January 2017 to February 2020. A retrospective comparison of the clinical manifestations and laboratory tests were conducted. The risk of ERD morbidity with PIH was predicted by using logistic regression combined with an ROC curve model.

RESULTS

There was no significant difference in age and body mass index between the two groups before pregnancy (P>0.05). However, significant differences were found in gestational weeks, duration of hypertension, maximum and minimum systolic and diastolic blood pressure (BP), and plasma total protein (PTP) concentration between the two groups (P<0.05). Binary logistic regression analysis showed that the maximum systolic BP (OR=1.050, 95%CI: 1.016-1.085) and PTP concentration (OR=0.764, 95%CI: 0.702-0.832) were independent prediction risks of ERD in PIH. The sensitivities of maximum systolic BP, PTP concentration and combined diagnosis were 0.717, 0.870, and 0.870, respectively; the specificities were 0.617, 0.837, and 0.908, respectively; the area under the curve (AUC) was 0.707 (95%CI: 0.622-0.792), 0.917 (95%CI: 0.868-0.967), and 0.933 (95%CI: 0.890-0.975), respectively; the AUC of combined diagnosis was higher than that of single diagnosis (P<0.01).

CONCLUSION

Logistic regression and ROC curve model combined with maximum systolic BP and PTP can improve the early identification of high-risk PIH patients in the hospital.

Eye diseases during pregnancy: a study with the medical data warehouse in the eye clinic of the Ludwig-Maximilians-Universität München in Munich in Germany

Objective

To analyze the most common ophthalmologic disorders in pregnant women seen in a hospital in Munich in Germany using a big data analysis system, as well as to compare the results obtained with those from other epidemiological studies that used different data acquisition methods.

Methods

We retrospectively analyzed electronic health records of pregnant women who were seen at the ophthalmology department from 2003 to 2019 at the Ludwig-Maximilians-Universität München hospital. The main complaints that led to ophthalmic consultations during this period were evaluated, and also the variation in intraocular pressure of patients throughout gestational trimesters by analyzing data from the data warehouse system.

Results

A total of 27,326 electronic health records were analyzed. Of participants, 149 (0.54%) required eye care during pregnancy. Their mean intraocular pressure was 17mmHg in the first trimester, 12mmHg in the second trimester, and 14mmHg in the third trimester. The most prevalent findings were dry eye (29.3%) and conjunctivitis (16%), and ametropia (16%). The most common posterior segment problem was diabetic retinopathy (4.6%). The lower mean intraocular pressure in the second and third trimester found in our study is in accordance with other studies that used other method for data acquisition.

Conclusion

The most common ophthalmic conditions found in this study population were dry eye, conjunctivitis, and ametropia. The use of data warehouse proved to be useful for acquiring and analyzing data from many patients. This study results are comparable with other studies in published literature that adopted different methodology.

Deficiency in Lyst function leads to accumulation of secreted proteases and reduced retinal adhesion

Chediak-Higashi syndrome, caused by mutations in the Lysosome Trafficking Regulator (Lyst) gene, is a recessive hypopigmentation disorder characterized by albinism, neuropathies, neurodegeneration, and defective immune responses, with enlargement of lysosomes and lysosome-related organelles. Although recent studies have suggested that Lyst mutations impair the regulation of sizes of lysosome and lysosome-related organelle, the underlying pathogenic mechanism of Chediak-Higashi syndrome is still unclear. Here we show striking evidence that deficiency in LYST protein function leads to accumulation of photoreceptor outer segment phagosomes in retinal pigment epithelial cells, and reduces adhesion between photoreceptor outer segment and retinal pigment epithelial cells in a mouse model of Chediak-Higashi syndrome. In addition, we observe elevated levels of cathepsins, matrix metallopeptidase (MMP) 3 and oxidative stress markers in the retinal pigment epithelium of Lyst mutants. Previous reports showed that impaired degradation of photoreceptor outer segment phagosomes causes elevated oxidative stress, which could consequently lead to increases of cysteine cathepsins and MMPs in the extracellular matrix. Taken together, we conclude that the loss of LYST function causes accumulation of phagosomes in the retinal pigment epithelium and elevation of several extracellular matrix-remodeling proteases through oxidative stress, which may, in turn, reduce retinal adhesion. Our work reveals previously unreported pathogenic events in the retinal pigment epithelium caused by Lyst deficiency. The same pathogenic events may be conserved in other professional phagocytic cells, such as macrophages in the immune system, contributing to overall Chediak-Higashi syndrome pathology.

Bilateral serous retinal detachment in a patient with atypical presentation of preeclampsia due to HELLP syndrome

Exudative retinal detachment (ERD) is a rare complication that occurring in 1% of patients with preeclampsia, its incidence is increased when it is associated with HELLP syndrome. Preeclampsia is defined by the development of arterial hypertension and proteinuira occurs after 20 weeks of gestation until postpartum. HELLP syndrome (low platelets, hemolysis and elevated liver enzymes) is a severe form of preeclampsia. ERD in preeclampsia is related to choroidal ischaemia, in the vast majority of the cases associated with hypertensive retinopathy. However, it has been proposed that the combination of hypertension with a microangiopathic hemolysis, hipercoagulability and hypoalbuminemia are the main factors contributing to the development of ERD. Its treatment includes a rapid resolution of labor to reverse ocular manifestations and prevent visual sequels. We describe the case of a pregnant woman with atypical preeclampsia who, in the postpartum of a cesarean, presented an ERD concomitantly with a HELLP syndrome.

Bilateral serous retinal detachment in a patient with atypical presentation of preeclampsia due to HELLP syndrome

Exudative retinal detachment (ERD) is a rare complication that occurring in 1% of patients with preeclampsia, its incidence is increased when it is associated with HELLP syndrome. Preeclampsia is defined by the development of arterial hypertension and proteinuira occurs after 20 weeks of gestation until postpartum. HELLP syndrome (low platelets, hemolysis and elevated liver enzymes) is a severe form of preeclampsia. ERD in preeclampsia is related to choroidal ischaemia, in the vast majority of the cases associated with hypertensive retinopathy. However, it has been proposed that the combination of hypertension with a microangiopathic hemolysis, hipercoagulability and hypoalbuminemia are the main factors contributing to the development of ERD. Its treatment includes a rapid resolution of labor to reverse ocular manifestations and prevent visual sequels. We describe the case of a pregnant woman with atypical preeclampsia who, in the postpartum of a cesarean, presented an ERD concomitantly with a HELLP syndrome.

Bilateral serous retinal detachment: an unusual complication of HELLP syndrome

A 23-year-old primigravida presented to the emergency department with reports of headache. On examination, her blood pressure was found to be 190/140 mm Hg. Her laboratory results were notable for proteinuria, deranged liver function and low platelets. She was diagnosed with HELLP syndrome and was delivered via caesarean section. She noticed diminution of vision 2 days after delivery. Fundus examination revealed bilateral serous retinal detachment involving the maculae. She was managed conservatively and had complete recovery of her vision by 3 weeks postpartum.

Experimental models and examination methods of retinal detachment

Retinal detachment refers to the separation of the retinal neuroepithelium and pigment epithelium, usually involving the death of photoreceptor cells. Severe detachment may lead to permanent visual impairment if not treated properly and promptly. According to the underlying causes, retinal detachment falls into one of three categories: exudative retinal detachment, traction detachment, and rhegmatogenous retinal detachment. Like many other diseases, it is difficult to study the pathophysiology of retinal detachment directly in humans, because the human retinal tissues are precious, scarce and non-regenerative; thus, establishing experimental models that better mimic the disease is necessary. In this review, we summarize the existing models of the three categories of retinal detachment both in vivo and in vitro, along with an overview of their examination methods and the major strengths and weaknesses of each model.

Management of a rhegmatogenous retinal detachment in a pregnant patient

Purpose

To describe the management of a rhegmatogenous retinal detachment (RRD) in a pregnant patient.

Observations

A 30-year-old, 26-week pregnant female presented with curtain vision loss in the left eye. Exam findings were significant in the left eye for an inferior fovea-sparing RRD. Care was coordinated and discussed with anesthesia and OB/GYN. The patient underwent surgery with monitored anesthesia care and a 41 scleral buckle, cryotherapy and C3F8 gas. The retina remained attached at 4 months post-operatively. A healthy girl was delivered via spontaneous vaginal delivery at 39 weeks.

Conclusion

Safe and successful treatment of RRD in pregnant patients can be achieved with careful coordination between ophthalmology, anesthesia, and obstetrics. An understanding of pregnancy specific considerations is important in order to optimize patient outcomes.

Bilateral serous retinal detachment associated with subretinal fibrin-like material in a case of pregnancy-induced hypertension

Purpose

To describe a case of bilateral serous retinal detachment (SRD) associated with subretinal fibrin-like material (SRFM) in pregnancy-induced hypertension (PIH).

Observations

Angiography of a 31-year-old primigravida with PIH who developed acute bilateral SRD with SRFM after caesarean section showed choroidal hypoperfusion and dye leakage. Optical coherence tomography revealed irregularity of the ellipsoid zone and retinal pigment epithelium. The patient's visual acuity was hand motion in the both eyes at the initial examination. After 30 days, SRD and SRFM spontaneously disappeared. Moreover, the EZ returned and the visual acuity significantly improved to 20/25 in the right and 20/20 in the left eye.

Conclusions and importance

Although there are reports on central serous chorioretinopathy or Vogt-Koyanagi-Harada disease, there have been no studies on SRFM complications in patients with PIH. In the current case, we speculated that SRFM was associated with acute intense choroidal ischemia and inflammation secondary to this ischemic condition. Distinguishing whether inflammation necessitating treatment is involved in SRFM may be difficult. Short observation intervals and frequent examinations are important to ensure that treatment timings are not missed.

Preeclamptic serous retinal detachment without hypertension: A case report

Preeclampsia is a disease of pregnancy classically defined by the development of new-onset hypertension and proteinuria. Serous retinal detachment is a rare complication of severe preeclampsia that is associated with a high incidence of morbidity and mortality. We present the case of a 24-year-old primigravida who was diagnosed with preeclamptic serous retinal detachment at 30 weeks of gestation that occurred in the absence of hypertension. The patient was delivered by cesarean section for fetal malpresentation and she had complete recovery of her vision by three months postpartum. Providers should exercise vigilance for preeclampsia in women presenting with new-onset visual symptoms, even in the absence of hypertension.

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Preeclampsia is a disease of pregnancy classically defined by the development of new-onset hypertension and proteinuria.

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Serous retinal detachment is a rare complication associated with a high degree of morbidity and mortality.

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We present the case of a 24-year-old with preeclamptic serous retinal detachment at 30 weeks occuring without hypertension.

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The patient delivered by cesarean for malpresentation with complete recovery of her vision by three months postpartum.

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Providers should be vigilant for preeclampsia in women with visual symptoms, even in the absence of hypertension.

Ultrasound assessment of visual loss during severe preeclampsia: a case report

Bilateral retinal detachments and cortical blindness are rare complications of preeclampsia and the association of the two pathologies is exceptional. We report the case of a preeclamptic patient who presented with an acute bilateral vision loss. Besides, her ocular ultrasound revealed bilateral retinal detachments and an elevated optic nerve sheath diameter. The patient underwent an urgent cesarean section. Subsequently, magnetic resonance imaging and ocular fundus examination confirmed the diagnosis.

Ocular changes during pregnancy

Purpose

To summarize available literature on physiologic and pathologic ocular changes during pregnancy.

Methods

Narrative review of literature.

Results

Ocular changes occur commonly during pregnancy. Although most of these are benign physiologic responses to the metabolic, hormonal, and immunologic modifications to adopt the gestational product, there is some serious pathology that may develop, exacerbate, or even resolve over the course of pregnancy which requires prompt diagnosis and management. The pathological eye conditions can be classified into preexisting pathologies and emerging ocular diseases. Regardless of the different mechanisms by which these ocular changes occur, the key point is the establishment of an effective perinatal screening program to monitor the new development or successive progression of these ocular abnormalities. Irrespective of the visual health status of the pregnant women, regular perinatal eye examination should be scheduled in order to assure continuous surveillance of healthy eyes. Treatment of pathologic ocular conditions or functionally disturbing benign changes relies on an appropriate patient selection.

Conclusions

Discriminating pathological eye disease from physiologic ocular changes is important in order to establish an individualized treatment or preventive plan and constitutes the mainstay of obstetric ophthalmology. This individualized approach should always weigh the ocular benefits of treatment to the mother against the potential harms to the fetus.

Point-of-care ultrasonography of the orbit for detection of retinal detachment in a patient with hemolysis, elevated liver enzymes, and low platelet count syndrome

Retinal detachment is a rare, but well-known cause of visual impairment in patients with hemolysis, elevated liver enzymes, and low platelet count (HELLP) syndrome. With supportive care, patients usually improve, with complete recovery of vision. Bedside ultrasonography of the orbit can be helpful for early detection of retinal detachment in these patients. Here, we present a case of HELLP syndrome presenting with severe visual symptoms. Retinal detachment was detected with point-of-care ocular sonography, which was confirmed with ophthalmoscopic examination. The patient was reassured of the favorable prognosis. Early initiation of aggressive supportive care was followed by progressive improvement of vision, which correlated with sonographic evidence of resolution of detachment. Her vision recovered completely in 2 weeks.

Retinal Pigment Epithelium Atrophy 1 (rpea1): A New Mouse Model With Retinal Detachment Caused by a Disruption of Protein Kinase C, θ

Purpose

Retinal detachments (RDs), a separation of the light-sensitive tissue of the retina from its supporting layers in the posterior eye, isolate retinal cells from their normal supply of nourishment and can lead to their deterioration and death. We identified a new, spontaneous murine model of exudative retinal detachment, nm3342 (new mutant 3342, also referred to as rpea1: retinal pigment epithelium atrophy 1), which we characterize herein.

Methods

The chromosomal position for the recessive nm3342 mutation was determined by DNA pooling, and the causative mutation was discovered by comparison of whole exome sequences of mutant and wild-type controls. The effects of the mutation were examined in longitudinal studies by clinical evaluation, electroretinography (ERG), light microscopy, and marker and Western blot analyses.

Results

New mutant 3342, nm3342, also referred to as rpea1, causes an early-onset, complete RD on the ABJ/LeJ strain background, and central exudative RD and late-onset RPE atrophy on the C57BL/6J background. The ERG responses were normal at 2 months of age but deteriorate as mice age, concomitant with progressive pan-retinal photoreceptor loss. Genetic analysis localized rpea1 to mouse chromosome 2. By high-throughput sequencing of a whole exome capture library of an rpea1/rpea1 mutant and subsequent sequence analysis, a splice donor site mutation in the Prkcq (protein kinase C, θ) gene, was identified, leading to a skipping of exon 6, frame shift and premature termination. Homozygotes with a Prkcq-targeted null allele (Prkcq^tm1Litt) have similar retinal phenotypes as homozygous rpea1 mice. We determined that the PKCθ protein is abundant in the lateral surfaces of RPE cells and colocalizes with both tight and adherens junction proteins. Phalloidin-stained RPE whole mounts showed abnormal RPE cell morphology with aberrant actin ring formation.

Conclusions

The homozygous Prkcq^rpea1 and the null Prkcq^tm1Litt mutants are reliable novel mouse models of RD and can also be used to study the effects of the disruption of PRKCQ (PKCθ) signaling in RPE cells.

Retinal detachment in hemolysis, elevated liver enzymes, and low platelet count (HELLP) syndrome: Color vision abnormality as the first and predominant manifestation

Serous retinal detachment is sometimes caused by hypertensive disorders in pregnancy and its associated conditions, in which the predominant eye symptoms are blurred vision, distorted vision, and reduced visual acuity. To our best knowledge, this is the first report of a puerperal woman with hemolysis, elevated liver enzymes, and low platelet count (HELLP) syndrome in whom color vision abnormality was the first and predominant manifestation of serous retinal detachment. At 32 weeks of gestation, the 34-year-old Japanese woman underwent cesarean section due to HELLP syndrome. She complained of color vision abnormality on day 1 post-partum and ophthalmological examination revealed serous retinal detachment of both eyes. The visual acuity was preserved. With supportive therapy, her color vision abnormality gradually ameliorated and retinal detachment completely resolved on day 34 post-partum without any sequelae. Obstetricians should be aware that color vision abnormality can be the first and predominant symptom of HELLP-related serous retinal detachment.

Bilateral exudative retinal detachment in a patient with early onset severe preeclampsia

This article describes a rare case of early onset severe preeclampsia presenting with loss of vision in both eyes due to retinal detachment. Retinal detachment has been mainly reported in late onset preeclampsia unlike in this case. Though, some authors believe that occurrence of maternal retinal detachment in cases of preeclampsia has no prognostic implication to the fetus, in this case, presence of retinal detachment was associated with foetal demise.

Partial HELLP syndrome with unilateral exudative retinal detachment treated conservatively

Peripartum vision loss, an uncommon, often reversible complication of pregnancy usually occurs in the setting of pre-eclampsia or eclampsia. The HELLP syndrome is characterized by hypertension, elevated liver enzymes and low platelets. This is a rare case of unilateral exudative retinal detachment associated with the Partial HELLP syndrome that occurred after delivery in a 23-year-old Indian woman. The retinal detachment subsequently reattached with good visual improvement under conservative treatment. This case highlights the importance of early intervention by the ophthalmologist when pregnant women complain about visual symptoms.

Contemporary clinical management of the cerebral complications of preeclampsia

The neurological complications of preeclampsia and eclampsia are responsible for a major proportion of the morbidity and mortality arising from these conditions, for women and their infants alike. This paper outlines the evidence base for contemporary management principles pertaining to the neurological sequelae of preeclampsia, primarily from the maternal perspective, but with consideration of fetal and neonatal aspects as well. It concludes with a discussion regarding future directions in the management of this potentially lethal condition.

[Retinal detachment in preeclampsia: a series of three cases]

Three Afro-Caribbean women presented with a decreased visual acuity associated with preeclampsia during the third trimester of pregnancy. Fundus examination exhibited a serous retinal detachment (SRD). Postpartum fluorescein and indocyanine green angiography indicated subretinal leakage induced by choroidal ischemia. The three patients had an improvement of their visual acuity to 20/20 within 2 to 3 months of the onset of symptoms. Fundus exam and fluorescein angiography showed no further abnormality. SRD in preeclampsia may have an impressive acute presentation but seems to resolve favorably spontaneously without intervention, upon delivery. Nevertheless, SRD must be considered to be a sign of imminent worsening of preeclampsia.