Ocular disease in 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.

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.

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.

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.

Review of the management of sight-threatening diabetic retinopathy during pregnancy

Diabetes mellitus (DM) is a noncommunicable disease reaching epidemic proportions around the world. It affects younger individuals, including women of childbearing age. Diabetes can cause diabetic retinopathy (DR), which is potentially sight threatening when severe nonproliferative DR (NPDR), proliferative DR (PDR), or sight-threatening diabetic macular oedema (STDME) develops. Pregnancy is an independent risk factor for the progression of DR. Baseline DR at the onset of pregnancy is an important indicator of progression, with up to 10% of women with baseline NPDR progressing to PDR. Progression to sight-threatening DR (STDR) during pregnancy causes distress to the patient and often necessitates ocular treatment, which may have a systemic effect. Management includes prepregnancy counselling and, when possible, conventional treatment prior to pregnancy. During pregnancy, closer follow-up is required for those with a long duration of DM, poor baseline control of blood sugar and blood pressure, and worse DR, as these are risk factors for progression to STDR. Conventional treatment with anti-vascular endothelial growth factor agents for STDME can potentially lead to foetal loss. Treatment with laser photocoagulation may be preferred, and surgery under general anaesthesia should be avoided. This review provides a management plan for STDR from the perspective of practising ophthalmologists. A review of strategies for maintaining the eyesight of diabetic women with STDR with emphasis on prepregnancy counselling and planning, monitoring and safe treatment during pregnancy, and management of complications is presented.

Preeclampsia-Pathophysiology and Clinical Presentations: JACC State-of-the-Art Review

Preeclampsia is a hypertensive disorder of pregnancy. It affects 2% to 8% of pregnancies worldwide and causes significant maternal and perinatal morbidity and mortality. Hypertension and proteinuria are the cornerstone of the disease, though systemic organ dysfunction may ensue. The clinical syndrome begins with abnormal placentation with subsequent release of antiangiogenic markers, mediated primarily by soluble fms-like tyrosine kinase-1 (sFlt-1) and soluble endoglin (sEng). High levels of sFlt-1 and sEng result in endothelial dysfunction, vasoconstriction, and immune dysregulation, which can negatively impact every maternal organ system and the fetus. This review comprehensively examines the pathogenesis of preeclampsia with a specific focus on the mechanisms underlying the clinical features. Delivery is the only definitive treatment. Low-dose aspirin is recommended for prophylaxis in high-risk populations. Other treatment options are limited. Additional research is needed to clarify the pathophysiology, and thus, identify potential therapeutic targets for improved treatment and, ultimately, outcomes of this prevalent disease.

Changes in choroidal circulation and pulse waveform in a case of pregnancy-induced hypertension with serous retinal detachment

Purpose

We aimed to examine the changes in choroidal blood flow (CBF), choroidal pulse waveform, and central choroidal thickness (CCT) in a case of pregnancy-induced hypertension (PIH) using laser speckle flowgraphy (LSFG) and enhanced depth imaging optical coherence tomography (EDI-OCT) before and after treatment with antihypertensive drugs.

Observations

A 24-year-old Japanese woman diagnosed with PIH presented with complaints of worsening and blurred vision in the right eye. Funduscopic findings at the initial visit showed serous retinal detachment (SRD), retinal hemorrhage, and arterial tortuosity. The LSFG color map showed a warm color. Macular mean blur rate (MBR), which is an index of relative blood flow velocity, in both eyes was high, along with choroidal thickening. Blowout time (BOT), which indicates the rate of time in which the MBR is greater than half the amplitude during one heartbeat, was low and acceleration time index (ATI), which represents the time-to-peak of MBR, was high. Several weeks after treatment with antihypertensive drugs, the CBF and ATI gradually decreased with regression of the SRD and thinning of the CCT. On the other hand, BOT gradually increased after treatment, showing a significant decrease in vascular resistance. Ocular perfusion pressure decreased after treatment because of the reduction in blood pressure.

Conclusions and Importance

LSFG might reveal choroidal overperfusion and increased vascular resistance, along with SRD and choroidal thickening, in a patient with PIH with reversal after treatment with antihypertensive drugs. These findings demonstrate the importance of evaluation of ocular blood flow and vascular resistance in women with PIH in order to routinely assess the clinical and systemic condition.

Refractive status during pregnancy in the United States: results from NHANES 2005-2008

PURPOSE

Anecdotal reports of refractive changes in pregnancy are familiar to optometrists and ophthalmologists. Refractive stability during pregnancy has implications in both prescribing of refractive correction and candidacy for refractive surgery. This study aims to examine refractive status in a nationally representative sample of US pregnant women.

METHODS

The National Health and Nutrition Examination Survey (NHANES) is a weighted, stratified, cross-sectional survey of the US population conducted every 2 years. During 2005-2006 and 2007-2008, the exam included multiple ophthalmic tests including refraction, keratometry, and lensometry. Female participants aged 20-44 years with available vision examination data were included in the study. Subjects were excluded if best obtainable visual acuity was worse than 20/40 or there was prior history of cataract or refractive surgery. The primary outcome was defined as refractive change stratified by trimester of pregnancy.

RESULTS

301 pregnant women were matched with 301 nonpregnant controls based on age, ethnicity, and education. There was no difference in refractive error between pregnant women and matched nonpregnant controls (all p > 0.99). For the refractive change analysis, a subgroup of 60 pregnant subjects with glasses at presentation was matched to 60 nonpregnant controls. Multivariate regression showed a significant increase in refractive change versus prior to glasses prescription by trimester of pregnancy (p = 0.02), though this change was not in a specific direction (i.e., no significant shift toward either myopia or hyperopia).

CONCLUSIONS

Pregnant women have greater refractive difference from prior spectacle prescription later in pregnancy, but the direction of this change is variable and not significant. This finding may reflect a longer time to last glasses prescription later in pregnancy, given concerns that refractive error fluctuates in pregnancy. Additional longitudinal studies are needed to better characterize the effects of pregnancy on refractive status.

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.

Neuropathological complications associated with hypertensive disorders of pregnancy

Objective: Hypertensive disorders in pregnancy particularly severe preeclampsia and eclampsia result in significant maternal and neonatal morbidity and mortality. Many of these misfunctions can aggravate some of the neuropathological complications of hypertensive disorders during pregnancy. Method: In this review article, we described some of the neuropathological complications associated with hypertensive disorders of pregnancy. Results and conclusion: It is explained how the possible mechanism of neuropathological events triggers some of the complications associated with hypertensive disorders of pregnancy. Conclusion: A strong plea is made for the early detection of high blood pressure, its immediate control with rapid acting anti-hypertensive agents if necessary and timeous delivery of fetus as the exact pathogenesis of preeclampsia remains unknown.

The Role of Melatonin in Oxidative Stress, DNA Damage, Apoptosis and Angiogenesis in Fetal Eye under Preeclampsia and Melatonin Deficiency Stress

Aim: The aim of this study was to investigate the possible mechanisms of ocular damage induced by pinealectomy (PNX) and preeclampsia (PE), and to determine the cellular and molecular effects of melatonin treatment on oxidative stress, DNA damage, molecular chaperone responses, induction of apoptosis and angiogenesis in the fetal eye of both PNX and PNX+PE animals. Material and Methods: We analysed therapeutic potential of melatonin on fetal eye damage in PNX and PNX+PE animals using Malondialdehyde (MDA), Random Amplified Polymorphic DNA (RAPD), qRT-PCR and Western blot assays. Results: Our study presents three preliminary findings: (a) in fetal eye tissues, PNX and PNX+PE significantly induce oxidative damage to both DNA and protein contents, leading to a dramatic increase in caspase-dependent apoptotic signalling in both mitochondrial and death receptor pathways; (b) the same conditions trigger hypoxia biomarkers in addition to significant overexpression of HIF1-α, HIF1-β, MMP9 and VEGF genes in the fetal eye; (c) finally, melatonin regulates not only the expression of genes encoding antioxidant enzymes and increase in DNA damage as well as lipid peroxidation but also limits programmed cell death processes in the fetal eye of PNX and PNX+PE animals . Furthermore, melatonin can relatively modulate genes in the HIF1 family, TNF-α and VEGF, thus acting as a direct anti-angiogenic molecule. In conclusion, both PNX and PNX+PE induce ocular damage at both cellular and molecular levels in fetal eye tissue of rats. Conclusion: Our results clearly indicate the potential of melatonin as a preventative therapeutic intervention for fetal ocular damage triggered by both PNX and PNX+PE.

Pre-eclampsia/Eclampsia as a Risk Factor of Noninfectious Uveitis Among Postdelivery Women

PURPOSE

We sought to analyze the incidence and risk of noninfectious uveitis (NIU) among postdelivery women with a history of pre-eclampsia/eclampsia (PEE).

DESIGN

Population-based retrospective matched cohort study.

METHODS

All participant data were retrieved from the Longitudinal Health Insurance Database 2005. Two thousand seventy-three postdelivery women ≥20 years of age were diagnosed with PEE between January 1, 1997 and December 31, 2012 and were included in the study. We traced the occurrence of NIU during 5 years of follow-up. The primary outcome measure was the occurrence of NIU with the use of anti-inflammatory drugs and adjudication by an ophthalmologist.

RESULTS

NIU occurred in 14 of 2073 (0.7%) postdelivery women with PEE. The incidence rate of NIU was 1.5 and 0.5 per 1000 person-years among postdelivery women with and without PEE, respectively (incidence rate ratio 2.96 [95% confidence interval 1.48-5.90]; P = .002). Postdelivery women with PEE demonstrated a significant increase in the cumulative incidence of NIU compared with those without PEE (P = .001). The risk of the occurrence of NIU was significantly higher in the PEE group than in the non-PEE group (adjusted hazard ratio 2.96 [95% CI 1.48-5.92]; P = .002) after adjusting for age, income, urbanization, and comorbidities.

CONCLUSIONS

This is the first study to substantiate an association between PEE and NIU. Our results suggest that PEE could be a potential risk factor for the occurrence of NIU among postdelivery women.

Pregnancy-induced hypertension-related chorioretinitis resembling uveal effusion syndrome: A case report

RATIONALE

Pregnancy-induced hypertension (PIH) is a major cause of maternal and fetal mortality. Hypertensive choroidopathy is a preliminary sign of vasogenic edema in the choroid, and is associated with PIH. Here, we report a post-natal case of PIH-related chorioretinitis with bilateral severe serous retinal detachment (SRD) resembling uveal effusion syndrome.

PATIENT CONCERNS

A 35-year-old woman was diagnosed with severe PIH at 37 weeks of pregnancy. She underwent an emergency cesarean delivery. Four days after delivery, she perceived a sudden decrease of vision. At presentation, fundus examination demonstrated bullous SRD and multiple white mottles in the posterior poles of both eyes. Optical coherence tomography (OCT) showed macula edema and retinal pigment epithelium (RPE) folds. Indocyanine green angiography (ICGA) demonstrated delayed filling of choroidal circulation in the early phase and multiple hyperfluorescent spots in the mid phase.

DIAGNOSES

PIH.

INTERVENTIONS

Antihypertension treatment alone resulted in gradual resolution of the SRD.

OUTCOMES

At 463 days after delivery, fundus photographs of both eyes showed leopard spots corresponding to hyperautofluorescent spots with dark rim observed on fundus autofluorescence images.

LESSONS

Ophthalmologists should be aware of PIH-related chorioretinitis with similar clinical manifestations as uveal effusion syndrome, and should treat with antihypertensive agents in cooperation with obstetricians.

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.

Ocular Changes During Pregnancy

Pregnancy is needed for the perpetuation of the human species, and it leads to physiological adaptations of the various maternal organs and systems. The eye, although a closed space, also undergoes some modifications, most of which are relatively innocuous, but they may occasionally become pathological. For women, pregnancy is a susceptibility period; however, for many obstetricians, their knowledge of the ocular changes that occur during pregnancy tends to be limited. For this reason, this is a important area of study as is necessary the development of guidelines to approach those changes. Of equal importance are the knowledge of the possible therapies for ophthalmological problems in this period and the evaluation of the mode of delivery in particular conditions. For this article, an extensive review of the literature was performed, and a summary of the findings is presented.

Management of Retinal Diseases in Pregnant Patients

Pregnancy leads to significant changes in the body, which potentially affect the retina. Pregnancy can induce disease, such as that seen in hypertensive retinopathy and choroidopathy. It can cause exudative retinal detachments in the HELLP syndrome (hemolysis, elevated liver enzymes and low platelets), disseminated intravascular coagulation (DIC), and thrombotic thrombocytopenic purpura (TTP), and provoke arterial and venous retinal occlusive disease. Pregnancy may also exacerbate pre-existing retinal disease, such as idiopathic central serous chorioretinopathy (ICSC) and diabetic retinopathy. Special consideration needs to be exercised when treating pregnant patients in choosing medications, as well as in selecting diagnostic modalities and surgical methods.

A survey of ophthalmologists and gynecologists regarding termination of pregnancy and choice of delivery mode in the presence of eye diseases

PURPOSE

To evaluate and compare the attitudes of ophthalmologists and gynecologists in suggesting appropriate approach to pregnancy in different ocular conditions.

METHODS

Specialty-specific questionnaires on delivery mode and abortion indications for ophthalmic patients (refractive, vascular, oncologic, retinal, glaucoma, postoperation, posttrauma, and infectious) were designed and distributed among physician staff of Farabi Eye Hospital and Yas Women Hospital in Tehran. Attitudes and preferences of the ophthalmologists and gynecologists were quantified and compared.

RESULTS

Participants were 29 ophthalmologists and 19 gynecologists. Their mean age was 49.73 ± 7.57 and 46.79 ± 1.36 years, respectively. More than 50-70% ophthalmologists were in favor of normal vaginal delivery (NVD) in all ocular diseases. All gynecologists (100%) expressed their need for an ophthalmologist's opinion for decision-making. Ophthalmologists' top choices for conditions potentially requiring a caesarean section were corneal transplants (34.5%), high myopia (23%), retinal detachment (29%), and orbital tumors (34.5%), while two gynecologists recommended abortion in the presence of intraocular and orbital tumors and retinal detachment. In the case of a history of refractive surgery, orbital tumor and intraocular tumor, ophthalmologists recommend NVD over caesarean section twice as much as their gynecologist peers. For history of retinal detachment, glaucoma, retinal vascular accident and intraocular hemorrhage, no single gynecologist recommend NVD. The corresponding figure for ophthalmologist-recommended NVD were 67, 84, 72, and 81%.

CONCLUSIONS

There is extreme inconsistency among ophthalmologists and gynecologists in managing ophthalmic-obstetric scenarios, especially for caesarean section indications. Clinical guideline development and consultation for decision-making in challenging cases are recommended.

Enhanced Depth Imaging Optical Coherence Tomography: A New Way Measuring Choroidal Thickness in Pregnant Women

The body changes markedly during pregnancy; each system behaves differently from a nonpregnant state. As the eyes are the only windows to see directly what is going on in the internal environment, more and more researches have been done to explain the association between ocular changes and the physiological and pathological changes during pregnancy. The choroid is one of the critical parts of the eye, providing nutrition. And abnormal choroid may result in ocular dysfunction and visual problems. As the optical coherence tomography develops, a rapid, direct, noninvasive, and nontoxic way is available to obtain the choroid situation of pregnant women, which may explain the mechanism of pregnancy-related eye diseases. This review would summarize relevant original articles published from January 1, 2008 to December 1, 2016 to assess the changes of choroidal thickness (CT) with enhanced depth imaging optical coherence tomography (EDI-OCT) during pregnancy. And the relationship between choroidal thickness changes and pregnancy remains uncertain. To our knowledge, this is the first review of EDI-OCT in assessing the choroidal thickness of the pregnant women.

Effect of pregnancy in myopia progression: the SUN cohort

PurposePrevious studies have suggested that pregnancy may induce myopia progression. However, no longitudinal study with a large sample size and long-term follow-up has assessed this association. Our objective was to investigate whether pregnancy was related to mid- or long-term myopic refraction changes.Patients and methodsA prospective study was conducted in a Mediterranean cohort. The study included 10 401 women (20-50 years old) from the SUN Project. SUN project is a multipurpose, prospective, and dynamic cohort of university graduates conducted in Spain. The recruitment of participants started in 1999 and it is permanently open. All participants in this cohort had university studies. Participants were followed up for a period of up to 14 years, and pregnancy and refractive changes were assessed through baseline and biennial questionnaires. Pregnancies and myopia were repeatedly assessed in each biennial follow-up questionnaire during a total of 14 years of follow-up.ResultsPregnancy was inversely associated with the risk of myopia development or progression during each of the 2 years periods, with fully adjusted hazard ratio=0.61; (95% confidence interval=0.49-0.75) after adjusting for known potential confounders.ConclusionTo our knowledge this is the first large-longitudinal assessment in young adult women, showing that pregnancy is inversely associated with myopia development or progression. Further studies are needed to confirm these epidemiological findings.

Using critical flicker frequency in the evaluation of visual impairment in preeclamptic women

OBJECTIVE

To assess critical flicker frequency (CFF) in normal uneventful pregnancy and preeclampsia.

STUDY-DESIGN

Case-control observational study at the University Hospital Jena and Outpatient Institute for Prenatal Diagnosis and Preventive Medicine. 25 non-pregnant women, 75 uncomplicated pregnant women in first, second and third trimester, and 15 women with overt preeclampsia. For comparison with preeclamptic patients we matched 15 normal pregnant women (mNP) for age, parity, body mass index, current smoking and family history of cardiovascular disease (CVD). We measured CFF using the portable HEPAtonorm Analyzer (nevoLAB GmbH, Germany). This device generates a flickering red light, starting with a frequency of 60Hz, giving the subjective an impression of a steady light. The participant signifies once the impression of a flickering light is recognized, and this CFF is recorded. Mean CFF and standard deviation is automatically calculated. Statistical analysis was performed using SPSS Version 22 for Windows. Following assessment of normal distribution with Kolmogorov-Smirnow test, comparisons were made with univariate and multivariate ANOVA and with unpaired and paired t test for continuous data and with χ² test for categorical data.

RESULTS

Critical flicker frequency in healthy pregnant women does not differ from nonpregnant women. No significant differences in CFF measurements exist in first, second, and third trimester. In preeclampsia, CFF is significantly decreased compared to normal pregnant women (PE 38.80±2.16 vs. mNP 46.23±3.37; p=0.000). This alteration persists even some weeks postpartum (PE 41.17±1.13 vs. mNP 46.45±3.44; p=0.003).

CONCLUSION

In preeclamptic women, CFF is decreased indicating an altered endothelial situation. The finding that CFF remains reduced postpartum may be explained by either the effect of preeclampsia on maternal endothelium causing longer lasting damage or indicate a preexisting endothelial disorder. Up to this point, precise responsible mechanisms for altered CFF in preeclampsia are currently unclear and further studies are needed.

Risk factors for central serous chorioretinopathy in pregnant Japanese women

AIM

This study was performed to determine risk factors for central serous chorioretinopathy (CSC) in pregnant women.

METHODS

This retrospective observational study was performed in a cohort of all 1881 women giving birth at a single center. The hospital database was searched to abstract all women diagnosed with pre-eclampsia (PE) as well as those visiting the eye clinic during the current pregnancy. Medical chart review was performed in all women diagnosed with CSC and PE.

RESULTS

PE developed in 73 (3.9%) women, six (8.2%) of whom visited the eye clinic for problems occurring in the current pregnancy; 47 of 1808 (2.6%) women without PE visited the eye clinic (P  = 0.015). Four women were identified as having developed CSC after onset of PE, and none of those without PE developed CSC (5.5% [4/73] vs 0.0% [0/1808], respectively, P <  0.0001). Stepwise regression analysis selected four risk factors for CSC: hematocrit value > 38.0% (odds ratio [OR], 22.9; 95% confidence interval [CI], 2.12-247), serum creatinine > 0.7 mg/dL (OR, 21.7; 95%CI, 1.12-422), time interval from diagnosis of PE until delivery > 14 days (OR, 20.0; 95%CI, 1.87-214), and urine protein : creatinine ratio (mg/mg) > 4.5 (OR, 15.7; 95%CI, 0.81-304). Hematocrit value > 38.0% was finally identified as the only independent risk factor (OR, 22.9; 95%CI, 2.12-1716) for CSC in PE women.

CONCLUSION

CSC was likely to occur in PE women, especially in those with hemoconcentration as a result of plasma leakage from the circulating blood due to increased vascular permeability.

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.

Comparison of subfoveal choroidal thickness in healthy pregnancy and pre-eclampsia

PURPOSE

Pregnancy is a known predisposing factor for central serous chorioretinopathy (CSC). Choroidal thickness (CT) increases in patients with CSC. This study was designed to evaluate CT in pregnant women.Patients and methodsThis was a prospective study. Fourteen healthy pregnant women and seven patients with pre-eclampsia were included. Twenty-one normal subjects were also recruited. CT was measured using enhanced-depth imaging optical coherence tomography.

RESULTS

The mean CT of normal subjects, healthy pregnant women and patients with pre-eclampsia were 264.95±21.03, 274.23±29.30 and 389.79±25.13 μm, respectively (normal subjects vs healthy gravidas: P>0.05; normal subjects vs pre-eclampsia: P<0.001; healthy gravidas vs pre-eclampsia: P<0.001). CT decreased from 381.05±22.96 μm to 335.17±9.97 μm 1 week after delivery in patients with pre-eclampsia.

CONCLUSIONS

Pregnancy itself did not increase CT, whereas pre-eclampsia did appear to result in increased CT. This suggests that additional unknown factors induce hyperpermeability in pregnant women.

The prevalence of retinal and optical coherence tomography findings in preeclamptic women

PURPOSE

To evaluate retinal and optical coherence tomography findings and establish their prevalence in preeclamptic women.

METHODS

Twenty-seven preeclamptic women who underwent clinical examinations with both slit-lamp biomicroscopy and optical coherence tomography were prospectively studied.

RESULTS

Three of the 4 women (14.8%) identified by clinical examinations as having retinal findings related to preeclampsia had visual disturbances. Optical coherence tomography revealed retinal pathology in 2 women (7.4%) consisting of retinal edema, subretinal fluid, photoreceptors irregularities, and lesions at the retinal pigment epithelium level (Elschnig spots). The mean retinal nerve fiber layer thickness was significantly higher in women with pathologic funduscopic findings (P = 0.009) than in women with normal eye examinations. All women with ocular findings had severe preeclampsia and higher systolic blood pressure than women without ocular findings (P = 0.03).

CONCLUSION

The prevalence of retinal involvement is high in severe preeclampsia and low in asymptomatic preeclampsia. Preeclamptic women diagnosed as having ocular involvement should be evaluated and monitored by optical coherence tomography, provided that their systemic condition allows it. Findings of retinal nerve fiber layer thickening in these women may indicate occult central nervous system involvement.

Visual acuity changes during pregnancy and postpartum: a cross-sectional study in Iran

In this research, we represent the changes in visual acuity during pregnancy and after delivery. Changes as myopic shift start during second trimester and will be stopped after delivery; however it is obtained that women will have the same refractive error as what they had in the first trimester, after postpartum. So, any change in their spectacle prescription during this period is forbidden. As a result, not only changing in hormones can cause myopic shift in vision, but also overweight has its retributive role. What we are trying to do is to notify gynecologists and optometrists to be aware of these changes, so as to leave spectacle prescription writing to the session after postpartum period.

Comparison of autofluorescence and optical coherence tomography findings in acute and chronic central serous chorioretinopathy

AIM

To discuss and compare the fundus autofluorescence (FAF) and optical coherence tomography (OCT) in acute or chronic central serous chorioretinopathy (CSCR).

METHODS

Medical records of 100 cases of CSCR were reviewed. Acute and chronic cases were evaluated according to the duration of decreased visual acuity, serous retinal detachment (RD) and focal leakage on fluorescein angiography (FA). Chi-square test was used for statistical analysis.

RESULTS

Forty cases had acute and 60 cases had chronic CSCR. FAF showed focal hypo-autofluorescence in 34 (85%) and iso-autofluorescence in 6 (15%) of acute cases and hypo-autofluorescence in 51 (85%), hyper-autofluorescence in 6 (10%) and iso-autofluorescence in 3 (5%) of chronic cases. OCT showed serous RD with distinct borders correlated with FAF findings (hypo-autofluorescence) in all acute CSCR cases. In chronic CSCR group, OCT showed serous RD with indistinct borders correlated with FAF findings. The differences between the OCT and FAF findings of the two groups were significant (P=0.000).

CONCLUSION

OCT and FAF findings can support the clinical observations in differential diagnosis of acute and chronic CSCR and help clinicians to evaluate retinal pigment epithelium, outer segments of photoreceptors and the components of serous RD.

Recurrence rates of ocular toxoplasmosis during pregnancy

PURPOSE

To investigate whether recurrence rates of ocular toxoplasmosis are higher during pregnancy in women of childbearing age.

DESIGN

Retrospective longitudinal cohort study.

METHODS

We reviewed medical records of all women seen at a university eye clinic (Utrecht, Netherlands) during episodes of active toxoplasmic retinochoroiditis that occurred while the women were of childbearing age (16-42 years). Each woman was sent a questionnaire requesting information regarding all pregnancies and episodes of ocular toxoplasmosis, whether or not episodes were observed at the eye clinic. Conditional fixed-effects Poisson regression was used to model incidence rate ratios of recurrence during pregnant versus nonpregnant intervals, adjusted for potential confounders, including age at time of active toxoplasmic retinochoroiditis and interval since last episode of active disease, which are known to influence risk for recurrence.

RESULTS

Questionnaires were returned by 50 (58%) of 86 women, 34 of whom had had 69 pregnancies during 584 person-years of study. There were 128 episodes of ocular toxoplasmosis during the study period (6 during pregnancy). First episodes of ocular toxoplasmosis occurred between ages 9.6 and 38.5 years. The youngest age at pregnancy was 16.1 years; the oldest age at childbirth was 40.9 years. The incidence-rate ratios for pregnant versus nonpregnant intervals were in the direction of lower recurrence rates during pregnancy, with point estimates of 0.54 and 0.75 under 2 different approaches, but the ratios were not significantly different from the null value (P values of 0.16 and 0.55).

CONCLUSIONS

Recurrence rates of ocular toxoplasmosis are probably not higher during pregnancy, in contrast to traditional beliefs.

Total macular volume and foveal retinal thickness alterations in healthy pregnant women

ABSTRACT Purpose: To evaluate whether there are alterations in total macular volume (TMV) and foveal retinal thickness (FT) values during pregnancy.

METHODS

This study included 60 healthy pregnant women in their first, second, and third trimester (groups 1, 2, and 3) and 20 nonpregnant women (group 4). TMV and FT values were measured by optical coherence tomography (OCT) in each group.

RESULTS

Mean TMV was 1.43 ± 0.56 mm(3), 1.88 ± 0.54 mm(3), 2.04 ± 0.66 mm(3) and 1.35 ± 0.41 mm(3) in groups 1, 2, 3, and 4, respectively. Mean FT was 199.20 ± 64.35 µ, 274.35 ± 67.45 µ, 287.95 ± 95.50 µ and 192.100 ± 58.61 µ in groups 1, 2, 3, and 4, respectively. There was statistical significance among group 1-2 (p1 = 0.014, p2 = 0.001), group 1-3 (p1 = 0.003, p2 = 0.002), group 2-4 (p1 = 0.001, p2 = 0.001), and group 3-4 (p1 = 0.001, p2 = 0.001) for both TMV and FT, respectively.

CONCLUSION

The increase of fluid in the body, in particular in the second and last trimester, may cause an increase of TMV and FT.

Pregnancy-associated retinal diseases and their management

Pregnancy-associated retinal diseases are conditions that may occur uniquely in pregnancy or, more commonly, general conditions that may worsen or alter during pregnancy as a result of hematologic, hormonal, metabolic, cardiovascular, and immunologic changes. Diabetic retinopathy (DR) is by far the most common retinal condition that is altered by pregnancy. However, there are currently no widely accepted, precise clinical guidelines regarding its management during pregnancy. At present it is not possible to predict who will regress and who will progress without treatment. Some of the variation in progression of DR in pregnancy may be a result of well-known risk factors such as hypertension or inadequate glycemic control prior to pregnancy. Other pregnancy-associated retinal diseases are relatively uncommon, and their treatments are poorly characterized. Pre-existing conditions include the white dot syndromes, such as punctuate inner choroidopathy and ocular histoplasmosis syndrome, as well as chorioretinal neovascularization from many other etiologies. Retinal and chorioretinal disorders that can arise during pregnancy include central serous chorioretinopathy and occlusive vasculopathy such as retinal artery occlusion (Purtschers-like retinopathy) and retinal vein occlusion. There remains a small group that appear to be unique to pregnancy, with pre-eclampsia- and eclampsia-associated retinopathy, disseminated intravascular coagulopathy, or amniotic fluid embolism being the best described. In angiogenic retinal diseases outside of pregnancy, the use of anti-vascular endothelial growth factor (anti-VEGF agents) has proven helpful. There are no safety data about the use of anti-VEGF agents during pregnancy, and conventionally the proposed interventions have been laser photocoagulation and systemic or intravitreal injections of steroids. Most of the literature on the treatment of pregnancy associated-chorioretinal neovascularization is anecdotal.

The eye and visual system in the preeclampsia/eclampsia syndrome: What to expect?

The preeclampsia/eclampsia syndrome is a multisystem disorder that can include cardiovascular changes, hematologic abnormalities, hepatic and renal impairment, and neurologic or cerebral manifestations. It also can affect the eye and visual pathways. Visual symptoms concern up to 25% of patients with severe preeclampsia and 50% of patients with eclampsia. This review discusses the ophthalmic complications of preeclampsia/eclampsia with focus on the hypertensive retinopathy, exudative retinal detachment and cortical blindness.

Adrenocortical adenoma and central serous chorioretinopathy: a rare association?

A 28-year-old man with bilateral central serous chorioretinopathy (CSCR) and body weight gain was diagnosed with Cushing's syndrome secondary to an adrenocortical adenoma. The patient had high levels of free cortisol and the tumor was confirmed by histopathology. After surgery, cortisol levels decreased and the CSCR spontaneously resolved. This case highlights the role of cortisol in the pathogenesis of CSCR. A diagnosis of endogenous Cushing's syndrome should be considered in patients with CSCR as an initial symptom.

Foveal and parafoveal retinal thickness in healthy pregnant women in their last trimester

Purpose

The inspection of foveal and parafoveal thickness in healthy pregnant women in the last trimester.

Materials and methods

This study included 40 healthy pregnant women in their last trimester (study group: 40 women, 80 eyes) and 37 nonpregnant women (control group: 37 women, 74 eyes). Visual acuity, intraocular pressure, slit lamp examination of anterior and posterior segments, and visual field examination with automated perimetry were performed in both groups. Foveal and parafoveal thickness in the four quadrants (upper, nasal, temporal, and inferior parafoveal) and peripapillary retinal nerve fiber layer were measured by optical coherence tomography. There were no systemic or ocular problems in either group. Findings were analyzed with statistical software. A P value <0.05 was considered statistically significant.

Results

Mean foveal and parafoveal thicknesses in the study group were: foveal 236.12 ± 27.28 μm, upper quadrant 321.31 ± 12.28 μm, temporal quadrant 307.0 ± 12.05 μm, inferior quadrant 317.0 ± 10.58 μm, and nasal quadrant 313.62 ± 14.51 μm. Mean foveal and parafoveal thicknesses in the control group were: foveal 224.62 ± 21.19 μm, upper quadrant 311.62 ± 12.71 μm, temporal quadrant 296.87 ± 13.78 μm, inferior quadrant 305.43 ± 13.25 μm, and nasal quadrant 304.93 ± 13.44 μm. Mean retinal nerve fiber layer thicknesses in the study and control group were 110 ± 12.4 μm and 108 ± 13.1 μm, respectively.

Conclusion

Mean retinal thickness in pregnant women was higher than control group in all measurements. Statistically significant difference in thickness was only found in upper, temporal, and inferior parafoveal areas.

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

OBJECTIVE

To review case reports of retinal detachment in women with pre-eclampsia/eclampsia.

METHODS

Medline was searched for case reports of retinal detachment associated with pre-eclampsia/eclampsia. Articles written in English, Spanish, or Portuguese and published between 1990 and 2010 were reviewed.

RESULTS

A total of 28 cases of retinal detachment were identified; 15 were associated with severe pre-eclampsia (3 of these probably had hemolysis, elevated liver enzymes, and low platelets [HELLP] syndrome), 9 with HELLP syndrome, 2 with eclampsia, and 2 with both HELLP syndrome and eclampsia. The majority (60%) of women were nulliparous, 4 had abruptio placentae, and cesarean delivery was performed in 76%. Retinal detachment was bilateral in 89% and associated with delivery of the fetus in 96%; 69% were diagnosed postpartum. Within 2-12 weeks postpartum, all patients had complete recovery of vision with clinical management.

CONCLUSION

Retinal detachment in pre-eclampsia/eclampsia might be associated with HELLP syndrome, indicating that microangiophatic hemolysis might have a role in the pathophysiology of retinal detachment. Its occurrence might not be correlated with the severity of pre-eclampsia because pre-eclampsia is a constellation of signs and symptoms (persistent vasospasms with hemolysis and hypoalbuminemia) rather than simply being hypertension.

[Eye and pregnancy.]

Pregnancy may cause ocular changes, for example refractive changes or contact lens intolerance. A number of ocular diseases may deteriorate. Especially preexisting diabetic retinopathy may worsen. Vaginal delivery is nearly always possible. Caesarean section is not required due to myopia, peripheral retinal degenerations or after retinal surgery. Most topically applied drugs usually used in ophthalmology are safe during pregnancy.

Low-dose aspirin as treatment for central serous chorioretinopathy

PURPOSE

To evaluate the effectiveness of low-dose aspirin for the treatment of central serous chorioretinopathy (CSCR).

PATIENTS AND METHODS

Patients with classical or multifocal CSCR were treated with aspirin 100 mg per day orally for 1 month followed by 100 mg on alternate days for 5 months. Treated patients were compared with historic controls consisting of patients with classical or multifocal CSCR previously followed up at our institution.

RESULTS

Mean visual acuity in the group treated with aspirin started to improve after the first week of therapy and continued to improve throughout the following 3 months. Visual recovery was slower in the untreated control group than in the treated group and achieved better visual acuity between the first and third month from the onset of the disease. There were no adverse events related to the administration of aspirin.

CONCLUSION

The results indicate that treatment with low-dose aspirin may result in more rapid visual rehabilitation with fewer recurrences in patient with CSCR compared with untreated historic controls. The effectiveness of treatment with aspirin supports our hypothesis regarding the role of impaired fibrinolysis and increased platelet aggregation in the choriocapillaris in the pathogenesis of CSCR.

A new strategy of treatment with low-dosage acetyl salicylic acid in patients affected by central serous chorioretinopathy

Central serous chorioretinopathy (CSCR) is an ocular disease characterized by serous detachment of the neurosensory retina at the posterior pole, with or without an associated retinal pigment epithelium (RPE) detachment. It is associated with different systemic diseases although the pathogenesis is unknown. Different therapies have been applied to treat CSCR with poor results. We reviewed the literature and found that in all the diseases associated with CSCR plasminogen activator inhibitor 1 (PAI-1) was increased. Acetyl salicylic acid (Aspirin) is effective in lowering PAI-1 levels and platelets aggregation; as such we decided to treat patients affected by CSCR with low dose Aspirin. From January 2005 to December 2008 we enrolled 107 patients, 85 male and 22 female, affected with active CSCR or the multifocal variant. Aspirin was administrated at an oral dose of 100 mg. per day for a month and then 100 mg. every other day for five months. After the first week of therapy and for the following three months the visual acuity improved and remained stable to the end of the follow-up (median follow-up 20 months). A recurrence of the disease interested the 6% of the patients. In this study low-dose Aspirin was able to treat central serous chorioretinopathy with a quick recovery of the visual acuity and a reduced number of recurrences during the follow-up. Besides the effectiveness of the treatment with Aspirin supports our observation regarding the role of impaired fibrinolysis and increased platelets aggregation in the choriocapillaris as genesis of CSCR.