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

The features of serous retinal detachment in preeclampsia viewed on spectral-domain optical coherence tomography

OBJECTIVE

To evaluate the characteristics of serous retinal detachment on spectral-domain optical coherence tomography in preeclampsia.

METHODS

In this retrospective case-series study, clinical characteristics of retinal damage were evaluated using spectral-domain optical coherence tomography (SD-OCT) imaging.

RESULTS

Thirty affected eyes from 16 pregnant women with preeclampsia were included. The features of serous retinal detachment, observed using SD-OCT, consisted of lesions located in the macular or peripapillary region; the presence of intraretinal or subretinal fluid (intraretinal fluid, IRF; subretinal fluid, SRF); ellipsoid zone integrity (normal/abnormal); intraretinal hyper-reflective dots; and Elschnig spots (retinal pigment epithelium lesions). Of the 30 affected eyes, 25 (83.33%) had lesions located in the macular region, 19 (63.33%) outside the macula (in the peripapillary region), and 14 (46.67%) in both. SD-OCT showed IRF in 2 eyes (6.67%), SRF in 30 eyes (100.00%), and both in 2 eyes (6.67%). The ellipsoid zone was disrupted in 20 eyes (66.67%), intraretinal hyper-reflective dots were observed in 4 eyes (13.33%), and Elschnig spots were observed in 20 eyes (66.67%).

CONCLUSION

Spectral-domain optical coherence tomography is a non-invasive, reliable imaging tool for the assessment of retinal pathologies in preeclampsia.

Evaluation of choroidal thickness and retinal nerve fiber layer thickness in Chinese pregnant women and healthy non-pregnant women

Purpose

To evaluate choroidal thickness and retinal nerve fiber layer (RNFL) thickness in different trimesters using enhanced depth imaging optical coherence tomography (EDI-OCT).

Methods

A prospective comparative study included 45 healthy pregnant women in the first trimester, 45 women in the second, 45 women in the third and 45 healthy non-pregnant women as the control group. Macular choroidal thickness was measured at three locations: The subfoveal, 1 ​mm temporal, and 1 ​mm nasal from the fovea with EDI-OCT. Peripapillary choroidal thickness (PPCT) and RNFL thickness parameters were automatically calculated by the Spectralis OCT.

Results

The subfoveal, temporal and nasal macular choroidal thickness were all significantly thicker in the second trimester, compared with those parameters in the first, the third trimesters and the control group (all P ​< ​0.05). The PPCT was significantly increased in the second trimeter compared with the control group at global, temporal, temporal inferior, nasal and nasal inferior positions (all P ​< ​0.05). The RNFL thickness was also significantly increased in pregnant women at nasal superior and nasal inferior quadrants (all P ​< ​0.05).

Conclusions

The choroidal thickness in pregnant women was found to be thicker than the control group, regardless of macular or optic disc location. Findings of RNFL thickening might indicate subclinical involvement of the central nervous system.

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.

Diminished choroidal blood flow in hypertensive and preeclamptic third trimester pregnancies using optical coherence tomography angiography

PURPOSE

The aim of this study was to compare choroidal adjusted flow index (AFI) in healthy, hypertensive & preeclamptic pregnancies using optical coherence tomography angiography (OCTA).

METHODS

In this prospective study, healthy, hypertensive & preeclamptic third trimester pregnant women underwent OCTA imaging. 3x3 & 6x6 mm choriocapillaris slabs were exported and the parafoveal area was marked by two concentric ETDRS circles at 1 & 3 mm, centered on the foveal avascular zone. Parafoveal AFI was calculated as a parameter of choroidal blood flow.

RESULTS

Fifteen eyes of fifteen women per group were recruited (45 eyes). AFI was significantly lower in the preeclamptic compared to the healthy & hypertensive groups (Tukey HSD: <0.001 in both groups on 3x3 mm, and 0.02 & 0.04 in 6x6 mm scans), and in the hypertensive compared to the healthy group (0.005 & 0.03 in 3x3 & 6x6 mm scans respectively).

CONCLUSIONS

Pregnancies complicated with preeclampsia revealed the lowest choroidal blood flow on OCTA followed by pregnancies with systemic hypertension compared to healthy pregnancies. We provide in-vivo documentation of choroidal ischemia, highlighting its culpability in hypertensive and preeclamptic retinochoroidal pathology, and the possibility of utilizing choroidal blood flow on OCTA as a precursor for disease progression.

Sequential measurement of the neurosensory retina in hypertensive disorders of pregnancy: a model of microvascular injury in hypertensive emergency

Optical coherence tomography of the eye suggests the retina thins in normal pregnancy. Our objectives were to confirm and extend these observations to women with hypertensive disorders of pregnancy (HDP). Maternal demographics, clinical/laboratory findings and measurements of macular thickness were repeatedly collected at gestational ages <20 weeks, 20-weeks to delivery, at delivery and postpartum. The primary outcome was the change in macular thickness from non-pregnant dimensions in women with incident HDP compared to non-hypertensive pregnant controls. Secondary outcomes were the relationship(s) between mean arterial pressure (MAP) and macular response. Data show macular thicknesses diminished at <20 weeks gestation in each of 27 pregnancies ending in HDP (mean 3.94 µm; 95% CI 4.66, 3.21) and 11 controls (mean 3.92 µm; 5.05, 2.79; P < 0.001 versus non-pregnant dimensions in both; P = 0.983 HDP versus controls). This thinning response continued to delivery in all controls and in 7 women with HDP superimposed on chronic hypertension. Macular thinning was lost after 20 weeks gestation in the other 20 women with HDP. MAP at loss of macular thinning in women without prior hypertension (n = 12) was identical to MAP at enrollment. However, mean MAP subsequently rose 19 mmHg (15, 22) leading to de novo HDP in all 12 women. Loss of thinning leading to a rise in MAP was also observed in 8 of 15 women with HDP superimposed on chronic hypertension. We conclude the macula thins in most women in early pregnancy. Those who lose this early macular thinning response often develop blood pressure elevations leading to HDP.

Evaluation of Choroidal Thickness during Pregnancy and Postpartum: A Longitudinal Study

Purpose

To assess the longitudinal changes of choroidal thickness using enhanced depth imaging optical coherence tomography (EDI-OCT) during pregnancy and postpartum.

Methods

The study included 23 eyes of 23 healthy pregnant women and 23 eyes of 23 healthy nonpregnant women. Choroidal thickness was measured manually with EDI-OCT at seven locations: The fovea, 500, 1000, and 1500 μm temporal (T) from the fovea and 500, 1000, and 1500 μm nasal (N) from the fovea. Measurements were obtained at each pregnancy trimester and 6 weeks postpartum and in the follicular phase of the menstrual cycle for the control group.

Results

The mean subfoveal choroidal thickness was 410.2 ± 82.4 μm, 434.8 ± 79.6 μm, 433.5 ± 80.3 μm, and 395.0 ± 71.1 μm in the first, second, and third trimesters and 6 weeks postpartum, respectively. In all seven measured locations, statistically significant changes were noted during pregnancy and postpartum in the choroidal thickness (P < 0.001). Choroidal thickness increased from the first trimester to the second and third trimester, after which it decreased at postpartum. Choroidal thickness was greater in the pregnant group during pregnancy and postpartum compared to the control group (P < 0.001).

Conclusions

This study indicated significant change in choroidal thickness at seven locations measured with EDI-OCT throughout pregnancy and 6 weeks after delivery. We showed that 6 weeks after delivery, choroidal thickness remains significantly higher than nonpregnant subjects.

Bilateral Exudative Retinal Detachment Complicating Preeclampsia With Partial Hemolysis, Elevated Liver Enzymes, and Low Platelet Count Syndrome

Serous retinal detachment is an uncommon complication of pregnancy that occurs in well-known situations, such as severe preeclampsia, eclampsia, or hemolysis, elevated liver enzymes, and low platelet count (HELLP) syndrome. The latter still does not reach a consensus, in particular on its classification and pathophysiology. We report the case of a young pregnant woman having a partial HELLP syndrome with massive proteinuria who presented a bilateral exudative retinal detachment having healed spontaneously after pregnancy termination and blood pressure control without requiring an ophthalmologic intervention.

Relationship between proteinuria and optical coherence tomographic features of the chorioretina in patients with pre-eclampsia

This retrospective study aimed to evaluate the correlation between ophthalmologic factors and proteinuria in patients with pre-eclampsia using swept-source optical coherence tomography (OCT) and OCT angiography. In total, 61 pregnant patients diagnosed with pre-eclampsia were recruited during their hospital stay. The authors investigated the relationship between urine protein–creatinine ratio (PCR) and chorioretinal measurements including choroidal thickness (CT), choroidal vascularity index (CVI), foveal avascular zone (FAZ), vascular density (VD), ganglion cell layer+ (GCL+) and GCL++. The associations between mean arterial pressure (MAP) and ophthalmologic factors were also evaluated. Central subfield CT of the right eye (p = 0.031) and paracentral CT of both eyes were related to higher PCR (≥1.35 mg/mg). A significant association with PCR after logarithm transformation was noted (r = 0.284, p = 0.026). Retinal measurements (FAZ, VD, GCL+ and GCL++) and CVI were not related with PCR. There was a positive association between MAP and PCR after logarithm transformation (r = 0.296, p = 0.021); however, chorioretinal factors were not related with MAP. In pregnant women with pre-eclampsia, CT using OCT is a novel factor that is correlated with PCR. Ocular structural alteration in patients with pre-eclampsia may be one of systemic vascular changes caused by pre-eclampsia rather than hypertension.

Subfoveal Choroidal Thickness and Associated Changes of Angiogenic Factors in Women with Severe Preeclampsia

OBJECTIVE

Severe preeclampsia complicates roughly 1% of all pregnancies. One defining feature of severe preeclampsia is new onset visual disturbance. The accessibility of the choroid to high-resolution, noninvasive imaging makes it a reasonable target of investigation for disease prediction, stratification, or monitoring in preeclampsia. This study aimed to compare subfoveal choroidal thickness between women with severe preeclampsia and those with normotensive pregnancies, and to investigate associations between such findings and other indicators of disease severity, including gestational age and serum angiogenic factors.

STUDY DESIGN

We designed a case-control study comprised of 36 women diagnosed with severe preeclampsia (cases) matched to 37 normotensive women (controls) by race/ethnicity and parity, all diagnosed in the postpartum period. All patients underwent enhanced depth imaging spectral-domain optical coherence tomography and serum analysis.

RESULTS

Cases showed no difference in subfoveal choroidal thickness compared with controls (p = 0.65). Amongst cases, subfoveal choroidal thickness and gestational age at delivery were inversely related (r = 0.86, p < .001). There was a positive association of placental growth factor with subfoveal choroidal thickness amongst cases (r = 0.54, p = 0.002).

CONCLUSION

This study suggests a relationship between the degree of disease severity and the magnitude of choroidal thickening. We also show an association between this index and placental growth factor level in the postpartum period.

Chorioretinal Alterations Induced by Preeclampsia

Hypertension during pregnancy, which is essentially a microvascular disease that destroys the end-organ microcirculation, should not be underestimated, as it could lead to organ failure in the kidneys, lungs, and brain. Preassessment of the microcirculatory state through systematic observation of the fundus has been proven to be noninvasive and feasible. Although hypertension in preeclampsia patients will resolve after childbirth, the sticking point is determining the best termination moment. Early diagnosis and treatment can prevent long-term ocular complications and cardiovascular risks for pregnant women in the future. In order to adjust the treatment strategy through more sensitive and precise fundus changes, we comprehensively summarized the common structural changes in the fundus in preeclampsia patients, including changes in the blood vessels, choroid, and retina, as well as the application of quantitative observation for chorioretinal alterations in recent years.

Evaluation of choroidal thickness and choroidal vascularity index during pregnancy

OBJECTIVE

To assess the choroidal structural characteristics in the first and third trimesters in pregnant women using enhanced depth imaging optical coherence tomography and binarization method.

DESIGN

Prospective study.

PARTICIPANTS

Twenty-five eyes of 25 pregnant women in the first trimester (group 1) and 25 eyes of 25 pregnant women in the third trimester (group 2) were examined. Healthy age-matched 25 participants were enrolled as a control group (group 3).

METHODS

The choroidal thickness (CT) was measured at 3 points; subfoveal, 1500 μm nasal to the fovea, and 1500 μm temporal to the fovea. Total choroidal area, luminal area, stromal area, stroma/lumen ratio, and choroidal vascularity index (CVI) were measured by Image-J software.

RESULTS

The mean subfoveal and nasal CT were statistically significantly increased in group 1 compared with controls (p = 0.005 and p = 0.004, respectively). The mean temporal CT was statistically significantly increased in group 1 compared with groups 2 and 3 (group 1 vs group 2, p = 0.043; group 1 vs group 3, p = 0.011). The mean total choroidal area, stromal area, and luminal area were significantly increased in groups 1 and 2 compared with control group (p < 0.001, p < 0.001, p < 0.001, and p < 0.001, p = 0.002, p = 0.002, respectively). There were no statistically significant differences among groups in terms of mean stroma/lumen ratio and CVI (p = 0.148 and p = 0.312, respectively).

CONCLUSIONS

There was a significant increase in subfoveal, temporal, and nasal CT in the first trimester. Total choroidal, stromal, and luminal areas were significantly increased in the first and third trimesters.

Antenatal and postpartum comparison of HD-OCT findings of macula, retinal nerve fiber layer, ganglion cell density between severe preeclampsia patients and healthy pregnant woman

AIM

To investigate the effects of severe preeclampsia on the retinal nerve fiber layer (RNFL), macula thickness and ganglion cell density in pregnancy and postpartum, using High Definition Optical Coherence Tomography (HD-OCT).

MATERIAL AND METHOD

The study group included 28 stable pregnant patients diagnosed with severe preeclampsia and the control group, 28 age and gestational week-matched healthy pregnant women. HD-OCT measurements were taken by the same researcher using a Cirrus HD-OCT device and were repeated at 8 weeks postpartum.

RESULTS

The mean systolic pressure, diastolic pressure, and intraocular perfusion pressure (IPP) values measured in pregnacy were determined to be higher in the preeclampsia group than in the control group (158.4 ± 7.3 vs.113.6 ± 6.8, 97.0 ± 5.7vs.73.8 ± 5.9 and 68.1 ± 3.9 vs.48.8 ± 3.3 mm Hg, respectively) (p < 0.05 for all). The mean RNFL, macula thickness, ganglion cell analysis, and intraocular pressure (IOP) values during pregnancy were determined to be similar in both groups (p > 0.05 for all). No significant difference was determined postpartum between the groups in respect of mean systolic pressure, diastolic pressure, RNFL, macula thickness, ganglion cell analysis, and IOP values (114.3 ± 5.0 vs 114.6 ± 5.9 mm Hg, 74.6 ± 5.1 vs.74.5 ± 5.5 mm Hg, 96.0 ± 7.3 vs. 95.9 ± 6.7 µm, 228.2 ± 18.9 vs.234.5 ± 15.4 µm, 81.8 ± 8.0 vs. 84.2 ± 4.6 µm, 14.1 ± 2.4 vs.13.8 ± 2, respectively) (p < 0.05 for all). Mean IPP during pregnancy was higher than the mean postpartum IPP in the severe pre-eclampsia group (68.1 ± 3.9 vs 49.1 ± 3.1 mm Hg) (p < 0.001).

CONCLUSION

This is the first study to have evaluated ganglion cell density of the retina, macula thickness, and RNFL using HD-OCT in severe pre-eclampsia cases, both during pregnancy and postpartum.

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.

Optical coherence tomography angiography findings in preeclampsia

OBJECTIVES

To investigate vascular density analysis in the superficial (SCP) and deep capillary plexus (DCP), foveal avascular zone (FAZ), peripapillary vascular density analysis (PPCVD), and peripapillary retinal nerve fiber thickness analysis (PPRNFL) using optical coherence tomography angiography (OCTA) in pregnant women with preeclampsia and to compare the obtained values with healthy pregnant and nonpregnant healthy individuals.

METHODS

A total of 98 pregnant women (55 had preeclampsia, 43 were healthy pregnant women) and 38 healthy nonpregnant women of reproductive age were included in the study. The patients were divided into three groups. Group 1 consisted of pregnant women with preeclampsia, group 2 comprised healthy pregnant women without preeclampsia, and group 3 consisted of healthy women who were not pregnant. All participants underwent a comprehensive ophthalmologic examination including OCTA.

RESULTS

Superficial foveal density (SFD) and deep foveal density (DFD) were lower in group 1 than in group 3 (p = 0.033, p = 0.041, respectively). Deep parafoveal density (DPD), deep temporal density (DTD), and deep superior density (DSD) values were lower in group 1 than in group 2 and group 3 (p = 0.001). PPRNFL superior and mean values were higher in group 1 and group 2 than in group 3 (p = 0.022, p = 0.029, respectively). The mean superior and inferior RPCVD values were significantly higher in group 1 than in group 2 and group 3 (p = 0.001, p = 0.043, and p = 0.001, respectively).

CONCLUSIONS

In preeclampsia, OCTA shows changes in the microvascular structure of the retina, even without retinopathy findings on biomicroscopy examination.

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.

Elschnig's Spots in the Acute and Remission Stages in Preeclampsia: Spectral-Domain Optical Coherence Tomographic Features

Purpose

Preeclampsia is a multisystem disorder defined as new onset of hypertension and proteinuria during the second half of pregnancy. Serous retinal detachment (SRD) is a known complication of preeclampsia caused by choroidal ischemia and subsequent disruption of blood-retinal barrier. Poor perfusion of the choriocapillaris causes Elschnig's spots. We aim to describe distinctive optical coherence tomography (OCT) features of a cluster of Elschnig's spots in a patient with severe preeclampsia during the acute and remission stages. We also present a summary of OCT features of preeclampsia patients with SRD.

Methods

Descriptive case report.

Results

V-shaped adhesions were observed at the location of each of the Elschnig's spots, the center of which showed disruption of the outer retinal bands (external limiting membrane, inner segment/outer segment junction layer), and the V-shaped outer parts remained tethered to retinal pigment epithelium (RPE)-Bruch's complex by hyperreflective exudate on the surface of RPE. These features parallel the histopathologic features described earlier. In an experimental model, Elschnig's spots showed a gradient of RPE damage from the center to the periphery, where RPE was necrotic in the center and edematous in the periphery. Three months later, spectral-domain OCT (SD-OCT) showed focal RPE elevations at the location of each of the Elschnig's spots.

Conclusions

We illustrate the distinctive SD-OCT features of a cluster of Elschnig's spots in the acute and chronic stages of preeclampsia and demonstrate the correlation with the previously described histopathologic features. Despite the favorable visual outcome, irreversible tissue damage may occur, necessitating prompt diagnosis and immediate therapeutic intervention.