Effect of Body Posture on Intraocular Pressure and Ocular Perfusion Pressure in Nonglaucomatous Pregnant Women

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.

Glaucoma in pregnancy: an update

PURPOSE OF REVIEW

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

RECENT FINDINGS

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

SUMMARY

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

Postural effects on spontaneous retinal venous pulsations in healthy individuals

PURPOSE

To assess amplitudes of spontaneous retinal venous pulsations (SVP) in three various postures (sitting, supine and lateral decubitus) in healthy individuals.

METHODS

Thirty participants (28 ± 8 years, 25 females) were included in the study. Intraocular pressure (IOP), blood pressure (BP) and SVP's were measured at three different postures using a calibrated Tono-Pen applanation tonometer, a digital sphygmomanometer, and a custom-built handheld video ophthalmoscope, respectively. Retinal venous pulsations (SVP) amplitudes were extracted from the retinal videos using a custom written MATLAB algorithm. Mean arterial pressure (MAP = (systolic + 2diastolic)/3) and mean ocular perfusion pressure (MOPP = (2/3 MAP)-IOP) were also calculated at each posture. A one-way ANOVA was applied to each parameter to determine any significant difference for the various postural changes.

RESULTS

Mean IOP increased (p < 0.0001) and mean SVP decreased (p < 0.0001) from sitting to supine. The mean IOP (mmHg) and SVP (MU; measuring units) in sitting, supine and lateral decubitus were 16.2 ± 2, 19.4 ± 4, 19.8 ± 2 mmHg and 5.8 ± 2, 4.5 ± 2, and 4.7 ± 2 MU, respectively. Mean arterial pressure (MAP) and MOPP also decreased significantly from sitting to supine (p < 0.001, p < 0.001) and sitting to lateral decubitus (p < 0.05, p < 0.01). There were no significant differences between IOP, SVP, MAP or MOPP during a postural modification from supine to lateral decubitus.

CONCLUSIONS

In this study, we showed a significant reduction in SVP amplitudes and a significant increase in IOP from sitting to supine position in a healthy young cohort. This supports the rationale to further study such phenomenon in ocular conditions such as glaucoma to determine whether relative SVP change, for a similar postural change, can reveal early signs of vascular dysfunction.

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.

Evidence-Based Approaches to Glaucoma Management During Pregnancy and Lactation

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