Pregnancy and the Eye

• Karen Gil MD, MHSN presented a lecture on "Pregnancy and the Eye" on Feb. 10, 2025

Changes and Processes

• Pregnancy causes changes in the normal physiology of the mother
• Hormone processes are altered during pregnancy
• Human Chorionic Gonadotropin is the first hormone elevated and tested for during pregnancy
• Estrogen and progesterone levels also change during pregnancy

Conjunctiva

• Conjunctival pigmentation can occur because pregnancy hormones enhance melanocyte pigmentation in the conjunctiva.
• Subconjunctival hemorrhages can occur due to forced or repetitive vomiting, leading to increased pressure.

Cornea

• Corneal sensitivity decreases which makes it more prone to lacerations, and returns after 2 months postpartum
• Corneal thickness increases by 1-16 microns due to fluid retention caused by hormones, and resolves shortly after birth
• Refraction exams should be postponed until 1 month after delivery due to these corneal changes, which return after delivery
• Increase in corneal curvature can increase astigmatism, it resolves shortly after birth, and patients should be advised to wait after delivery for prescriptions
• Tear production decreases, particularly in the third trimester (80%) with staining most commonly inferiorly
• Keratitis Sicca can occur temporarily during pregnancy and will be more intense, Restasis (cyclosporine) can be used for severe keratoconjunctivitis sicca
• Contact lens intolerance can occur due to changes in corneal thickness, curvature and tear film, and discontinuation of wear may be required
• Herpes simplex virus can activate due to pregnancy immunosuppression, and is more common in contact lens users
• Krukenberg spindles can happen for an unknown reason secondary to rubbing, with pigmentary migration to the aqueous and deposition onto the corneal endothelium
• Krukenberg spindles disappear after pregnancy as pregnant women lose some pigment when the iris swells, but do not cause pigmentary dispersion glaucoma

IOP, Lens and Extraocular Muscles

• IOP decreases by 20% during pregnancy, necessitating a history since it can have a hypotensive effect until delivery
• Hypothesized to occur from an increased facility of outflow and increased uveoscleral outflow due to hormone effects, such as from progesterone
• Lens curvature increases anteriorly
• Can cause transient loss of accommodation, with thickening of the ciliary body due to fluid retention
• Returns to normal after delivery, but presbyopic patients may have a permanent effect
• Some reports indicate that having more babies could increase the risk of developing bilateral cataracts
• Strabismus may develop because muscles can become inflamed, with more common superior oblique (SO) palsy and 6th nerve palsy
• Trochlear nerve palsy can occur because the trochlea ligament can get swelled

Pathological Conditions

• Includes Dermatologic, Eyelid, Retinal, and Neurological conditions

Dermatologic Conditions

• Chloasma is a flat, blotchy, brown hyperpigmentation, usually in the cheeks and above the lips, also known as the "mask of pregnancy."
• Chloasma is from hypermelanosis of the skin which fades a few months after delivery
• Elevated levels of melanocyte-stimulating hormone (MSH), estrogen, and progesterone cause chloasma
• Spider angiomas are reddish-purple spidery superepithelial blood vessel growths that can potentially break
• Spider angiomas are painless, can be related to liver disease and increased portal pressure, and typically occur on the face or upper body, caused by high estrogen levels

Eyelid, Retinal and Neurological Conditions

• Ptosis, or unilateral upper-lid ptosis, is related to fluid retention or hormonal effects
• Advising patients to sleep in a propped-up position helps reduce edema, but to rule out Horner's syndrome in these cases
• Signs of Horner's Syndrome include: ptosis, miosis, anhydrosis and congenital iris heterochromia
• Thyroid Orbitopathy worsens during the first trimester and is related to thyroid stimulating activity of hCG such as Aggravation or pre-existing Graves or appear novo hyperthyroidism
• Gestational transient thyrotoxicosis, with TSH low and T3/T4 high
• Risk of fetal thyrotoxicosis from transplacental transfer of thyroid simulating antibodies
• Patients with ocular surface keratopathy such as lubricants, punctum plugs, steroids or cyclosporine, or tarsorrhaphy is needed in severe cases where eye is exposed and dry.
• Strabismus may be managed with prism or patching.
• Treatment of PTU (Propylthiouracil) is limited in transfer into placenta and breast milk
• Patients with hypothyroidism may have to continue TX to prevent cretinism
• Pre-eclampsia and eclampsia are related to blood pressure elevation
• AKA Pregnancy-Induced Hypertension (PIH)
• Can cause sudden onset of stroke-like focal deficits
• 5% of patients experience it in their first pregnancy after week 20th
• Pre-eclampsia develops second half of pregnancy
• The classic triad is Hypertension, Peripheral Edema and Proteinuria from surianalysis
• Eclampsia occurs late in pregnancy, and is defined by eclampsia with convulsions
• Complete resolution occurs 4 hours to 8 days after delivery, or usually a few days.
• The difference between pre-eclampsia and eclampsia is seizures
• Transient visual changes such as scotoma, diplopia, decrease vision, and photopsias.
• 20% of pre-eclamptic patients have visual changes, and 50% of eclamptic patients have visual changes
• Hypertensive retinopathy includes, Arteriolar narrowing (become attenuated), Hemorrhages, Cotton wool spots (ischemic damage to aggregated NFL axons), Hard exudates (lipids accumulate), Retinal edema, and Papilledema (optic nerve swelling).
• Cortical vision loss may occur, probably related to a cerebral vasospasm with ischemic injury and bleeding of central retinal artery
• Central Serous Chorioretinopathy is the accumulation of fluid under the retina, specifically detachment in the macula from pregnancy hormone changes may induce exudation of fluid from capillaries under the macula, related to type A personalities
• More common in the third trimester, causing neurosensory detachment of macula, central blurry vision, and resolves within a few months after delivery
• Patients complain of a central scotoma
• Pituitary Adenomas: Microadenomas are <10 mm / Macroadenomas are >10mm
• Pituitary adenomas are commonly asymptomatic, with 16.7% estimated prevalence, but usually symptomatic
• Can enlarge during pregnancy.
• Pituitary adenoma is diagnosed by measuring prolactin, but prolactin increases during pregnancy
• Common visual field defect includes bitemporal hemianopsia
• Bromocriptine and cabergoline treatment not given during pregnancy unless size increases
• Idiopathic Intracranial Hypertension (IIH) is AKA Benign Intracranial Hypertension or Pseudotumor Cerebri
• IIH is a syndrome of increased intracranial pressure, with Normal brain imaging and Normal CSF
• Elevated CSF pressure without mass association
• Unknown etiology
• Occurs in pregnant and non pregnant (obese) Symptoms include frontal headache, Scotoma, visual changes with VF loss, and Neck pain
• Characteristics signs of which are, bilateral papilledema, and Flame hemorrhages
• To diagnose, MRI is done, Lumbar puncture is used for CSF analysis, as well as Ophthalmoscopy examination
• A multi prong treatment approach is utilized including: Weight control, Oral Steroids given for 6 weeks to prevent permanent damage 1mg/kg/day, Oral Azetazolamide (Diamox); only begin to use after 5 months of pregnancy, If all those fail employ either: Serial lumbar punctures, Optic nerve fenestration-or cut the meninges. Important notes on these treatments are: diet is possible during pregnancy so calorie deficient diet, only trimester-teratogenic, remove CSF, but only do if severe papilledema. Finally only if all the steps above fail employ: Lumboperitoneal shunt-place a shunt toward the peritoneum, this procedure is a worry invasive and only to be used if the other methods employed all don’t work.
• Intracranial Meningioma:
• Most easy to treat.
• Is a growth of cancer cells in the brain.
• Happens in places there are meninges- coverings
• Occurs in women 75 % of the time
• Slow growth with visual disturbances
• Commonly causes: A decreases in VA, VF defect, oculomotor palsies CN III,, Papilledema. And Late optic atrophy
• Well encapsulated and normally non-metastatic.
• In pregnancy can expand rapidly but also has potential hormone association. 70% Meningiomas can express hormones like progesterone receptors while 30 % express estrogen.
• To confirm diagnosis a CT scan of orbit is needed to confirm meningioma Note: to treat these types of issues typically acetaminophen is utilized if that doesn’t work try ketorolac Some important symptoms to be wary of include: Optic neve sheet meningioma,CON IV: hyperopia, and -CN VI: medial hyperopia,
• Brachytherapy and external - directly as to not affect beam radiation during the baby, this the last step. Pregnancy but symptoms can disappear after the pregnancy Ocular Migraine: Commonly effects the eye Patient most likely has a normal migraine but aura is 90 % different Visual Disturbances
• 47 % during the first trimester
• 85 % of the 2nd trimester
• 87 % in the third
• 79 % remission after term and during the remainder of the patients time in preganancy Safe and affective treatment include: : Acetaminophen→ always safest Choice. Opioids→Not all type of it are recommend some one it are; tramadol.
• Relaxation Beta Blockers→Labetalol- don’t use in bp patient
• or Anti-depressants→ Amitriptyline