Eye manifestations during pregnancy

1
Eye manifestations during pregnancy

• By
• Dr Mohamed Abusharifa, MD
• Ophthalmic surgeon
• Tulkarem - Palestine

2
TARGET

• To highlight those the eye problems,
  which are related with pregnancy,
• without interfering into treatment modalities

3
Eye manifestations during pregnancy

• Ocular changes that occur in pregnancy are
  usually TRNSIENT in nature, but occasionally
  there may be PERMANENT disorders

Courtesy of Sunness JS. The pregnant womans
eye. Surv of
Ophthalmology 198832219-38
4
PLAN

1. NEURO-OPHTHALMOLOGICAL
   changes appearing in pregnancy
2. The effects of pregnancy on PRE-EXISTING
   ocular disorders
3. Ocular disorders associated with
   PREGNANCY-RELATED diseases
4. Eye changes developing
   DURING PREGNANCY

5
BUT BEFORE proceeding into presentation

• please pay attention to the following
  5 slides

6
nausea severe vomiting severe
headache intracranial disorders in a pregnant
1
7
Newborn with hydrocephalus due to congenital
toxoplasmosis
2
(From Dubey JP, and Beattie CP. Toxoplasmosis of
animals and Man. CRC Press, Baca Raton, Florida,
52, 1988.)
8

3
A toxoplasmosis lesion in the
center of retina
Normal retina
Courtesy of KANSKI Clinical Ophthalmology
9
4
Normal retina
Diabetic retinopathy
Courtesy of KANSKI Clinical Ophthalmology
10
NO contact lenses during pregnancy
5

X
11
Now presentation starts

• NEURO-OPHTHALMOLOGICAL
  changes appearing in pregnancy
• The effects on PRE-EXISTING
  ocular disorders
• Ocular disorders associated with
  PREGNANCY-RELATED diseases
• Eye changes developing
  DURING PREGNANCY

12
NEURO-OPHTHALMOLOGICAL
changes appearing in pregnancy

• Some of the symptoms which are regarded normal in
  pregnancy, such as nausea
  vomiting
  may be signs of intracranial disorders

Courtesy of T. Walsh, Neuro-Ophthalmology Clinica
l Signs Symptoms
13
NEURO-OPHTHALMOLOGICAL
changes in pregnancy

• Nausea severe vomiting should be considered
  seriously while doing D.D. in a
  pregnant having
• Visual disturbances
• Persistent headache
• Visual field defects
• Oculomotor palsies

Courtesy of T. Walsh, Neuro-Ophthalmology Clinica
l Signs Symptoms
14
NEURO-OPHTHALMOLOGICAL cases included in DD
during pregnancy

• Pseudotumor cerebri
• (benign intracranial hypertension)
• Prolactinoma (adenoma of pituitary gland)
• Venous sinus thrombosis

15
NEURO-OPHTHALMOLOGICAL cases included in DD
during pregnancy

• Pseudotumor cerebri
• (benign intracranial hypertension)
• Prolactinoma (adenoma of pituitary gland)
• Venous sinus thrombosis

16
NEURO-OPHTHALMOLOGICAL
changes in pregnancy
Pseudotumor cerebri
(benign intracranial
hypertension)

• Typical symptoms findings
• Blur vision
• Headache
• Nausea severe vomiting
• 6th nerve palsy
• Edema of optic disc

Courtesy of T. Walsh, Neuro-Ophthalmology Clinica
l Signs Symptoms
17
nausea severe vomiting severe headache
18
Left Lateral Rectus Muscle palsy due
to Left 6th nerve palsy
Right Lateral Rectus Muscle palsy due to Righ
6th nerve palsy
Courtesy of KANSKI Clinical Ophthalmology
19
EDEMA OF OPTIC DISC

• edema of optic disc

Normal optic disc
Courtesy of T. Walsh, Neuro-Ophthalmology Clinica
l Signs Symptoms
20
NEURO-OPHTHALMOLOGICAL cases included in DD
during pregnancy

• Pseudotumor cerebri
• (benign intracranial hypertension)
• Prolactinoma
• (adenoma of pituitary gland)
• Venous sinus thrombosis

21
NEURO-OPHTHALMOLOGICAL cases included in DD
during pregnancy

• Pseudotumor cerebri
• (benign intracranial hypertension)
• Prolactinoma
• (adenoma of pituitary gland)
• Venous sinus thrombosis

22
NEURO-OPHTHALMOLOGICAL cases included in DD
during pregnancy

• Prolactinoma
• A noncancerous tumor (adenoma) affecting the
  pituitary gland that causes increase in the
  production of the hormone prolactin (LTH)

23
NEURO-OPHTHALMOLOGICAL
changes in pregnancy

• Prolactinoma
• Symptoms findings
• Galactorrhea
• Amenorrhea
• Fatigue
• Decreased libido
• Headache
• Visual disturbances (due to pressure on the optic
  nerve)
• Visual field defects (due to pressure on the
  optic chiasm)

24
Pituitary gland
25
Pituitary gland pressing on optic chiasm
from below
26
Optic chiasm
Optic nerve
tip
Courtesy of Dynamic Human Anatomy Student
Version
27
Enlarged sella turcica due to pressure caused by
pituitary adenoma
28

normal Visual field in Left Eye
Pts view
Courtesy of D. J. Spalton Atlas of CLINICAL
OPHTHALMOLOGY
29
normal visual field in Right Eye
Pts view
Courtesy of D. J. Spalton Atlas of CLINICAL
OPHTHALMOLOGY
30
Asymmetric bitemporal visual field loss
due to pressure on the optic
chiasm optic nerve from below
Courtesy of Visual Fields Examination
Interpretation Publication of American
Academy of Ophthalmology
31
Pituitary adenoma (prolactinoma)
Courtesy of Visual Fields Examination
Interpretation Publication of American
Academy of Ophthalmology
32
NEURO-OPHTHALMOLOGICAL cases included in DD
during pregnancy

• Prolactinoma
• It is recommended that any pregnant with a known
  pituitary prolactinoma must
• have regular visual field follow-up to rule out
  enlargement which leads to compression of optic
  chiasm and causes
  
  
  
  
  uncorrected
  visual field loss

Courtesy of Visual Fields Examination
Interpretation Publication of
American Academy of Ophthalmology
33
NEURO-OPHTHALMOLOGICAL cases included in DD
during pregnancy

• Pseudotumor cerebri
• (benign intracranial hypertension)
• Prolactinoma
• (adenoma of pituitary gland)
• Venous sinus thrombosis

34
NEURO-OPHTHALMOLOGICAL cases included in DD
during pregnancy

• Pseudotumor cerebri
• (benign intracranial hypertension)
• Prolactinoma
• (adenoma of pituitary gland)
• Venous sinus thrombosis

35
NEURO-OPHTHALMOLOGICAL cases included in DD
during pregnancy

• Venous sinus thrombosis
• is a form of brain stroke that results from
  thrombosis of the dural venous sinuses

Courtesy of Lanska DJ, Kryscio RL. Risk factors
for peripartum pastpartum stroke intracranial
venous thrombosis. Stroke 2000311274-82
36
NEURO-OPHTHALMOLOGICAL cases included in DD
during pregnancy

• Venous sinus thrombosis
• Increased risk of occurrence in
• Cesarean delivery
• Advanced maternal age
• Hypertension
• Infections

Courtesy of Lanska DJ, Kryscio RL. Risk factors
for peripartum pastpartum stroke intracranial
venous thrombosis. Stroke 2000311274-82
37
Venous sinuses
38
NEURO-OPHTHALMOLOGICAL cases included in DD
during pregnancy

• Venous sinus thrombosis
• Signs symptoms
• Throbbing headache
• Focal or generalized seizures
• Paresis
• Optic disc edema

Courtesy of Lanska DJ, Kryscio RL. Risk factors
for peripartum pastpartum stroke intracranial
venous thrombosis. Stroke 2000311274-82
39
nausea severe vomiting severe headache
40
Venous sinus thrombosis

• thrombus

Courtesy of Lanska DJ, Kryscio RL. Risk factors
for peripartum pastpartum stroke intracranial
venous thrombosis. Stroke 2000311274-82
41
EDEMA OF OPTIC DISC

• edema of optic disc

Normal optic disc
Courtesy of T. Walsh, Neuro-Ophthalmology Clinica
l Signs Symptoms
42
PLAN

1. NEURO-OPHTHALMOLOGICAL
   changes appearing in pregnancy
2. The effects on PRE-EXISTING
   ocular disorders
3. Ocular disorders associated with
   PREGNANCY-RELATED diseases
4. Eye changes developing
   DURING PREGNANCY

43
The effects of pregnancy on
PRE-EXISTING ocular disorders

• Diabetic retinopathy
• Graves disease
• Glaucoma
• Uveitis

44
The effects of pregnancy on
PRE-EXISTING ocular disorders

• Diabetic retinopathy
• Graves disease
• Glaucoma
• Uveitis

45
The effects of pregnancy on
PRE-EXISTING ocular disorders

• Diabetic retinopathy
• is the most ocular disorder modified by
  pregnancy

Courtesy of Sheth BP. Does pregnancy accelerate
the rate of progression of diabetic retinopathy?
Curr Diab Rep 20022327-30
46
The effects of pregnancy on
PRE-EXISTING ocular disorders

• Diabetic retinopathy
• its progression is affected by
• Duration of DM
• Presence of diabetic retinopathy at conception
• Sugar control during pregnancy

Courtesy of Sheth BP. Does pregnancy accelerate
the rate of progression of diabetic retinopathy?
Curr Diab Rep 20022327-30
47
The effects of pregnancy on
PRE-EXISTING ocular disorders

• Diabetic retinopathy
• Ophthalmic status should be evaluated before
  pregnancy
• Good sugar control throughout pregnancy
• Eye exam every 3 months
• Treatment by laser photocoagulation before
  pregnancy may reduce progression by 50

Courtesy of Sheth BP. Does pregnancy accelerate
the rate of progression of diabetic retinopathy?
Curr Diab Rep 20022327-30
48
The effects of pregnancy on
PRE-EXISTING ocular disorders
Diabetic retinopathy
Normal retina
Courtesy of KANSKI Clinical Ophthalmology
49
The effects of pregnancy on
PRE-EXISTING ocular disorders

• Diabetic retinopathy

laser photocoagulation
50
The effects of pregnancy on
PRE-EXISTING ocular disorders

• Diabetic retinopathy
• Graves diseas
• Glaucoma
• Uveitis

51
The effects of pregnancy on
PRE-EXISTING ocular disorders

• Diabetic retinopathy
• Graves diseas
• Glaucoma
• Uveitis

52
The effects of pregnancy on
PRE-EXISTING ocular disorders

• Graves disease
• Pre-existing hyperthyroidism can be
• aggravated in pregnancy.

Courtesy of Amino N et al. Aggravation of
thyrotoxicosis in early pregnancy and after
delivery in Graces disease. J Clin Endocr Metab
198255108-12
53
The effects of pregnancy on
PRE-EXISTING ocular disorders

• The initial onset of Graves disease
• may occur during pregnancy

Courtesy of Amino N et al. Aggravation of
thyrotoxicosis in early pregnancy and after
delivery in Graces disease. J Clin Endocr Metab
198255108-12
54
The effects of pregnancy on
PRE-EXISTING ocular disorders
Thyroid ophthalmopathy
Courtesy of KANSKI Clinical Ophthalmology
55
The effects of pregnancy on
PRE-EXISTING ocular disorders

• Diabetic retinopathy
• Graves disease
• Glaucoma
• Uveitis

56
The effects of pregnancy on
PRE-EXISTING ocular disorders

• Diabetic retinopathy
• Graves disease
• Glaucoma
• Uveitis

57
Glaucoma

• (increase in intraocular pressure)

• leads to
• optic disk atrophy
• loss in visual field

Courtesy of F. Newell Ophthalmology principles
concepts
58
atrophic glaucomatous optic disk
NORMAL OPTIC DISK
Courtesy of Kanski CLINICAL OPHTHALMOLOGY
59
Progression of glaucomatous visual field loss
Courtesy of Kanski CLINICAL OPHTHALMOLOGY
60
The effects of pregnancy on
PRE-EXISTING ocular disorders

During pregnancy occurs decrease in intraocular
pressure (temporary control) !!!
Courtesy of Johnson SM, Martinez M, Freedman S.
Management of glaucoma in pregnancy lactation.
Surv. Ophthalmol 200145449-54
61
The effects of pregnancy on
PRE-EXISTING ocular disorders

• Diabetic retinopathy
• Graves disease
• Glaucoma
• Uveitis

62
The effects of pregnancy on
PRE-EXISTING ocular disorders

• Diabetic retinopathy
• Graves disease
• Glaucoma
• Uveitis

63
The effects of pregnancy on
PRE-EXISTING ocular disorders
Uveitis

• A non-infectious inflammation of uvea, which
  sometimes accompanies inflammations of connective
  tissue arthritis, spondyloarthritis .etc

Courtesy of F. Newell Ophthalmology principles
concepts
64
The effects of pregnancy on
PRE-EXISTING ocular disorders

• During pregnancy also occurs temporary
  improvement of uveitis !!!

Courtesy of Sunness JS, Santos A, Pregnancy the
Mothers eye Lippincott Williams Wilkins2001
65
PLAN

1. NEURO-OPHTHALMOLOGICAL
   changes appearing in pregnancy
2. The effects on PRE-EXISTING
   ocular disorders
3. Ocular disorders associated with
   PREGNANCY-RELATED diseases
4. Eye changes developing
   DURING PREGNANCY

66
Ocular disorders associated with
PREGNANCY- RELATED diseases

• Toxoplasmosis
• Toxemic retinopathy of pregnancy

67
Ocular disorders associated with
PREGNANCY- RELATED diseases

• Toxoplasmosis
• Toxemic retinopathy of pregnancy

68
Toxoplasmosis

• Is an infection caused by the intracellular
  protozoon (Toxoplasma gondii), by ingestion of
  raw or undercooked meat containing oocysts, or by
  exposure to oocysts in cat feces

Fabiana Maria Ruiz Lopes - Toxoplasma gondii
infection in pregnancy Brazilian Journal of
Infectious Diseases
69
Neonatal congenital toxoplasmosis

• It is acquired transplacentally, which may
  cause
• Abortion
• Miscarriage or stillbirth
• Chronic chorioretinitis blindness
• Severe jaundice hepatosplenomegaly
• CNS lesions
• Hydrocephalus
• Intracerebral calcification
• Mental retardation
• convulsions

Fabiana Maria Ruiz Lopes - Toxoplasma gondii
infection in pregnancy Brazilian Journal of
Infectious Diseases
70
Girl with hydrocephalus due to congenital
toxoplasmosis.
Brain calcification in congenital toxoplasmosis
(From Dubey JP, and Beattie CP. Toxoplasmosis of
animals and Man. CRC Press, Baca Raton, Florida,
52, 1988.)
71
Ocular disorders associated with
PREGNANCY- RELATED diseases
Toxoplasmosis lesion in center of retina
Normal retina
Courtesy of KANSKI Clinical Ophthalmology
72
Suggestion

• The serological research for toxoplasmosis in
  pregnant women should be mandatory by law, as in
  some countries France Austria,
• Neonatal screening programs for congenital
  toxoplasmosis should be done routinely as Guthrie
  test for PKU (phenylketonuria).

Courtesy of Fabiana Maria Ruiz Lopes - Toxoplasma
gondii infection in pregnancy Brazilian Journal
of Infectious Diseases
73
Ocular disorders associated with
PREGNANCY- RELATED diseases

• Toxoplasmosis
• Toxemic retinopathy of pregnancy

74
Ocular disorders associated with
PREGNANCY- RELATED diseases

• Toxoplasmosis
• Toxemic retinopathy of pregnancy

75
Ocular disorders associated with
PREGNANCY- RELATED diseases

• Toxemic retinopathy of pregnancy occurs
• During pre-eclampsia
• Premature separation of the placenta (Abruptio
  placentae)
• Retention of dead fetus

Courtesy of Sunness JS. The pregnant womans
eye. Surv of
Ophthalmology 198832219-38
76
Ocular disorders associated with
PREGNANCY- RELATED diseases

• Toxemic retinopathy of pregnancy
• Cotton wool spots
• Retinal hard exudates
• Edema of optic disc
• Retinal hemorrhages
• Serous chorioretinopathy

Courtesy of Sunness JS. The pregnant womans
eye. Surv of
Ophthalmology 198832219-38
77
Toxemic retinopathy of pregnancy
edema of optic disc retinal hemorrhages
cotton-wool spots central exudates
Normal retina
Courtesy of KANSKI Clinical Ophthalmology
78
Toxemic retinopathy of pregnancy
Central serous chorioretinopathy
Normal retina
Courtesy of KANSKI Clinical Ophthalmology
79
PLAN

1. NEURO-OPHTHALMOLOGICAL
   changes appearing in pregnancy
2. The effects on PRE-EXISTING
   ocular disorders
3. Ocular disorders associated with
   PREGNANCY-RELATED diseases
4. Eye changes developing
   DURING PREGNANCY

80
Eye changes developing DURING
PREGNANCY

• ON
• LIDS
• CORNEA
• TEARS PRODUCTION
• LENS

81
Eye changes developing DURING
PREGNANCY

• Chloasma on LIDS
• (Chloasma gravidarum)
• (Mask of pregnancy)
• Blotchy brown discoloration
  around lids, due to
  pigmentation
  
  It
  fades in postpartum period
• No treatment needed

Courtesy of Sushma Sharma - Review Pregnancy and
the eye
82
Eye changes developing DURING
PREGNANCY
Corneal edema on CORNEA
Increased corneal thickness

• Due to fluid retention
• This (edema) causes
  
• MYOPIC change
• Intolerance to CL due to traumatic effects on
  corneal surface

Normal corneal thickness
Courtesy of Sushma Sharma - Review Pregnancy and
the eye
83
Eye changes developing DURING
PREGNANCY

• Decrease in tears production
• in 80 of pregnant women
• It causes Intolerance to wearing CL

Courtesy of Sushma Sharma - Review Pregnancy and
the eye
84
Pregnants are advised to

• avoid wearing CL

X
Courtesy of Sushma Sharma - Review Pregnancy and
the eye
85
Eye changes developing DURING
PREGNANCY

• on lens increase in lens curvature
• leads to Temporary myopia

Increased lens curvature
Normal lens curvature
86
conclusion

• 1. Attention to NAUSEA VOMITTING when
  accompanied by intracranial disorders
• 2. SEROLOGICAL RESEARCH for toxoplasmosis in
  pregnant women.
• Neonatal screening for CONGENITAL
  TOXOPLASMOSIS
• 3. Good control of SUGAR in diabetic pregnants
• 4. No CONTACT LENSES during pregnancy

87
THANK YOU