Eye Care for Pregnant and Postpartum Patients

Women undergo tremendous physiological changes during the 9 months of pregnancy and the following postpartum period. Abnormal stress is placed on the body, which can result in eye- and vision-related changes. Optometrists need to carefully manage any pre-existing ocular and systemic conditions patients may suffer from during this period. The postpartum phase results in substantial immune changes in the body, often triggering a new onset or exacerbation of autoimmune diseases. This article details the eye-related pregnancy and postpartum conditions and complications that can arise in expecting mothers.

OVERVIEW

A normal pregnancy is associated with remarkable changes to the immune and endocrine systems, enabling the development and survival of the placenta and fetus. A full-term pregnancy lasts between 39 0/7 weeks of gestation through 40 6/7 weeks of gestation, according to the American College of Obstetricians and Gynecologists (ACOG).¹ These weeks are grouped into three trimesters (Figure 1).

The fourth trimester is the unofficial name given to the postpartum period (when the mother’s physiologic changes return to their nonpregnant state). The ACOG considers postpartum up to 12 weeks after birth.² However, because the body doesn’t always return to baseline at this time, the postpartum period can last up to 12 months after birth. After delivery, there is an abrupt estrogen and progesterone withdrawal, while prolactin levels remain high.

REFRACTIVE CHANGES

Women may undergo vision changes throughout pregnancy and into the postpartum period. These changes are usually mild and temporary myopic changes that resolve after the body returns to its pre-pregnancy state. This could be due to pregnancy-related fluid retention, which causes an increase in corneal curvature during the second and third trimesters. This edema tends to resolve after delivery or with the cessation of breastfeeding.³ Because of this, optometrists should advise waiting 8 weeks postpartum to obtain a new spectacle or contact lens prescription.

Providers should manage pregnant patients with hyperopic shifts due to uncontrolled diabetes similarly to other diabetic patients. These patients should be given a prescription if necessary for optimal vision, but they should also be cautioned that their vision and prescription will continue to change as glycemic levels fluctuate.

OCULAR COMPLICATIONS

Pregnant patients commonly have dry eye syndrome and contact lens intolerance. Tear production tends to decrease during pregnancy, which results in dry eye syndrome. Altered tear composition, increased corneal thickness, and increased corneal curvature may all be causes of contact lens intolerance in our pregnant and postpartum patients.³

During pregnancy, an increase in estrogen and progesterone is believed to cause an increase in melanin, which often results in increased pigmentation or dark patches on the skin and around the eyes, known as melasma.⁴

Chronic, noninfectious uveitis doesn’t usually flare up during pregnancy. This may be due to heightened immune suppression. When flare-ups do occur, they typically happen during the first trimester and rebound within the first 6 months postpartum. Due to the potential teratogenic and adverse effects of many immunosuppressive agents, providers must take precautions when treating pregnant and breastfeeding patients. Short-acting, topical corticosteroids are an ideal initial approach to reduce the risk of potential harm to mother and fetus.⁵

Central Serous Chorioretinopathy

Central serous chorioretinopathy (CSCR) should be a differential for pregnant patients complaining of decreased vision, a central scotoma, or metamorphopsia. Although it is 10 times more common in men, pregnant women run a strong risk for CSCR, especially during the third trimester. During pregnancy, it often presents as an RPE detachment with surrounding subretinal exudates. The primary etiology of CSCR is unknown; however, hemodynamic and hormonal changes, as well as increased endogenous corticosteroid levels, may all play a role in CSCR during pregnancy. In most cases, CSCR is self-limiting, and vision tends to resolve within a few months.⁶

Purtscher-Like Retinopathy

Purtscher-like retinopathy (Purtscher retinopathy without associated trauma) has been seen in the immediate postpartum period. It’s also associated with preeclampsia, amniotic fluid emboli, and hypercoagulability. These symptoms most often present as sudden and severe bilateral vision loss shortly after delivery. A fundus examination usually reveals multiple cotton wool spots, with or without intraretinal hemorrhage. The retinal changes and vision tend to resolve spontaneously. Other occlusive vascular disorders such as arterial and vein occlusions have been reported during pregnancy but are less common.³

Toxoplasma Gondii

Toxoplasma gondii can easily pass to the fetus through the placenta if a mother acquires the infection during pregnancy. The passage is easier as the placenta matures, so the risk of fetal infection increases each trimester with the rate increasing from 25% to 65%. Central nervous system involvement and life-threatening fetal complications can occur with congenital toxoplasmosis, so it’s important to take caution and provide proper treatment.⁶ For mothers with latent ocular toxoplasmosis, reactivation can occur during pregnancy; however, fetal infection is uncommon.^3,7

SYSTEMIC COMPLICATIONS

Diabetes

Diabetic patients who become pregnant greatly increase their risk of developing diabetic retinopathy (DR). For those who already have DR, their risk of progression increases drastically.^3,4 For this reason, patients with diabetes should receive a baseline ophthalmic examination before becoming pregnant, if possible, and during the first trimester of pregnancy. DR that occurs during pregnancy tends to spontaneously regress after delivery. However, women remain at risk for DR progression up to 1 year postpartum.^3,4

Optometrists should manage patients with proliferative DR or clinically significant macular edema just as they manage nonpregnant patients. Gestational diabetes is not a risk factor for DR;³ however, it can cause various complications in mothers (Table).⁸

Hypertension

Preeclampsia occurs when a pregnant woman is hypertensive and has high levels of protein in her urine. It typically develops after week 20 of pregnancy and can be a serious and fatal condition if not managed immediately. Eclampsia occurs when a preeclamptic patient has seizures.³

Signs of preeclampsia include headaches, blurry vision, light sensitivity, or dark spots in the vision. Retinal changes are similar to those seen in hypertensive retinopathy, including diffuse retinal edema, hemorrhages, exudates, and cotton wool spots. The earliest retinal changes seen are focal arteriolar spasms, which occur in 50% to 100% of preeclamptic patients. Exudative retinal detachment is seen in 1% of preeclamptic patients and 10% of eclamptic patients.³ It is essential for eye care providers to recognize these signs in their pregnant and postpartum patients because preeclampsia can sometimes occur even after delivery.

IMMUNOLOGIC DISEASES

Considerable changes occur in the immune and endocrine system during pregnancy to allow for the development of the placenta and fetus. During these 9 months, thyroid disease, rheumatoid arthritis, and multiple sclerosis tend to ameliorate, while lupus, myasthenia gravis, and inflammatory bowel disease worsen.^3,9

After childbirth, there is an abrupt estrogen and progesterone withdrawal and high levels of prolactin for breastfeeding mothers. The postpartum body again undergoes substantial immune changes that can result in new onset or exacerbation of autoimmune diseases. The postpartum period has a negative effect on all autoimmune diseases, worsening symptoms, so providers should place special attention on the ocular manifestations during the postpartum period.

MEDICATION DOS AND DONTS

We must be cautious when prescribing any medication to our pregnant and breastfeeding patients. Regardless of the pregnancy category, it is best to prescribe a minimal concentration and dose of the medication to limit systemic absorption and toxicity (Figure 2). To further limit systemic absorption, punctal occlusion should be performed for 2 minutes.

Often, our pregnant and breastfeeding patients are rushed in and out of the office after refraction and an undilated examination. We refrain from using medicated drops and assume that a spectacle or contact lens prescription is the best that we can offer them during this sensitive time. However, with the substantial changes their bodies are undergoing, these patients may be struggling with a variety of ocular and visual conditions. Most often, ocular complications during this time are mild, transient, and require little to no treatment. Be that as it may, serious and life-threatening conditions can occur, and we must recognize these changes as health care providers.