Eye manifestations during pregnancy By Dr Mohamed Abusharifa

Eye manifestations during pregnancy By Dr Mohamed Abusharifa, MD Ophthalmic surgeon Tulkarem - Palestine 1

TARGET To highlight those the eye problems, which are related with pregnancy, without interfering into treatment modalities 2

Eye manifestations during pregnancy Ocular changes that occur in pregnancy are usually TRNSIENT in nature, but occasionally there may be PERMANENT disorders 3 Courtesy of: Sunness JS. The pregnant woman’s eye. Surv of Ophthalmology 1988; 32: 219 -38

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 4

BUT BEFORE proceeding into presentation please pay attention to the following 5 slides : 5

1 6 nausea + severe vomiting + severe headache + intracranial disorders in a pregnant

Newborn with hydrocephalus due to congenital toxoplasmosis 2 7 (From Dubey JP, and Beattie CP. Toxoplasmosis of animals and Man. CRC Press, Baca Raton, Florida, 52, 1988. )

A toxoplasmosis lesion in the center of retina 8 3 Normal retina Courtesy of KANSKI : Clinical Ophthalmology

4 Diabetic retinopathy 9 Normal retina Courtesy of KANSKI : Clinical Ophthalmology

5 NO contact lenses during pregnancy = 10 X

Now presentation starts: 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 11

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 12 Clinical Signs & Symptoms

NEURO-OPHTHALMOLOGICAL changes in pregnancy Nausea & severe vomiting should be considered seriously while doing D. D in a pregnant having: ü Visual disturbances ü Persistent headache ü Visual field defects ü Oculomotor palsies Courtesy of: T. Walsh, Neuro-Ophthalmology 13 Clinical Signs & Symptoms

NEURO-OPHTHALMOLOGICAL cases included in DD during pregnancy: pregnancy ØPseudotumor cerebri (benign intracranial hypertension) ØProlactinoma (adenoma of pituitary gland) ØVenous sinus thrombosis 14

NEURO-OPHTHALMOLOGICAL cases included in DD during pregnancy: pregnancy ØPseudotumor cerebri (benign intracranial hypertension) ØProlactinoma (adenoma of pituitary gland) ØVenous sinus thrombosis 15

NEURO-OPHTHALMOLOGICAL changes in pregnancy Pseudotumor cerebri (benign intracranial hypertension) Typical symptoms & findings: – Blur vision – Headache – Nausea & severe vomiting – 6 th nerve palsy – Edema of optic disc Courtesy of: T. Walsh, Neuro-Ophthalmology 16 Clinical Signs & Symptoms

nausea + severe vomiting + severe headache 17

Right Lateral Rectus Muscle palsy due to Righ 6 th nerve palsy Left Lateral Rectus Muscle palsy due to Left 6 th nerve palsy Courtesy of KANSKI: Clinical Ophthalmology 18

EDEMA OF OPTIC DISC Normal optic disc 19 Courtesy of: T. Walsh, Neuro-Ophthalmology Clinical Signs & Symptoms edema of optic disc

NEURO-OPHTHALMOLOGICAL cases included in DD during pregnancy: • Pseudotumor cerebri (benign intracranial hypertension) • Prolactinoma (adenoma of pituitary gland) 20 • Venous sinus thrombosis

NEURO-OPHTHALMOLOGICAL cases included in DD during pregnancy: • Pseudotumor cerebri (benign intracranial hypertension) • Prolactinoma (adenoma of pituitary gland) 21 • Venous sinus thrombosis

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) 22

NEURO-OPHTHALMOLOGICAL changes in pregnancy Prolactinoma Symptoms & findings: • Galactorrhea • Amenorrhea • Fatigue • Decreased libido • Headache • Visual disturbances (due to pressure on the optic nerve) nerve • Visual field defects (due to pressure on the optic chiasm) chiasm 23

Pituitary gland 24

Pituitary gland pressing on optic chiasm from below 25

Optic chiasm Optic nerve tip 26 Courtesy of: Dynamic Human Anatomy Student Version

Enlarged sella turcica due to pressure caused by pituitary adenoma 27

normal Visual field in Left Eye Pt’s view 28 Courtesy of D. J. Spalton: Atlas of CLINICAL OPHTHALMOLOGY

normal visual field in Right Eye Pt’s view 29 Courtesy of D. J. Spalton: Atlas of CLINICAL OPHTHALMOLOGY

ric bitemporal visual field loss due to pressure on the optic chiasm & optic nerve from below 30 Courtesy of Visual Fields: Examination & Interpretation Publication of American Academy of Ophthalmology

Pituitary adenoma (prolactinoma) 31 Courtesy of Visual Fields: Examination & Interpretation Publication of American Academy of Ophthalmology

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 32 Courtesy of Visual Fields: Examination & Interpretation Publication of American Academy of Ophthalmology

NEURO-OPHTHALMOLOGICAL cases included in DD during pregnancy: • Pseudotumor cerebri (benign intracranial hypertension) • Prolactinoma (adenoma of pituitary gland) • Venous sinus thrombosis 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: Venous sinus thrombosis is a form of brain stroke that results from thrombosis of the dural venous sinuses 35 Courtesy of Lanska DJ, Kryscio RL. Risk factors for peripartum & pastpartum stroke& intracranial venous thrombosis. Stroke 2000; 31: 1274 -82

NEURO-OPHTHALMOLOGICAL cases included in DD during pregnancy: Venous sinus thrombosis Increased risk of occurrence in : ØCesarean delivery ØAdvanced maternal age ØHypertension ØInfections 36 Courtesy of Lanska DJ, Kryscio RL. Risk factors for peripartum & pastpartum stroke& intracranial venous thrombosis. Stroke 2000; 31: 1274 -82

Venous sinuses 37

NEURO-OPHTHALMOLOGICAL cases included in DD during pregnancy: Venous sinus thrombosis Signs & symptoms: § Throbbing headache § Focal or generalized seizures § Paresis § Optic disc edema 38 Courtesy of Lanska DJ, Kryscio RL. Risk factors for peripartum & pastpartum stroke& intracranial venous thrombosis. Stroke 2000; 31: 1274 -82

nausea + severe vomiting + severe headache 39

Venous sinus thrombosis thrombus 40 Courtesy of Lanska DJ, Kryscio RL. Risk factors for peripartum & pastpartum stroke& intracranial venous thrombosis. Stroke 2000; 31: 1274 -82

EDEMA OF OPTIC DISC Normal optic disc 41 Courtesy of: T. Walsh, Neuro-Ophthalmology Clinical Signs & Symptoms edema of optic disc

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 42

The effects of pregnancy on PRE-EXISTING ocular disorders – – 43 Diabetic retinopathy Graves’ disease Glaucoma Uveitis

The effects of pregnancy on PRE-EXISTING ocular disorders – – 44 Diabetic retinopathy Graves’ disease Glaucoma Uveitis

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 2002; 2: 327 -30 45

The effects of pregnancy on PRE-EXISTING ocular disorders Diabetic retinopathy its progression is affected by : 1. Duration of DM 2. Presence of diabetic retinopathy at conception 3. Sugar control during pregnancy 46 Courtesy of Sheth BP. Does pregnancy accelerate the rate of progression of diabetic retinopathy? Curr Diab Rep 2002; 2: 327 -30

The effects of pregnancy on PRE-EXISTING ocular disorders Diabetic retinopathy 1. Ophthalmic status should be evaluated before pregnancy 2. Good sugar control throughout pregnancy 3. Eye exam every 3 months 4. 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 2002; 2: 327 -30 47

The effects of pregnancy on PRE-EXISTING ocular disorders Diabetic retinopathy 48 Normal retina Courtesy of KANSKI : Clinical Ophthalmology

The effects of pregnancy on PRE-EXISTING ocular disorders Diabetic retinopathy 49 laser photocoagulation

The effects of pregnancy on PRE-EXISTING ocular disorders • • 50 Diabetic retinopathy Graves’ diseas Glaucoma Uveitis

The effects of pregnancy on PRE-EXISTING ocular disorders • • 51 Diabetic retinopathy Graves’ diseas Glaucoma Uveitis

The effects of pregnancy on PRE-EXISTING ocular disorders Graves’ disease Pre-existing hyperthyroidism can be aggravated in pregnancy. 52 Courtesy of Amino N et al. Aggravation of thyrotoxicosis in early pregnancy and after delivery in Graces’ disease. J Clin Endocr Metab 1982; 55: 108 -12

The effects of pregnancy on PRE-EXISTING ocular disorders The initial onset of Graves’ disease may occur during pregnancy 53 Courtesy of Amino N et al. Aggravation of thyrotoxicosis in early pregnancy and after delivery in Graces’ disease. J Clin Endocr Metab 1982; 55: 108 -12

The effects of pregnancy on PRE-EXISTING ocular disorders Thyroid ophthalmopathy 54 Courtesy of KANSKI : Clinical Ophthalmology

The effects of pregnancy on PRE-EXISTING ocular disorders • • 55 Diabetic retinopathy Graves’ disease Glaucoma Uveitis

The effects of pregnancy on PRE-EXISTING ocular disorders • • 56 Diabetic retinopathy Graves’ disease Glaucoma Uveitis

Glaucoma (increase in intraocular pressure) pressure leads to: Øoptic disk atrophy Øloss in visual field 57 Courtesy of F. Newell: Ophthalmology principles & concepts

NORMAL OPTIC DISK 58 atrophic glaucomatous optic disk Courtesy of Kanski: CLINICAL OPHTHALMOLOGY

Progression of glaucomatous visual field loss 59 Courtesy of Kanski: CLINICAL OPHTHALMOLOGY

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 2001; 45: : 449 -54 60

The effects of pregnancy on PRE-EXISTING ocular disorders – – 61 Diabetic retinopathy Graves’ disease Glaucoma Uveitis

The effects of pregnancy on PRE-EXISTING ocular disorders – – 62 Diabetic retinopathy Graves’ disease Glaucoma Uveitis

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 63

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 Mother’s eye: Lippincott Williams & Wilkins; 2001 64

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 65

Ocular disorders associated with PREGNANCY- RELATED diseases o Toxoplasmosis o Toxemic retinopathy of pregnancy 66

Ocular disorders associated with PREGNANCY- RELATED diseases o Toxoplasmosis o Toxemic retinopathy of pregnancy 67

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 68 Fabiana Maria Ruiz Lopes - Toxoplasma gondii infection in pregnancy Brazilian Journal of Infectious Diseases

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

Girl with hydrocephalus due to congenital toxoplasmosis. 70 Brain calcification in congenital toxoplasmosis (From Dubey JP, and Beattie CP. Toxoplasmosis of animals and Man. CRC Press, Baca Raton, Florida, 52, 1988. )

Ocular disorders associated with PREGNANCY- RELATED diseases Toxoplasmosis lesion in center of retina 71 Normal retina Courtesy of KANSKI : Clinical Ophthalmology

Suggestion • • 72 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

Ocular disorders associated with PREGNANCY- RELATED diseases o Toxoplasmosis o Toxemic retinopathy of pregnancy 73

Ocular disorders associated with PREGNANCY- RELATED diseases o Toxoplasmosis o Toxemic retinopathy of pregnancy 74

Ocular disorders associated with PREGNANCY- RELATED diseases Toxemic retinopathy of pregnancy occurs: üDuring pre-eclampsia üPremature separation of the placenta (Abruptio placentae) ü Retention of dead fetus 75 Courtesy of: Sunness JS. The pregnant woman’s eye. Surv of Ophthalmology 1988; 32: 219 -38

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 76 Courtesy of: Sunness JS. The pregnant woman’s eye. Surv of Ophthalmology 1988; 32: 219 -38

Toxemic retinopathy of pregnancy edema of optic disc & retinal hemorrhages & cotton-wool spots & central exudates 77 Normal retina Courtesy of KANSKI : Clinical Ophthalmology

Toxemic retinopathy of pregnancy Central serous chorioretinopathy 78 Normal retina Courtesy of KANSKI : Clinical Ophthalmology

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 79

Eye changes developing DURING PREGNANCY ON: ON • • 80 LIDS CORNEA TEARS PRODUCTION LENS

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 81

Eye changes developing DURING PREGNANCY Corneal edema on CORNEA Increased corneal thickness Due to fluid retention This (edema) causes: 1. MYOPIC change 2. Intolerance to CL due to traumatic effects on corneal surface Normal corneal thickness 82 Courtesy of Sushma Sharma - Review: Pregnancy and the eye

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 83

Pregnants are advised to avoid wearing CL = 84 Courtesy of Sushma Sharma - Review: Pregnancy and the eye X

1. Eye changes developing DURING PREGNANCY on lens = increase in lens curvature leads to: Temporary myopia Increased lens curvature 85 Normal lens curvature

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 86

THANK YOU 87