retinopathies in pregnancy, retina problems in pregnancy

1. Nawat Watanachai
Chiangmai University Hospital
RCOPT mid 2013

2. Many emotional and
physical changes
 including eyes


3. Normal eye changes in pregnancy
 Pregnancy induced chorioretinopathy
 Retinal diseases that are affected by pregnancy


4. 


Cornea
◦ increase thickness 1
◦ Increase curvature 2
◦ Decrease sensitivity 3
Lens
◦ Increase thickness 1
◦ Increase curvature 1
IOP
◦ Decrease in 3rd trimester 4
1 Riss B, Riss P. Corneal sensitivity in pregnancy. Ophthalmologica 1981; 183:57—62.
2 Weinreb RN, Lu A, Beeson C. Maternal corneal thickness during pregnancy. Am J Ophthalmol 1988; 105:258—260.
3 Park SB, Lindahl KJ, Temnycky GO, Aquavella JV. The effect of pregnancy on the corneal curvature. CLAO J 1992; 18:256—259.
4 Akar Y, Yucel I, Akar ME, et al. Effect of pregnancy on intraobserver and intertechnique agreement in intraocular pressure measurements.
Ophthalmologica 2005; 219:36—42.

5. 
Retina
◦ Retinal thickness
 slightly increases during 2nd-3rd
trimesters 1
◦ Retinal venous diameter
 decreased during the 3rd trimester 2
1. Dinn, Robert B. BS*; Harris, Alon MSc, PhD†; Marcus, Peter S. MD‡. Ocular Changes in Pregnancy. Obstetrical &
Gynecological Survey:
February 2003 - Volume 58 - Issue 2 - pp 137-144
2. The effect of pregnancy on retinal hemodynamics in diabetic versus nondiabetic mothers ☆
Lisa S Schocket, MDa, Juan E Grunwald, MDa, , , Amy F Tsang, MAa, Joan DuPonta American Journal of OphthalmologyVolume
128, Issue 4, October 1999, Pages 477–484

6. ●
●
Early preg -> hyperdynamic circulation
controlled by an autoregulatory mechanism in the
retinal vasculature
Success
 not develop retinopathy
–
–
Failed
 increased blood flow velocity
 petential damage to capillary endothelium
Chen HC et al. Retinal blood flow changes during pregnancy in women with diabetes. Invest Ophthalmol Vis Sci 1994;
35:3199–3208.

8. Central serous chorioretinopathy (CSCR)
 Valsava retinopathy
 Purtscher’s retinopathy
 Preeclampsia/ eclampsia associated retinopathy
◦ (HT retinopathy)

RAO, RVO
 Bullous ERD


9. ●
●
10:1 male predominance outside the context of
pregnancy
closure when women become pregnant
Chumbley LC, Frank RN. Central serous retinopathy and pregnancy. Am J Ophthalmol 1974; 77:158—160.

10. ●
CSCR
●
●
●
unilateral
with or without fibrin formation
Most cases
●
●
occurred during the 3rd trimester
recurring in subsequent pregnancies
Sunness JS, Haller JA, Fine SL. Central serous chorioretinopathy and pregnancy. Arch Ophthalmol 1993; 111:360—364.
Gass JDM. Central serous chorioretinopathy and white subretinal exudation during pregnancy. Arch Ophthalmol 1991; 109:677—681.

11. ●
Investigations
●
●
OCT >>>>>> FA/ICG
CSCR
●
●
●
spontaneously resolved
during the early postpartum
not associated with any adverse
fetal outcomes C/S Rx
conservatives

12. ●
●
●
unilateral or bilateral
self limiting
increased intra-thoracic or
intraabdominal pressure
●
●
●
 sharp rise in the intraocular venous pressure
 rupture of superficial
retinal capillaries
Constipation/ delivery

13. ●
No specific treatment is needed
●
●
Laser posterior hyaloidotomy
the diagnosis should be made only after excluding
other causes of retinal haemorrhages

14. ●
(reported) developing after child birth
●
●
●
Preeclampsia/ eclampsia
compliment activated leuko-embolus formation?
No treatment is needed

15. ●
How common
●
●
●
●
25% of the patients with preeclampsia
50% with eclampsia
Mostly asymptomatic
Few suffers visual disturbance
●
blurred vision, diplopia, photopsia, scotomata, amaurosis and
chromatopsia and cortical blindness
DieckmannWJ (1952) The toxemias of pregnancy, 2nd edn. Mosby, St Louis

16. ●
common ocular findings
●
●
●
●
●
Focal/ general constriction or
spasm of the retinal arterioles
CWS
intra retinal haemorrhages,
retinal oedema
optic nerve oedema
in a patient with mild
preeclampsia
●
Look for cowexisting DM/
chronic HT
Jaffe G, Schatz H Ocular manifestations of preeclampsia. Am
J Ophthalmol 1987;103:309–315

17. ●
Choroidal involvement
●
●
yellow- white focal lesions at the level of
the RPE
serous retinal detachment
●
●
●
often bullous
usually bilateral
Elschnig’s spots
●
●
small, isolated areas of
hyperpigmentation
surrounding yellow or red halos
A.M. Joussen, T.W.Gardner, B. Kirchhof , S.J. Ryan . Retinal Vascular Disease:691-699

18. ●
prognosis
●
●
●
Good
Generally do not need specific
treatment
But NEED Systemic
treatment
●
●
●
antihypertensive therapy
magnesium sulfate
early delivery of the fetus when
indicated
A.M. Joussen, T.W.Gardner, B. Kirchhof , S.J. Ryan . Retinal Vascular Disease:691-699

20. ●
●
pre-existing DM
preexisting
posterior uveitis

21. ●
Changes in hemodynamics
increased level of various growth factors and
hormones
●
DR may start/ progress during pregnancy
●
Who will be attacked?  Risk factors
●

22. DM duration
<15 yrs
DR
Progression
18%
> 15 yrs
39%
Chew EY, Mills JL, Metzger BE, et al. Metabolic control and progression of retinopathy. The Diabetes in Early Pregnancy Study.
DiabetesCare 1995; 18:631—637.

23. ●
The Diabetes in Early Pregnancy Study (DIEP)
–
Prospective cohort
–
140 pregnant diabetic women
–
Retinopathy was most likely to progress in
●
Poorest control at baseline
●
largest improvement during early pregnancy
Chew EY, Mills JL, Metzger BE, et al. Metabolic control and progression of retinopathy. The Diabetes in Early Pregnancy Study.
DiabetesCare 1995; 18:631—637.

24. Baseline DR
progression
No DR
10.3%
Progression to
PDR
-
Only
microaneurysms
Mild NPDR
21.1%
-
18.8%
6.3%
Moderate NPDR
54.8%
29%
Chew EY, Mills JL, Metzger BE, et al. Metabolic control and progression of retinopathy. The Diabetes in Early Pregnancy Study.
DiabetesCare 1995; 18:631—637.

25. ●
●
additionally hazardous during pregnancy
In at least one major study,
●
all patients with severe PDR
●
●
also had proteinuria indicating a generalized vasculopathy
DR in patients with eclampsia/preeclampsia is more likely to
progress
Phelps RL et al Changes in diabetic retinopathy during pregnancy. Correlations with regulation of hyperglycemia. Arch Ophthalmol 1984;
104:1806–1810

26. ●
rapid normalization of sugar level
●
●
●
 hypoglycemia
retinal hypoxia and
 new CWS and intra retinal microvascular
abnormalities
Chew EY, Mills JL, Metzger BE, et al. Metabolic control and progression of retinopathy. The Diabetes in Early Pregnancy Study.
DiabetesCare 1995; 18:631—637.

27. Risk factors for the DR progression
●
–
Duration of DM 1
Poor metabolic control
–
Baseline severity of DR
–
HT, PIH and preeclampsia 2,3
–
Rapid normalization of glucose levels during pregnancy 1
–
1.
2.
●
1. Chew EY, Mills JL, Metzger BE, et al. Metabolic control and progression of retinopathy. The Diabetes in Early Pregnancy
Study. DiabetesCare 1995; 18:631—637.
2. Rosenn B, Miodovnik M, Kranias G, et al. Progression of diabetic retinopathy in pregnancy: association with hypertension in
pregnancy. Am J Obstet Gynecol 1992; 166:1214—1218.
8. Loukovaara S, Harju M, Kaaja R, Immonen I. Retinal capillary blood flow in diabetic and nondiabetic women during
pregnancy and postpartum period. Invest Ophthalmol Vis Sci 2003; 44:1486—1491.

28. I know it
●
●
●
early education and good
counselling of diabetic
women in childbearing age
good glucose control
Treat diabetic retinopathy
prior to conception

29. ●
●
DR that progress during pregnancy commonly
regress after delivery
But somes with rapid progression or high-risk PDR
will progress
●
Can cause VH/ TRD/ NVG/ blindness
●
Should be treated
Chan WC, Lim LT, Quinn MJ, et al. Management and outcome of sightthreatening diabetic retinopathy in pregnancy. Eye 2004; 18:826—
832.

31. ●
non-infectious uveitis
●
●
●
May flare-up in disease activity within the 1st trimester
And then slow down later
Rebound within 6 months of delivery.
Peter K Rabiah,Albert T Vitale. Noninfectious uveitis and pregnancy. American Journal of Ophthalmology 2003; 136:91-98

32. ●
Most common
●
●
VKH and Behcet disease
Most flare-ups were
effectively treated with
observation/corticosteroids
Peter K Rabiah,Albert T Vitale. Noninfectious uveitis and pregnancy. American Journal of Ophthalmology 2003; 136:91-98

33. Central serous chorioretinopathy (CSCR)
 Valsava retinopathy
 Purtscher’s retinopathy
 Preeclampsia/ eclampsia associated retinopathy
◦ (HT retinopathy)

●
●
pre-existing DM
preexisting posterior uveitis

34. We need healthy
moms to take care of
these guys!