How to manage retinal disease in pregnant patients
Take-home: Pregnant patients require special care and surveillance when retinal diseases are present.
Advancing pregnancy induces obvious physical changes for women over time. However, numerous not-so-obvious physiologic, hormonal, and metabolic changes also occur during pregnancy that ophthalmologists should make themselves aware.
Some of these changes include: increased serum cortisol, increases in blood pressure during the third trimester, increased blood volume, insulin resistance with worsening glycemic control, and hypercoagulability.
Considering these complications, pregnancy might induce certain retinal and choroidal diseases, such as hypertensive retinopathy and choroidopathy, exudative retinal detachment, and retinal vascular occlusive diseases, as well as exacerbate other diseases, according to Mark Johnson, MD, and Julie M. Rosenthal, MD.
Induced retinal/choroidal diseases
Hypertensive retinopathies and choroidopathies that might develop are the pregnancy-induced hypertension (PIH) syndromes of preeclampsia and eclampsia. The former includes hypertension, peripheral edema, and proteinuria, and the latter is defined as pre-eclampsia plus seizures.
The fundus findings associated with the PIH syndromes that ophthalmologists should be alerted are arteriolar constriction, retinal hemorrhages, cotton-wool spots, retinal edema, and lipid exudates; the presence of subretinal fluid (choriocapillaris infarction); and optic disc edema and/or ischemia.
Dr. Johnson, professor of ophthalmology and visual science, University of Michigan Kellogg Eye Center, Ann Arbor, recounted the case of a 41-year-old woman who presented with a three-day history of blurred vision, back pain, and hypertension late in the third trimester. Her visual acuity levels were 20/100 and 20/400 in the right and left eyes, respectively. After the patient underwent a C-section, the visual acuity levels and the fundus findings returned to normal.
Exudative retinal detachment
In pregnant patients who develop an exudative retinal detachment, physicians should consider the presence of the HELLP syndrome [Hemolysis, Elevated Liver enzymes, Low Platelets], which is a life-threatening liver disorder.
“The HELLP syndrome occurs in up to 15% of women with pre-eclampsia and is associated with infant mortality in as high as 25% of cases,” noted Dr. Rosenthal, clinical instructor, ophthalmology and visual Sciences, University of Michigan Kellogg Eye Center.
In patients with HELLP syndrome, exudative retinal detachments can develop bilaterally along with yellow-white subretinal deposits, and vitreous hemorrhages. The only treatment is immediate delivery of the infant after the pregnant woman is stabilized.
Other disorders in pregnancy with which exudative retinal detachments can be associated are disseminated intravascular coagulation and thrombotic thrombocytopenic purpura.