How to manage retinal disease in pregnant patients
In patients with diabetic retinopathy, the rate at which retinopathy progresses doubles in pregnant patients compared with those who are not pregnant. Dr. Johnson explained that after adjusting for hemoglobin A1C values, pregnancy itself is associated with retinopathy progression.
In the Diabetes in Early Pregnancy Study, the investigators found that in 55% of patients with moderate, non-proliferative diabetic retinopathy (NPDR) at baseline, there was two-step Early Treatment Diabetic Retinopathy progression and 29% progressed to PDR.
The Diabetes Control and Complications Trial also reported that retinopathy in type 1 diabetes progresses faster during pregnancy and further found that the long-term risk of progression of early retinopathy was not increased by pregnancy.
When managing patients with diabetes, Dr. Johnson suggested following the American Academy of Ophthalmology Preferred Practice Patterns. They involve maximization of glycemic control before conception and examination during the first trimester with follow-up determined based on the severity of the retinopathy.
Patients with no retinopathy or with mild-to-moderate NPDR should be examined every three to six months, and those with severe NPDR or worse every one to three months. Surveillance should continue during the first year postpartum.
Patients who develop gestational diabetes do not require an eye examination during pregnancy. Drs. Johnson and Rosenthal recommended that for patients with PDR, panretinal photocoagulation should be performed at diagnosis and anti-vascular endothelial growth factor (VEGF) therapy should be avoided.
Patients with mild diabetic macular edema can be observed as the disease might resolve after delivery. If treatment is needed, focal laser or intravitreal triamcinolone can be considered, but anti-VEGF treatments should be avoided.