Download Optometry and The Pregnant Patient

Optometry and the Pregnant Patient
Marc B. Taub OD, FAAO
Mary Bartuccio OD, FAAO
A. Systemic Changes in the Pregnant Women
a. Hormonal
i. The placenta
ii. Fetal adrenal
iii. Maternal endocrine glands
b. Cardiovascular
c. Metabolic
d. Hematologic
e. Immunologic
B. Ocular Changes in the Pregnant Women
a.
b.
c.
d.
e.
Intraocular Pressure
Cornea
Visual Fields
Dermatologic
Conjunctiva
C. Pre-existing Conditions
a. Diabetic Retinopathy
i. Findings
1. Similar findings and grading as with traditional , nonpregnant patients
2. Gestational diabetes has not been associated with the
development of retinopathy
ii. Risk Factors
1. Hypertension
2. Metabolic Control
3. Duration of Diabetes
4. Baseline Severity of Retinopathy
5. Retinal Blood Flow
iii. Treatment
1. Standard treatment as put forth in EDTRS except the time
table is “pushed up”
a. Minimal/no retinopathy-evaluation every 3 months
b. Moderate baseline retinopathy-fundoscopic
evaluations every 4-6 weeks,
i. If progression, evaluate every 2 weeks for
determination of high risk characteristics.
ii. If proliferation, photocoagulation should be
initiated on a limited basis.
iii. Best course of action is full treatment of
proliferative changes prior to conception.
iv. Macular Edema
1. Cystoid macular edema versus CSME.
2. May occur with or without retinopathy.
3. Regression post-partum may or may no occur.
a. Variable visual recovery.
b. Laser photocoagulation may cause exacerbation.
c. Salt-restriction and diuretics have had minimal
effect.
b. Pituitary Tumor-Prolactinoma
i. Findings
1. Most remain asymptomatic, but symptoms have been noted
as early as the first trimester.
2. Visual disturbances, headaches and diabetes insipidus are
common complaints.
3. Patients with macroadenomas tend to have a greater chance
of growth and development of symptoms.
ii. Evaluation
1. Microadenomas- assessed each trimester with confrontation
fields, with a red pin or if symptoms occur, Goldmann
(kinetic) perimetry.
2. Macroadenomas -visual acuity and Goldmann (kinetic)
perimetry performed every six weeks
3. With either type, if symptoms arise, an MRI must be
performed.
iii. Treatment
1. Must be initiated with evidence of tumor growth
2. Bromocriptine vs. Cabergline
3. Glucocorticoids
4. Transphenoidal surgery
c. Sarcoidosis
i. Findings
1. Clinical features of Sarcoidosis
a. Ocular Signs
b. Systemic Signs
2. Pregnancy may reduce signs and symptoms but,
exacerbation can occur postpartum.
3. Inactive cases do not become active during pregnancy.
ii. Patient Prognosis Factors
1. Poor patient prognosis factors
iii. Diagnostic Testing
1. Lab testing: positive ACE, PPD (rule out TB)
2. Radiological testing: Chest X-ray
3. Biopsy of any granulomas
iv. Treatment
1. Most follow a benign course
2. Evaluation by a pulmonary specialist should occur prior to
conception.
3. Glucocorticoids
d. Toxoplasmosis
i. Findings
1. Clinical Findings:
a. Retinal findings- active vs. inactive.
2. Can be acquired congenitally via acute maternal infection
during pregnancy or by ingestion of infected meat.
ii. Transmission
1. The severity of congenital infection is highest if acquired
during the first trimester.
2. The frequency of transmission is greatest during the third
trimester.
3. Reactivation of the disease during pregnancy does not lead
to fetal transmission.
iii. Diagnostic Testing
1. Lab tests: Serum anti-toxoplasma antibody titer
iv. Treatment
1. Spiramycin vs. Pyrimethamine
e. Graves’ Disease
i. Findings
1. Clinical findings:
a. Ocular
b. Systemic
2. Tends to remit late in pregnancy with relapse postpartum.
3. Preterm delivery, perinatal mortality and maternal heart
failure are more common.
ii. Diagnostic Testing
1. Lab tests: Thyroid function (T3, T4, TSH)
2. Radiological testing: CT scan of orbital area.
3. Visual Field
4. Forced Duction Testing
iii. Treatment
1. Mild cases may be monitored but moderate to severe cases
require action
2. Anti-thyroid med.ications
D. Pregnancy-Induced Conditions
a. Central Serous Choroiretinopathy (CSCR)
i. Epidemiology
ii. Signs/Symptoms
1. Recurrence in successive pregnancies.
2. Resolution with macular mottling and RPE clumping.
iii. Diagnostic Testing
1. OCT vs. FA
iv. Treatment
1. Supportive vs. focal laser photocoagulation
b. Pseudotumor Cerebri
i. Epidemiology
ii. Signs/Symptoms
1. Clinical Findings:
a. Ocular
b. Systemic
2. Mostly developed in the first trimester, but occurs
throughout pregnancy.
3. Recurrence in successive pregnancies.
4. Pregnancy effects the visual outcome in some patients.
iii. Diagnostic Testing
1. Lab tests: Lumbar puncture and analysis
2. Radiological testing: MRI of the Brain
3. Visual field testing
iv. Treatment
1. Glucocorticoids vs. Lumbar puncture vs. Optic nerve
sheath decompression
c. Hypertensive Disorders
i. Classification
ii. Signs/Symptoms
1. Retinal Detachment
2. Blindness
d. Coagulation Disorders
i. Disseminated Intravascular Coagulopathy (DIC)
1. Description
2. Ocular findings
ii. Thrombotic Thrombocytopenic Purpura (TTP)
1. Description
2. Ocular findings
E. Medications and Pregnancy
a. Category Scale
 Description of FDA guidelines
i.
ii.
iii.
iv.
v.
Category A
Category B
Category C
Category D
Category X
b. Topical pharmaceuticals
 Indications, Contra-indications and Side Effects
ii. Glaucoma
iii. Anti-Viral
iv. Anti-Microbial
v.
vi.
vii.
viii.
Anti-Allergy
Steroid
NSAIDS
Diagnostics
1. Proparacaine
2. Tripicamide
3. Phenylephrine
4. NaFl
c. Ocular Pharmaceuticals
 Indications, Contra-indications and Side Effects
ii. Glaucoma
iii. Anti-Viral
iv. Anti-Microbial
v. Anti-Allergy
vi. Steroid
vii. Pain Management