Alterações oftalmológicas na gravidez

Marcos-Figueiredo, Pedro; Marcos-Figueiredo, Ana; Menéres, Pedro; Braga, Jorge

doi:10.1055/s-0037-1605366

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Review Article • Rev. Bras. Ginecol. Obstet. 40 (01) • Jan 2018 • https://doi.org/10.1055/s-0037-1605366 copiar

Alterações oftalmológicas na gravidez

Autoria SCIMAGO INSTITUTIONS RANKINGS

Resumo

A gravidez é necessária à perpetuação da espécie humana, levando a adaptações fisiológicas dos diversos órgãos e sistemas maternos. O olho, apesar de uma cavidade fechada, sofre também algumas modificações, a maioria relativamente inócuas, que pontualmente poderão se tornar patológicas. A gravidez assume-se como um período particular de suscetibilidade para a mulher; no entanto, muitos obstetras têm conhecimento limitado sobre as alterações oftalmológicas na gravidez. Por conseguinte, impõe-se o seu estudo, bem como a elaboração de diretrizes para lidar com essas mudanças. De igual importância são o conhecimento da eventual terapêutica para problemas oftalmológicos neste período e a avaliação do tipo do parto em condições particulares. Desta forma, foi efetuada uma revisão bibliográfica extensa e apresentada uma síntese do tema.

Palvras-chave:
gravidez; oftalmologia; medicação ocular; fisiologia ocular; patologia ocular

Physiological changes
	Physiology	Considerations	Trimester (+)	Prognosis
Eyebrows/ Chloasma	5–70%, increased pigmentation (malar region/eyebrows)		Third	Reversible
Tear Film	Modified ↓	Dry eye syndrome	Third	Reversible
Pupil	↑ Photopic and mesopic diameter		Third	Reversible
Cornea	↓ Sensitivity, ↑ thickness (minimal), ↑ curvature	Contact lens intolerance	Second/Third	Reversible
Lens	Transient loss of accommodation		All	Reversible
Iris	3%, Krukenberg spindle(pigment deposit on the posterior cornea)		First/Second	Reversible
Intraocular Pressure	↓ Intraocular pressure		Third	Reversible
Choroid	↑Choroidal thickness	Exception of preeclampsia;macula unchanged	First	Reversible
Visual field	Minimal changes	Asymptomatic	Third	Reversible
Hemeralopia	Difficulty to see in bright light		Third	Reversible
Hyposphagma	10%, conjunctival hemorrhage	Monitoring of blood pressure	Postpartum	Reversible

Ocular symptoms¹1 Gouveia EB, Conceição PS, Morales MS. [Ocular changes during pregnancy]. Arq Bras Oftalmol 2009;72(02):268-274	Ocular signs¹1 Gouveia EB, Conceição PS, Morales MS. [Ocular changes during pregnancy]. Arq Bras Oftalmol 2009;72(02):268-274
Blurred vision	Retinal arteriolar abnormalities
Decreased vision	Serous retinal detachment (1% in cases of preeclampsia, 10% in cases of eclampsia, without fetal detrimental effect)⁴4 Chawla S, Chaudhary T, Aggarwal S, Maiti GD, Jaiswal K, Yadav J. Ophthalmic considerations in pregnancy. Med J Armed Forces India 2013;69(03):278-284
Flashes	Ischemic optic neuropathy
Floaters	Hypertensive retinopathy (if severe)
Scotomas
Visual field defects
Diplopia
Blindness (loss of vision with normal pupillary function and ophthalmoscopic examination) is rare; it occurs in up to 15% of the cases of preeclampsia/eclampsia, by involvement of the occipital cortex.
↓
Constitute severity criteriaMay represent features of imminent seizures in cases of preeclampsia, particularly postpartum.¹1 Gouveia EB, Conceição PS, Morales MS. [Ocular changes during pregnancy]. Arq Bras Oftalmol 2009;72(02):268-274 ⁴4 Chawla S, Chaudhary T, Aggarwal S, Maiti GD, Jaiswal K, Yadav J. Ophthalmic considerations in pregnancy. Med J Armed Forces India 2013;69(03):278-284
Obstetrical assessment is imposed ⇒ excluding preeclampsia ⇒ ophthalmological observation.
Prognosis ⇒ generally good (although scotomas may persist for months).
May occur only in the postpartum period, with resolution of the detachments occurring sometimes in this period.³3 Mackensen F, Paulus WE, Max R, Ness T. Ocular changes during pregnancy. Dtsch Arztebl Int 2014;111(33-34):567-575, quiz 576

Preconception – ideal
Early patient education is fundamental.
Pregnancies in the third decade (risk ↑ exponentially with maternal age).⁴4 Chawla S, Chaudhary T, Aggarwal S, Maiti GD, Jaiswal K, Yadav J. Ophthalmic considerations in pregnancy. Med J Armed Forces India 2013;69(03):278-284
Stable glucose values and treatment.⁴4 Chawla S, Chaudhary T, Aggarwal S, Maiti GD, Jaiswal K, Yadav J. Ophthalmic considerations in pregnancy. Med J Armed Forces India 2013;69(03):278-284
Severe diabetic retinopathy - risk progression ↑ – delay conception until stabilization of ocular disease.²2 Samra KA. The eye and visual system in pregnancy, what to expect? An in-depth review. Oman J Ophthalmol 2013;6(02): 87-91
Treatment
Referral to an ophthalmologist is mandatory.
The treatment is the same as the one offered to non-pregnant women (except for the expectant approach, which can be weighed until postpartum).²2 Samra KA. The eye and visual system in pregnancy, what to expect? An in-depth review. Oman J Ophthalmol 2013;6(02): 87-91
Varies with disease severity at conception.⁴4 Chawla S, Chaudhary T, Aggarwal S, Maiti GD, Jaiswal K, Yadav J. Ophthalmic considerations in pregnancy. Med J Armed Forces India 2013;69(03):278-284
Some guidelines (without large amounts of evidence, especially in developed countries).²⁴24 Morrison JL, Hodgson LA, Lim LL, Al-Qureshi S. Diabetic retinopathy in pregnancy: a review. Clin Experiment Ophthalmol 2016; 44(04):321-334
Laser or vitrectomy if needed (except in cases of macular edema).³3 Mackensen F, Paulus WE, Max R, Ness T. Ocular changes during pregnancy. Dtsch Arztebl Int 2014;111(33-34):567-575, quiz 576

Pathological changes
	Pathology	Considerations	Trimester (+)	Prognosis
Pregnancy-induced hypertension
	40 to 100%variable retinopathy	↓ than half symptomaticretinal changes related to the severity of hypertension	All	Generally good
	Vasospasm(50–100% preeclampsia)	Positive correlation (degree of retinopathy, severity of preeclampsia, maternal blood pressure and fetal mortality)	All	Reversible, scotomas may persist for monthsRelated to the ocular fundus
Punctate inner choroidopathy
	Possible development of choroidal neovascular membranes during pregnancy		First	Reversible
Central serous retinopathy
	Spontaneous and localized serous detachment of the sensorineural retina in the macula	Affects 0.008% ofpregnant women(90% of the female population affected)	Third	Reversible↑ the probability of recurrence outsidepregnancy/subsequent gestation
Occlusive vascular diseases
→ Purtscher-like retinopathy	Cotton wool spots and retinal hemorrhage		Labor/Postpartum	Reversible
→ Disseminated intravascularcoagulation	Thrombus dissemination (choroid involved)Serous detachment		First/ Third	Mostly reversibleEpithelial alterations may persist
→ Thrombotic thrombocytopenicpurpura	10% with retinal vascular occlusion, retinal hemorrhage, serous detachment, optic disc neovascularization	Similar to Purtscher-like retinopathy (if the optic nerve vessels are involved)	Third/ Postpartum	Reversible
→ Amniotic fluid embolism	Retinal occlusions may occur	Central retinal artery may be involved	Labor/ Delivery/ Immediate postpartum	Little attention(80% mortality rate)
Diabetic retinopathy
	Type 1 diabetes mellitus more associated with proliferative retinopathy	Pregnancy (major and independent risk factor for the progression)Gestational diabetes without association	First/ Second	Reversible
Uveitis
	Not well-established	Fewer recurrences	All/ Postpartum	Reversible
	Not well-established	Possible exacerbations	First/Postpartum	Reversible
Antiphospholipid syndrome
	Susceptible to arterial/venous thrombosis	May include vascular thrombosis of the retina, choroid, optic nerve as well as oculomotor nerves	All	Reversible
Ptosis
	Different from oculomotor paralysis	Ptosis, often unilateral, presents or worsens during pregnancy	All	Reversible
	Horner syndrome (may occur after epidural analgesia)
	Transient facial paralysis (↑ 3x)
Hyperemesis gravidarum
	Nystagmus and extraocular muscle paralysis	If severe, it may lead to Wernicke encephalopathy	First	Reversible(with vitamin supplements)
Optic neuropathy
	Generally ischemic	Severe antepartum/ postpartum hemorrhage may cause posterior ischemic optic neuropathy	Third/ Postpartum	Reversible
	↑ Incidence of anterior ischemic optic neuropathy		Third/ Postpartum	Reversible
Intraocular tumors
→ Pituitary adenoma	Visual changes, bitemporal field defects, diplopia	Surveillance is usually sufficient	All	Reversible
→ Uveal melanoma	Asymptomatic/paracentral scotoma/blurred visual acuity	Etiology and growth uncertain	All	_
→ Choroidal osteoma	Frequently asymptomatic	Etiology of exacerbation unknown	All	Reversible
→ Meningioma	Proptosis/disc edema	If preexisting, it may manifest	Second half	_
Other diseases
→ Graves' disease	Vertical diplopia, proptosis, eyelid retraction, chemosis, periorbital edema	Associated thyroid ophthalmopathy	First/ Second/Postpartum	Reversible
→ Posterior scleritis	Visual loss, serous retinal detachment, choroidal folds, subretinal mass		All	Reversible
→ Immunological diseases	Improvement in ocular and systemic manifestations	↑ endogenous corticosteroids in pregnancy	Recurrence postpartum (occasionally)	Reversible

Sympathomimetic drugs (brimonidine, clonidine, dipivefrin)
Local use may have systemic effects.³3 Mackensen F, Paulus WE, Max R, Ness T. Ocular changes during pregnancy. Dtsch Arztebl Int 2014;111(33-34):567-575, quiz 576
Acetazolamide
It was associated with neonatal acidosis.
Levels can be monitored during pregnancy and puerperium (very low) – suggesting safe use.³3 Mackensen F, Paulus WE, Max R, Ness T. Ocular changes during pregnancy. Dtsch Arztebl Int 2014;111(33-34):567-575, quiz 576 ³²32 Chung CY, Kwok AK, Chung KL. Use of ophthalmic medications during pregnancy. Hong Kong Med J 2004;10(03):191-195 ³⁶36 Lee AG, Pless M, Falardeau J, Capozzoli T,Wall M, Kardon RH. The use of acetazolamide in idiopathic intracranial hypertensionduring pregnancy. Am J Ophthalmol 2005;139(05):855-859
Reserved for lack of alternatives.³3 Mackensen F, Paulus WE, Max R, Ness T. Ocular changes during pregnancy. Dtsch Arztebl Int 2014;111(33-34):567-575, quiz 576
Prostaglandins
Should be used sensibly (they may increase uterine smooth muscle tone and decrease fetal perfusion). Locally, their concentration is low, and they are rapidly catabolized (cases of toxicity with ocular administration have not been reported).
Pilocarpine
Less studied (with effects in high doses in animals).
Reduced benefit does not justify use during pregnancy.
It should be replaced by a medical/surgical alternative.³3 Mackensen F, Paulus WE, Max R, Ness T. Ocular changes during pregnancy. Dtsch Arztebl Int 2014;111(33-34):567-575, quiz 576

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[1] Address for correspondence Pedro Figueiredo, MD, Hospital Senhora da Oliveira (HSO), Rua dos Cutileiros, Creixomil 4835-044, Guimarães, Portugal (e-mail: pedrofigueiredoficial@gmail.com).