OcuLearning › Systemic

Pregnancy

ROUTINE — Systemic

Symptoms

  • headaches and blurred vision
  • photopsias (flashes) and scotomas (blind spots)
  • diplopia (double vision)
  • dry eye symptoms: grittiness and irritation

Clinical Findings

Physiologic & reversible

  • refractive shift: transient myopic shift (0.5–1.5 D); resolves ~6 weeks postpartum
  • cornea: decreased sensitivity and increased thickness (affects contact lens fit)
  • intraocular pressure: typically decreases by ~10%
  • chloasma: periocular skin pigmentation (melasma)

Preeclampsia & eclampsia

  • hypertensive retinopathy: focal arteriolar narrowing, hemorrhages, and cotton-wool spots
  • serous retinal detachments: bilateral and bullous; occurs in ~10% of eclamptic patients
  • cortical blindness (pres): "brisk pupils without rapd"; suggests occipital lobe edema

Disease exacerbation

  • diabetic retinopathy (dr): rapid progression, especially if severe before conception
  • central serous chorioretinopathy (cscr): triggered by third-trimester steroid surge
  • tumors: pituitary adenomas and meningiomas may enlarge due to hormonal stimulation

Etiology

Systemic changes

  • hormonal fluctuations: drive corneal changes and tumor growth
  • hypercoagulability: peaks 6 weeks postpartum; increases risk of vein/artery occlusions
  • hypertensive spectrum: preeclampsia/eclampsia after 20 weeks gestation

Pituitary events

  • sheehan syndrome: pituitary infarct following severe obstetric hemorrhage
  • lymphocytic hypophysitis: autoimmune pituitary inflammation

Red Flags

  • vision symptoms + high bp (≥140/90): maternal emergency; suspect preeclampsia
  • cortical blindness: pupils respond but patient cannot see; suspect eclampsia/pres
  • diabetic retinopathy: severe npdr/pdr requires monthly to trimonthly screening
  • brimonidine use: strictly contraindicated (neonatal apnea/death risk)

Investigations

Routine screening

  • blood pressure and urinalysis (proteinuria) at every eye visit for pregnant patients
  • dilated fundus exam: each trimester for pre-existing diabetics

Imaging safety

  • mri brain/orbits: safe without contrast (gadolinium is category c)
  • fa/icg angiography: category c; defer unless essential for vision-threatening disease
  • oct: safe and essential for monitoring cme or cscr

Treatment

Preeclampsia/eclampsia

  • blood pressure control and seizure prophylaxis (magnesium sulfate)
  • definitive treatment is delivery of the fetus

Diabetic retinal disease

  • panretinal photocoagulation (prp) is preferred over anti-vegf during pregnancy

Glaucoma

  • punctal occlusion with all drops; beta-blockers are generally safest
  • avoid brimonidine; use prostaglandins/cais only if benefits outweigh risks

Clinical Pearl

pregnancy accelerates diabetic retinopathy — screen every trimester, and counsel patients that stable dr before conception is the best predictor of an uneventful pregnancy for the eyes.

Differential Diagnosis

  • • primary intracranial hypertension (pseudotumor cerebri)
  • • optic neuritis
  • • migrainous aura
  • • pituitary apoplexy

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