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Gebelik ve Göz

Authors:
  • Shri Lal Bahadur Shastri Government Medical College and Hospital,Nerchowk,Distt. Mandi,Himachal Pradesh.

Abstract

Visual obscurations are common during pregnancy. The ocular effects of pregnancy may be physiological,pathological or may be modifications of pre-existing conditions. While most of the described changes are transient in nature, others extend beyond delivery and may lead to permanent visual impairment. Also, pregnancy can affect vision through systemic disease that are either specific to the pregnancy itself or systemic diseases that occur more frequently in relation to pregnancy. Neuro-ophthalmological disorders should be kept in mind in pregnant women presenting with visual acuity or field loss. Therefore, it is important to be aware of the ocular changes in pregnancy in order to counsel and advice women who currently are, or are planning to become pregnant.
Arşiv Kaynak Tarama Dergisi
Archives Medical Review Journal
Pregnancy and Eye
Gebelik ve Göz
Anubhav Chauhan
Department of Ophthalmology, Regional Hospital Hamirpur, Himachal Pradesh, India
ABSTRACT
Visual obscurations are common during pregnancy. The ocular effects of pregnancy may be
physiological, pathological or may be modifications of pre-existing conditions. While most of the
described changes are transient in nature, others extend beyond delivery and may lead to permanent
visual impairment. Also, pregnancy can affect vision through systemic disease that are either specific
to the pregnancy itself or systemic diseases that occur more frequently in relation to pregnancy.
Neuro-ophthalmological disorders should be kept in mind in pregnant women presenting with visual
acuity or field loss. Therefore, it is important to be aware of the ocular changes in pregnancy in order to
counsel and advice women who currently are, or are planning to become pregnant.
Key words:
Ocular, pregnancy, blindness.
ÖZET
Göz kararmaları gebelikte yaygın olarak görülür. Gebeliğin göze etkileri fizyolojik, patolojik ya da
önceden var olmuş modifikasyonlar olabilir. Tanımlanan değişikliklerin çoğu doğal olarak ortaya
çıkarken genelde geçicidir fakat diğerleri doğumdan sonrasına aktarılarak kalıcı görme bozukluğuna
neden olabilir. Ayrıca gebelik ya da gebeliğin kendine özgü sistemik hastalıklar veya gebelik ile ilişkili
daha sık meydana gelen sistemik hastalıklar aracılığıyla görüşü etkileyebilir. Nöro-oftalmolojik
bozukluklar gebe kadınlarda görsel netlik ya da görsel alan kaybı ile başvurduklarında akılda
bulundurulmalıdır. Bu bağlamda gebelik planlaması yapan kadınlara danışma ve tavsiye verme için
gebelikteki oküler değişikliklerinin farkında olmak çok büyük önem arz etmektedir.
Anahtar kelimeler:
Oküler, gebelik, körlük.
Arşiv Kaynak Tarama Dergisi . Archives Medical Review Journal 2016; 25(1):1-13
doi:10.17827/aktd.80328
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Pregnancy and Eye
Introduction
Pregnancy implies progressive anatomical and physiological changes that are not only
confined to the reproductive organs, but also to all the systems of the body1. Pregnancy results
in a lot of hormonal changes in the body and the eyes are of no exception2. In general, the
ocular effect of pregnancy can be divided in to physiologic and pathologic changes 3 . Most of
the physiologic changes that occur as a result of pregnancy are usually marked in the third
trimester. This is because at this period, hormonal activity is at its peak. However, these
changes are transient because several weeks at postpartum, all hormonal activities return to
their pre-pregnant state4.
The aim of this study is to give an overview on the changes that can affect the ocular health
and vision of a pregnant woman and keep the ophthalmologist/physician aware of the
physiologic changes of pregnancy, the effect of pregnancy on pre-existing ocular disease and
the ocular manifestations of systemic diseases in pregnant women. The physiological changes
in eyes include the following systems.
Oculo-Cutaneous
Chloasma which is also known as mask of pregnancy is a hormonal mediated process,
characterized by increased pigmentation around the eyes and cheeks. The pigmentation
changes tend to fade slowly postpartum5. It is caused by increased pigmentation related to
increased estrogen and progesterone6. It is postulated that hormonal variations of pregnancy
increase melanin as a result of an increase in both melanogenesis and melanocytosis3.
Ptosis (drooping of the eyelids) has been reported during and after normal pregnancy and is
thought to be related to fluid retention and hormonal changes. It requires no treatment.
Ocular motility defects can present for the first time during pregnancy6.
Cornea
Corneal sensitivity has been found to decrease in the later part of pregnancy. Krukenberg
spindles on the cornea have been observed early in pregnancy and they tend to decrease in
size during the third trimester and postpartum. The mechanism presumably is related to
hormonal changes such as low progesterone levels, however, by the third trimester, an
increase in progesterone and aqueous outflow often result in decreased or absence of
Krukenberg spindles 5. The loss of corneal sensitivity during pregnancy cannot account for the
difficulty encountered by some women in wearing their contact lenses. It is more likely to be
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due to a variation in corneal topography as a result of oedema7. Park et al. showed that there
was a statistically significant increase in corneal curvature during the second and third
trimesters which resolved completely after delivery or after the cessation of breast feeding3.
Pre-existing conditions, such as keratoconus may progress during pregnancy8. Only a few
cases of iatrogenic keratectasia and keratoconus occurring during pregnancy have been
reported. There is growing evidence that the massive estrogen increase in late pregnancy
increases the risk of keratectasia in predisposed individuals9. In the literature, four cases of
keratoconus progression were reported as developing during pregnancy without any
accompanying factors. Various studies have demonstrated elevated levels of collagenolytic
and gelatinolytic activities in keratoconic corneas. Matrix metalloproteinase (MMP) levels are
increased, whereas tissue inhibitors of MMPs (TIMPs) are decreased in the keratoconic corneas
as well as during pregnancy too10. Several clinical observations suggest that thyroid gland
dysfunction is associated with keratoconus pathophysiology11. Corrective procedures such as
laser refractive surgery are contraindicated during this time5.
Contact lens intolerance:
The sensitivity of the pregnant mother’s cornea decreases
significantly which may cause problems for contact lens wearers who may traumatize their
corneas more than usual12.
Change in refraction:
The tendency of fluid retention affects your refraction. It is usually a
temporary change and you need not get your eyes re-tested during the later stages of
pregnancy and for at least the first 6 weeks after child birth12. Pregnant women usually have
about twofold increase in secretion of aldosterone. This, along with the actions of estrogens,
causes a tendency to reabsorb excess sodium from the renal tubules and to retain fluid. Also,
the bone marrow becomes increasingly active and produces extra red blood cells to go with
the excess fluid volume. Fluid retention can cause the curvature of the cornea to become
steeper, causing light rays from objects to become focused in front of the retina, as it happens
in myopia4.
Cornea-Conjuctiva
Dry eyes:
Some women experience dry eyes during pregnancy. This is usually temporary and
goes away after delivery12. This may occur as a result of the direct disruption of lacrimal acinar
cells through pregnancy enhanced immune-reactivity of prolactin, transforming growth factor
beta 1, and epidermal growth factor in ductal cells3. In one study, a decrease in tear
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production occurred during the third trimester of pregnancy in approximately 80% of
pregnant women6.
Conjunctival blood vessels:
Changes in conjunctival blood vessels have been described
toward the end of pregnancy. These changes include a granularity of conjunctival venules,
mild spasm of conjunctival arterioles, and decreased visualization of conjunctival capillaries.
Excessive vomiting during pregnancy can cause conjunctival petechiae12.
Glaucoma
Intra-ocular pressure:
The normal intra-ocular (IOP) pressure may decrease slightly and may
persist for several months postpartum. This could be advantageous to patients suffering from
glaucoma12. The reduced IOP is likely due to an increase in the facility of outflow via one of
several possible mechanisms, including increased uveo-scleral outflow due to hormonal
changes, decreased episcleral venous pressure and decreased pressure in the upper
extremities5. Estrogen causes dilatation of the vessels of the circulatory system leading to
decreased arterial pressure and thus a reduction in aqueous humor production2. Progesterone
has glucocorticoid antagonistic properties and this antagonistic action helps in the lowering of
the IOP1.
Visual field (VF) changes:
The classical field change is a bitemporal hemianopsia. However,
visual field changes varying from slight temporal or concentric contraction to complete
homonymous hemianopsia have been reported. Proposed mechanisms are equally diverse
and include changes to the pituitary gland that may affect the optic chiasm. These
asymptomatic visual field changes were shown to be completely reversible postpartum5. Akar
et al. found that the visual field mean threshold sensitivity increased significantly in the third
trimester3.
Crystalline Lens and Uvea
Lens:
The curvature of the crystalline lens can increase, causing a myopic shift in refraction6.
Pizzarell reported a worsening of myopia with pregnancy4 .
Accomodation:
Transient loss of accommodation has been seen during and after pregnancy.
Accommodative insufficiency and paralysis have been documented in association with
lactation5.
Uveitis:
The immunosuppressive effects and high steroid levels present in pregnant women
may cause improvement of uveitis during pregnancy but there is a risk of exacerbation
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postpartum5. The development of anterior uveitis associated with ankylosing spondylitis can
be more common in the early postpartum period. Postpartum endogenous candidal
endophthalmitis, presumed to be related to intravascular dissemination around the time of
delivery, has been reported6. In some cases, patients with Vogt-Koyanagi-Harada (VKH)
disease became pregnant and their ophthalmic findings improved during pregnancy in spite
of tapering of systemic corticosteroids13.
Pathological effects of pregnancy on eyes and diseases modified by pregnancy are as follows :
Oculo-Vascular Changes
Diabetes mellitus:
This is the most common ocular condition modified by pregnancy6.
Gestational diabetes poses a very low risk for the development of retinopathy. In patients who
had nonproliferative diabetic retinopathy (DR), studies demonstrated that as many as 50% of
them may show an increase in their nonproliferative retinopathy. Approximately 5-20 % of
these patients develop proliferative changes. An ophthalmologic examination at least once
every trimester is recommended. Studies on patients with proliferative diabetic retinopathy
have shown that a progression of disease may occur in as many as 45% of them. In patients
with proliferatve diabetic retinopathy, monthly ophthalmic examinations are warranted.
Proliferative diabetic retinopathy may regress at the end of the third trimester or postpartum.
Patients with proliferative diabetic retinopathy, cesarean section should be considered to
prevent vitreous hemorrhage due to Valsalva maneuver used during labor. Diabetic macular
edema may develop or worsen during pregnancy12.
Factors that have been shown to influence the progression of DR in pregnancy include, the
pregnant state itself, duration of diabetes, degree of retinopathy at time of conception,
metabolic control of diabetes, and the presence of coexisting hypertension. The exact
pathogenesis for the progression of DR during pregnancy remains controversial2. Some studies
demonstrated a decrease in retinal venous diameter and volumetric blood flow in diabetic
patients during pregnancy and hypothesized that this may exacerbate retinal ischemia and
hypoxia3. Chen et al. measured volumetric blood flow in the major retinal veins during
pregnancy in diabetic women, found a connection between progression of retinopathy and
increased volumetric total blood flow in a retinal quadrant14.
Occlusive vascular disorders:
It is well appreciated that pregnancy represents a
hypercoagulable state in which both clotting factors and clotting activity are increased. Both
branch and central retinal artery occlusions have been reported to occur in pregnancy12.
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Gonzalvo et al. reported a case of central retinal vein occlusion associated with pre-eclampsia
and HELLP (haemolysis, elevated liver enzymes and low platelets) syndrome, a thrombotic
microangiopathic vasculopathy following caesarean section15.
Pregnancy induced hypertension (pre-eclampsia)/eclampsia:
Von Graefe first described
retinal changes in pre-eclamptic women in 185515. Ocular involvement reported in these
patients includes conjunctival vascular anomalies, hypertensive retinopathy, exudative retinal
detachment, vitreous and preretinal haemorrhage, ischaemic optic neuropathy and
hypertensive choriodopathy. Out of the visual symptoms blurred vision is most common16.
Patients may present with symptoms of headache and visual disturbances in the form of
scotoma. Visual disturbances develop in perhaps 25% of women with severe pre eclampsia17.
The development of complete blindness is rare and seen in only 1%-3% of cases18. Rasdi et al
from Malaysia studied a group of patients with hypertensive disorders of pregnancy. The
retinal changes were seen in 21.5% of preeclampsia/eclampsia. The most common
abnormality seen in the fundus is narrowing of retinal arterioles. In a study, Reddy from India
has reported retinal changes in 53.4% preeclampsia19. The mechanism of such changes
remain unknown, but is believed to be a result of a combination of factors, including pre-
existing vascular disease, hormonal changes, endothelial damage, alterations in cerebral
autoregulation and hypoperfusion-induced ischaemia 15. Pre-eclampsia is associated with
choroidal ischaemia and increased microvascular permeability, a combination that is likely to
increase the fragility of new choroidal vessels. The Valsalva manoeuvre during labour might
also provoke choroidal haemorrhage20.
In eclampsia, retinal changes are likely to occur when diastolic blood pressure ( BP) is more
than 100 mm of Hg and systolic BP is above 150 mm of mercury5. Reversible cortical blindness
and extraocular muscle palsy, though rare, have been well documented in the eclamptic
patients16. The three most common visual complications of preeclampsia and eclampsia are
hypertensive retinopathy, exudative retinal detachment and cortical blindness21.
Disseminated intravascular coagulation (DIC) can occur with severe pre-eclampsia. The
choroidal involvement causes a serous retinal detachment, which resolves with the resolution
of DIC5.Placental thromboplastin may release into maternal circulation and activate the
extrinsic coagulation system with resultant DIC22.
Exudative retinal detachment occurs in 1% of pre-eclamptic patients and up to 10 % of
eclamptic patients. It is thought to be caused by choroidal ischemia5. The majority of patients
who manifest serous detachment during pregnancy have, with clinical management,
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complete recovery within weeks after delivery, and there is no need for any surgical
intervention23.
HELLP syndrome:
Approximately 10 % of women with severe pre-eclampsia develop the
HELLP syndrome. Ocular findings include bilateral serous retinal detachment with
yellow/white sub-retinal opacities and sometimes vitreous hemorrhage5.
Cortical blindness:
Cortical blindness refers to reduced vision from bilateral damage to any
portion of the visual pathways posterior to the lateral geniculate nucleus 19. The most common
etiology is bilateral posterior cerebral artery infarction24. Cortical blindness is a clinical
syndrome characterized by intact pupillary reflexes and normal fundoscopic findings.
Neuroimaging findings in cortical blindness range from normal to typical findings such as
bilateral cortical occipital lesions with hypodensity on computerized tomography (CT) or
hyperdensity on T2-weighted magnetic resonance imaging ( MRI)21. Hinchey J et al between
1988 and 1994, found only three cases that had reversible cortical blindness following
eclampsia. Some other studies suggest vascular endothelial damage as the underlying
mechanism in this case of preeclampsia related transient cortical blindness25. Isolated cortical
blindness has been thought to occur in only 1% to 3% of pregnancies complicated by
preeclampsia-eclampsia26.
Thrombotic thrombocytopenic purpura (TTP):
It is rare but can develop in association with
pregnancy. Visual symptoms occur in approximately 10% of these women and are generally
related to serous retinal detachment, arteriolar constriction and optic disc oedema6.
Antiphospholipid syndrome (APS):
It is an autoimmune disorder characterized by either a
history of vascular thrombosis or pregnancy morbidity in association with the presence of
antiphospholipid antibodies. Conjuctival telangiectasia or conjuctival microaneurysms,
episcleritis, limbal or filamentary keratitis and iritis have been described as the APS ocular
features from the anterior segment, vitritis, retinal detachment, posterior scleritis, branch or
central retinal vein occlusion, bilateral choroidal infarction, cilioretinal artery occlusion,
venous tortuosity, retinal haemorrhages, cotton-wool spots and central serous type
chorioretinopathy from the posterior segment and monocular or bilateral transient visual loss,
transient visual field loss, ischemic optic neuropathy and progressive optic nerve atrophy as
the neuro-ophthalmologic features of APS27.
Venous sinus thrombosis:
Pregnancy has increased susceptibility to venous sinus
thrombosis. Significant increased risk is associated with caesarean delivery, increasing
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maternal age, hyperemesis gravidarum, intercurrent infection and maternal hypertension.
Common signs and symptoms are headache, focal or generalised seizures, paresis and
papilloedema6.
Macular Changes
Central serous retinopathy (CSR):
Chumbley and Frank reported central serous retinopathy
in a 34-vear-old woman during 4 consecutive pregnancies, with remission after delivery or
spontaneous abortion. Probably circulatory changes in the choriocapillaris can provoke central
serous choroidopathv in pre-disposed eyes28. Kitzmann et al. reported the results of a
population based study on the incidence of CSR in Olmsted, Minnesota from 1980 to 2002 and
found 11 females with CSR confirmed by fluorescein angiography, one of who was pregnant
(9%), Kitzmann et al. also reported nine cases of CSR without confirmation by fluorescein
angiography, pregnancy was one of the risk factors affecting this group (one patient)2. The
macula is especially affected by pregnancy even when healthyfor example, two studies
reported infrequent central serous chorioretinopathy in the third trimester in healthy
pregnant women29.
Toxoplasmic retinochoroiditis:
Silveira et al. have reported a case of maternofetal
transmission in a preconceptionally immunised woman. This finding could be accounted for
by a down-regulation of the T-cell-mediated immune response that is observed during
pregnancy. This contention is supported by the findings of Ramchani et al. who reported a
case of acquired ocular toxoplasmosis occurring during pregnancy without transmission of the
disease to the child30.
Choroid neovascularisation (CNV):
Healthy pregnancy is associated with increased activity
of many angiogenic factors, including vascular endothelial growth factor (VEGF), placental
growth factor (PlGF), erythropoietin (EPO) and nitric oxide, which can all stimulate retinal
neovascularisation and CNV20. CNV occurrence during pregnancy has been reported as a
complication of presumed ocular histoplasmosis syndrome or punctuate inner
chorioretinopathy31.
Optic Nerve Changes
Optic neuritis and neuropathy:
The association of optic neuritis and pregnancv has
previously been suggested28. There appears to be a decreased incidence of optic neuritis
during pregnancy, perhaps because of the immunosuppressive effects6.
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Other Oculo-CNS Changes
Retinitis pigmentosa progression in some cases is seen. Choroidal haemangiomas have been
reported to undergo rapid growth during pregnancy but some can regress postpartum5. With
pregnancy, previously asymptomatic pituitary adenomas or microadenomas may enlarge and
result in various ophthalmic symptoms such as headache, visual field change, and/or visual
acuity loss12. The tumor and intrasellar contents may expand superiorly, compressing the optic
chiasm, optic tracts, and optic nerves, producing decreased visual acuity in 52% and visual
field defects in 64% of patients8. Meningiomas may have a very aggressive growth pattern
during pregnancy that is difficult to manage. They may regress postpartum but may regrow
during subsequent pregnancy 12. The ophthalmic findings reported are decreased visual
acuity, visual field defects (for example, bitemporal hemianopia), oculomotor palsy and disc
oedema6.
Sheehan syndrome/Pituitary apoplexy:
Sheehan’s syndrome (SS) is a pituitary failure
occurring in women after labour. The prevalence of SS in India is estimated to be 2.73.9%
among parous women older than 20 years32. It is considered a potentially visually-threatening
disorder as a result of sudden increase in pituitary size from infarction or hemorrhage. The
classic VF defect is a bitemporal superior quadrantic defect. Ophthalmoplegia occurs in 78% of
cases. It results from compression of the cavernous sinus, which makes cranial nerves III, IV,
and VI vulnerable to injury. Oculomotor nerve is involved most commonly. Horner syndrome
may develop from damage to the sympathetic fibers3 . Common predisposing factors include
closed head trauma, hypotension, hypertension, history of pituitary irradiation, cardiac
surgery, anticoagulant therapy and pregnancy. Clinical features of pituitary apoplexy include
sudden onset of headache, nausea, vomiting, visual symptoms, ptosis, altered mental status
and endocrinologic dysfunction8.
Idiopathic intracranial hypertension (IIH):
IIH is a syndrome of raised intracranial pressure
in the absence of clinical, laboratory, or radiological evidence of intracranial space-occupying
lesions33. Common symptoms are headache, pulsatile tinnitus, nausea, transitory visual
obscurations, diplopia and blurred vision. In theory, IIH may be attributed to the following
factors; parenchymal edema, increased cerebral blood volume, excessive cerebrospinal fluid
(CSF) production, compromised CSF resorption, and venous outflow obstruction. Both
pregnancy and exogenous estrogens are thought to promote IIH or worsen it. Since Quincke
first related menstrual irregularity and pregnancy to IIH over a century ago, a number of
isolated case reports and a few larger series have described patients who developed IIH during
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Pregnancy and Eye
pregnancy34. The condition was considered ‘benign’ in comparison with cases of tumour but it
has been argued that loss of visual function in up to 25% of cases and progression to blindness
if untreated means that it should not be considered ‘benign’ as far as visual function is
concerned35. Decreased flow in the optic nerve results in papilledema and vision changes.
When the abducens nerve is involved, diplopia occurs. Most patients have some evidence of
optic nerve disease, such as slightly reduced visual acuity, color deficiency,a visual field defect,
or an afferent pupillary defect36.
A few other diseases also need attention during pregnancy:
Graves’ disease:
Hyperthyroidism occurs in 2/1000 pregnancies, the commonest cause (85%)
being Graves’ hyperthyroidism37. It is an important cause of unilateral and bilateral proptosis.
Graves’ disease tends to remit late in pregnancy and relapse postpartum5.
Myaesthenia gravis (MG):
The effect of pregnancy on MG varies considerably among women
and even between pregnancies in the same woman. During pregnancy, symptoms worsened
for 41% of women with MG, while 30% showed no change, and 29% had remission of
symptoms. Improvement of symptoms during the second and third trimesters has been
attributed to normal immunosuppressive changes. Thus, women with MG should delay
pregnancy for at least 2 years after disease onset 38.
Conclusion
This article provides a practical overview for pregnant women and the ophthalmologist.
Recognizing various ocular symptoms and signs in pregnancy, as well as understanding the
treatment strategies, are critical for proper management of these patients. Doctors should
treat each pregnant woman on an individual basis and should have a firm understanding of
the various ocular changes associated with pregnancy and the implication they may have for
management.Therefore in pregnant and postpartum women, a high index of suspicion and a
thorough ophthalmic evaluation can often be vision and life saving.
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Arşiv Kaynak Tarama Dergisi . Archives Medical Review Journal
Chauhan
13
Correspondence Address / Yazışma Adresi
Anubhav Chauhan
Pine Castle, Near Mist Chamber
Khalini,Shimla 171002,
Himachal Pradesh ,India.
e-mail: chauhan.anubhav2@gmail.com
Geliş tarihi/Received: 01.04.2015
Kabul tarihi/Accepted
: 29.04.2015
Arşiv Kaynak Tarama Dergisi . Archives Medical Review Journal
Article
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Background: Numerous physiological changes occur in the body during pregnancy and the eye is no exception. Pregnancy brings in an increase in hormones that may cause changes in the vision by altering the strength of refraction. The temporary changes in the vision will return to normal after the delivery. Aim: To study the physiological IOP changes in the second and third trimesters of pregnancy, as pregnancy affects the preexisting ocular conditions such as diabetic retinopathy, toxaemia of pregnancy, tumours and immunological disorders, but it can have beneficial effects on one such pre-existing condition such as glaucoma. Settings and Designs: In the present study, the IOP in the right and left eyes was recorded by Schioltz tonometry in the second and third trimester pregnant women of the age group 20-30 years, who were without any refractive error presently and previously. Methods and Materials: The IOP changes of 30 pregnant women in the second trimester were compared to that of 30 pregnant women in the third trimester. Statistical Analysis: The data which was obtained was analyzed by using the Student's t-test. Results: During the second and third trimesters, the p values of the IOP in both the eyes are highly significant (<0.0001). Conclusion: The physiological decrease in the IOP during pregnancy is due to an increase in the aqueous outflow because of the influence of increased progesterone and the beta subunit of the human chorionic gonadotrophin levels.
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When pregnancy is complicated by Idiopathic intracranial hypertension (IIH) the management and treatment of the disorder can be problematic. So, the aim of this work is to evaluate the course, management of pregnant IIH patients and the visual and pregnancy outcomes. Subjects and Methods: Case series of 13 pregnant women diagnosed with IIH. IIH symptoms, neuro-ophthalmological findings, IIH management, visual and pregnancy outcomes were documented. Results: This study included thirteen pregnant females with clinical diagnosis of IIH. Their age ranged from 23 to 38 years (mean 28.1±4.2). The gestation age at the time of IIH diagnosis ranged from 6-24 weeks (mean 12.4±5.4). Ten patients were obese. The main presenting symptoms were headache (84.6%), transient visual obscuration (77 %), dizziness (38.5%), diplopia, pulsatil tinnitus, nausea and vomiting (30.8%), and blurred vision (23.1%). On examination, four patients had bilateral six nerve palsy. Fundus examination of these patients at the time of presentation revealed that six patients (i.e., twelve eyes) had early papilledema and seven patients had established papilledema. All patients had visual field changes in the first examination. Ten patients were treated by serial lumbar puncture. Not all the patients adhered to the diet, eight patients accepted to be on diet control. Five patients were taking acetazolamide after the first trimester. After intervention, visual function improved in all cases. There were 11 full term pregnancies with normal delivery in 9 patients. Conclusions: IIH appears to present during the first two trimesters of pregnancy with typical symptoms and findings. Visual outcome is similar as for non-pregnant women. Treatment should be oriented towards dietary control, without ketosis. Repeated lumbar puncture, and acetazolamide if needed after the first trimester, can be helpful.
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When pregnancy is complicated by Idiopathic intracranial hypertension (IIH) the management and treatment of the disorder can be problematic. So, the aim of this work is to evaluate the course, management of pregnant IIH patients and the visual and pregnancy outcomes. Subjects and Methods: Case series of 13 pregnant women diagnosed with IIH. IIH symptoms, neuro-ophthalmological findings, IIH management, visual and pregnancy outcomes were documented. Results: This study included thirteen pregnant females with clinical diagnosis of IIH. Their age ranged from 23 to 38 years (mean 28.1±4.2). The gestation age at the time of IIH diagnosis ranged from 6-24 weeks (mean 12.4±5.4). Ten patients were obese. The main presenting symptoms were headache (84.6%), transient visual obscuration (77 %), dizziness (38.5%), diplopia, pulsatil tinnitus, nausea and vomiting (30.8%), and blurred vision (23.1%). On examination, four patients had bilateral six nerve palsy. Fundus examination of these patients at the time of presentation revealed that six patients (i.e., twelve eyes) had early papilledema and seven patients had established papilledema. All patients had visual field changes in the first examination. Ten patients were treated by serial lumbar puncture. Not all the patients adhered to the diet, eight patients accepted to be on diet control. Five patients were taking acetazolamide after the first trimester. After intervention, visual function improved in all cases. There were 11 full term pregnancies with normal delivery in 9 patients. Conclusions: IIH appears to present during the first two trimesters of pregnancy with typical symptoms and findings. Visual outcome is similar as for non-pregnant women. Treatment should be oriented towards dietary control, without ketosis. Repeated lumbar puncture, and acetazolamide if needed after the first trimester, can be helpful.
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A 28-year-old woman with bilateral stable keratoconus for 2 years came with a complaint of recent blurring of vision 4 weeks postpartum. Her best-corrected visual acuity had dropped by three lines in the right eye and two lines in the left eye with the same manifest refraction. Corneal topography and Scheimpflug imaging revealed mild progression of the keratoconus, but not enough to explain the drop in visual acuity. However, fundus examination revealed temporal disk pallor in both eyes. Visual field analysis revealed classic bitemporal hemianopia. Subsequently, magnetic resonance imaging (MRI) of brain was performed which revealed a pituitary macroadenoma with pituitary apoplexy that was impinging on the pons. Based on these findings, urgent neurosurgery was performed, and the patient regained her visual acuity and fields 2 weeks later. Neuro-ophthalmologic disorders should always be kept as a differential diagnosis in pregnant and postpartum women. A high index of suspicion from the ophthalmologist can often avert life-threatening problems. Key message Neuro-ophthalmologic disorders can masquerade as a variety of clinical presentations in pregnant and postpartum women. A high index of suspicion from the ophthalmologist can often avert life-threatening problems. How to cite this article Shetty R, D’Souza S, Kankariya VP, Srivastava S, Vasavada V, Wadia K. Neurologic Disorder Masquerading as Postpregnancy Progression of Keratoconus. Int J Kerat Ect Cor Dis 2012;1(3):205-208.