1. 1 Eye manifestations during pregnancy By Dr Mohamed Abusharifa, MD Ophthalmic surgeon Tulkarem - Palestine

2. 2 To highlight those the eye problems, which are related with pregnancy, without interfering into treatment modalities TARGET

3. 3 TRNSIENT PERMANENT Ocular changes that occur in pregnancy are usually TRNSIENT in nature, but occasionally there may be PERMANENT disorders Eye manifestations during pregnancy Courtesy of: Sunness JS. The pregnant woman’s eye. Surv of Ophthalmology 1988;32:219-38

4. 4 PLAN 1.NEURO-OPHTHALMOLOGICAL changes 1.NEURO-OPHTHALMOLOGICAL changes appearing in pregnancy PRE-EXISTING 2.The effects of pregnancy on PRE-EXISTING ocular disorders PREGNANCY-RELATED diseases 3.Ocular disorders associated with PREGNANCY-RELATED diseases DURING PREGNANCY 4.Eye changes developing DURING PREGNANCY

5. 5 BEFORE BUT BEFORE proceeding into presentation pay attention please pay attention to the following 5 slides :

6. 6 nausea + severe vomiting + severe headache + intracranial disorders in a pregnant 1

7. 7 Newborn with hydrocephalus due to congenital toxoplasmosis (From Dubey JP, and Beattie CP. Toxoplasmosis of animals and Man. CRC Press, Baca Raton, Florida, 52, 1988.) 2

8. 8 Normal retina Courtesy of KANSKI : Clinical Ophthalmology A toxoplasmosis lesion in the center of retina 3

9. 9 Diabetic retinopathy Normal retina Courtesy of KANSKI : Clinical Ophthalmology 4

10. 10 NO contact lenses during pregnancy X = 5

11. 11 Now presentation starts: 1.NEURO-OPHTHALMOLOGICAL changes 1.NEURO-OPHTHALMOLOGICAL changes appearing in pregnancy PRE-EXISTING 2.The effects on PRE-EXISTING ocular disorders PREGNANCY-RELATED diseases 3.Ocular disorders associated with PREGNANCY-RELATED diseases DURING PREGNANCY 4.Eye changes developing DURING PREGNANCY

12. 12 NEURO-OPHTHALMOLOGICAL changes NEURO-OPHTHALMOLOGICAL changes appearing in pregnancy normal nausea & vomiting intracranial disorders Some of the symptoms which are regarded normal in pregnancy, such as : nausea & vomiting may be signs of intracranial disorders Courtesy of: T. Walsh, Neuro-Ophthalmology Clinical Signs & Symptoms

13. 13 NEURO-OPHTHALMOLOGICAL changes NEURO-OPHTHALMOLOGICAL changes in pregnancy Nausea & severe vomiting D.D Nausea & severe vomiting should be considered seriously while doing D.D. in a pregnant having: Visual disturbances Visual disturbances Persistent headache Persistent headache Visual field defects Visual field defects Oculomotor palsies Oculomotor palsies Courtesy of: T. Walsh, Neuro-Ophthalmology Clinical Signs & Symptoms

14. 14 NEURO-OPHTHALMOLOGICAL included in DD during pregnancy NEURO-OPHTHALMOLOGICAL cases included in DD during pregnancy:  Pseudotumor cerebri (benign intracranial hypertension)  Prolactinoma (adenoma of pituitary gland)  Venous sinus thrombosis

15. 15  Pseudotumor cerebri ( benign intracranial hypertension )  Prolactinoma (adenoma of pituitary gland)  Venous sinus thrombosis NEURO-OPHTHALMOLOGICAL cases included in DD during pregnancy NEURO-OPHTHALMOLOGICAL cases included in DD during pregnancy:

16. 16 NEURO-OPHTHALMOLOGICAL changes NEURO-OPHTHALMOLOGICAL changes in pregnancy Typical symptoms & findings: Typical symptoms & findings: –Blur vision –Headache –Nausea & severe vomiting –6 th nerve palsy – Edema of optic disc Courtesy of: T. Walsh, Neuro-Ophthalmology Clinical Signs & Symptoms Pseudotumor cerebri (benign intracranial hypertension )

17. 17 nausea + severe vomiting + severe headache

18. 18 Left Left Lateral Rectus Muscle palsy due to Left 6th nerve palsy Courtesy of KANSKI: Clinical Ophthalmology Right Right Lateral Rectus Muscle palsy due to Righ 6th nerve palsy

19. 19 EDEMA OF OPTIC DISC Courtesy of: T. Walsh, Neuro-Ophthalmology Clinical Signs & Symptoms edema of optic disc Normal optic disc

20. 20 Pseudotumor cerebriPseudotumor cerebri (benign intracranial hypertension) (benign intracranial hypertension) ProlactinomaProlactinoma (adenoma of pituitary gland) (adenoma of pituitary gland) Venous sinus thrombosisVenous sinus thrombosis NEURO-OPHTHALMOLOGICAL cases included in DD during pregnancy:

21. 21 Pseudotumor cerebriPseudotumor cerebri (benign intracranial hypertension) (benign intracranial hypertension) ProlactinomaProlactinoma (adenoma of pituitary gland) (adenoma of pituitary gland) Venous sinus thrombosisVenous sinus thrombosis NEURO-OPHTHALMOLOGICAL cases included in DD during pregnancy:

22. 22 NEURO-OPHTHALMOLOGICAL cases included in DD during pregnancy: Prolactinoma hormone prolactin (LTH) A noncancerous tumor (adenoma) affecting the pituitary gland that causes increase in the production of the hormone prolactin (LTH)

23. 23 NEURO-OPHTHALMOLOGICAL changes NEURO-OPHTHALMOLOGICAL changes in pregnancy Prolactinoma Symptoms & findings: Galactorrhea Amenorrhea Fatigue Decreased libido HeadacheHeadache pressureoptic nerveVisual disturbances (due to pressure on the optic nerve) pressureoptic chiasm Visual field defects (due to pressure on the optic chiasm)

24. 24 Pituitary gland

25. 25 Pituitary gland pressing on optic chiasm from below

26. 26 Optic chiasm Courtesy of: Dynamic Human Anatomy Student Version tip Optic nerve

27. 27 Enlarged sella turcica due to pressure caused by pituitary adenoma

28. 28 Pt’s view normal Visual field in Left Eye Courtesy of D. J. Spalton: Atlas of CLINICAL OPHTHALMOLOGY

29. 29 Right Eye normal visual field in Right Eye Courtesy of D. J. Spalton: Atlas of CLINICAL OPHTHALMOLOGY Pt’s view

30. 30 Asymmetric bitemporal visual field loss due to pressure on the optic chiasm & optic nerve from below Courtesy of Visual Fields: Examination & Interpretation Publication of American Academy of Ophthalmology

31. 31 Pituitary adenoma (prolactinoma) Courtesy of Visual Fields: Examination & Interpretation Publication of American Academy of Ophthalmology

32. 32 NEURO-OPHTHALMOLOGICAL cases included in DD during pregnancy: Prolactinoma recommended known It is recommended that any pregnant with a known pituitary prolactinoma must visual field follow-up enlargement uncorrected visual field loss have regular visual field follow-up to rule out enlargement which leads to compression of optic chiasm and causes uncorrected visual field loss Courtesy of Visual Fields: Examination & Interpretation Publication of American Academy of Ophthalmology

33. 33 NEURO-OPHTHALMOLOGICAL cases included in DD during pregnancy: Pseudotumor cerebri (benign intracranial hypertension) Prolactinoma (adenoma of pituitary gland) Venous sinus thrombosis

34. 34 NEURO-OPHTHALMOLOGICAL cases included in DD during pregnancy: Pseudotumor cerebri (benign intracranial hypertension) Prolactinoma (adenoma of pituitary gland) Venous sinus thrombosis

35. 35 NEURO-OPHTHALMOLOGICAL cases included in DD during pregnancy: Venous sinus thrombosis brain stroke is a form of brain stroke that results from thrombosis of the dural venous sinuses Courtesy of Lanska DJ, Kryscio RL. Risk factors for peripartum & pastpartum stroke& intracranial venous thrombosis. Stroke 2000;31:1274-82

36. 36 NEURO-OPHTHALMOLOGICAL cases included in DD during pregnancy: Venous sinus thrombosis Increased risk of occurrence in :  Cesarean delivery  Advanced maternal age  Hypertension  Infections Courtesy of Lanska DJ, Kryscio RL. Risk factors for peripartum & pastpartum stroke& intracranial venous thrombosis. Stroke 2000;31:1274-82

37. 37 Venous sinuses

38. 38 NEURO-OPHTHALMOLOGICAL cases included in DD during pregnancy: Venous sinus thrombosis Signs & symptoms:  Throbbing headache seizures  Focal or generalized seizures  Paresis  Optic disc edema Courtesy of Lanska DJ, Kryscio RL. Risk factors for peripartum & pastpartum stroke& intracranial venous thrombosis. Stroke 2000;31:1274-82

39. 39 nausea + severe vomiting + severe headache

40. 40 Venous sinus thrombosis thrombus Courtesy of Lanska DJ, Kryscio RL. Risk factors for peripartum & pastpartum stroke& intracranial venous thrombosis. Stroke 2000;31:1274-82

41. 41 EDEMA OF OPTIC DISC Courtesy of: T. Walsh, Neuro-Ophthalmology Clinical Signs & Symptoms edema of optic disc Normal optic disc

42. 42 PLAN 1.NEURO-OPHTHALMOLOGICAL changes 1.NEURO-OPHTHALMOLOGICAL changes appearing in pregnancy PRE-EXISTING 2.The effects on PRE-EXISTING ocular disorders PREGNANCY-RELATED diseases 3.Ocular disorders associated with PREGNANCY-RELATED diseases DURING PREGNANCY 4.Eye changes developing DURING PREGNANCY

43. 43 PRE-EXISTING The effects of pregnancy on PRE-EXISTING ocular disorders –Diabetic retinopathy –Graves’ disease –Glaucoma –Uveitis

44. 44 PRE-EXISTING The effects of pregnancy on PRE-EXISTING ocular disorders –Diabetic retinopathy –Graves’ disease –Glaucoma –Uveitis

45. 45 PRE-EXISTING The effects of pregnancy on PRE-EXISTING ocular disorders Diabetic retinopathy is the most ocular disorder modified by pregnancy Courtesy of Sheth BP. Does pregnancy accelerate the rate of progression of diabetic retinopathy? Curr Diab Rep 2002;2:327-30

46. 46 PRE-EXISTING The effects of pregnancy on PRE-EXISTING ocular disorders Diabetic retinopathy its progression is affected by : 1.Duration of DM 2.Presence of diabetic retinopathy at conception 3.Sugar control during pregnancy Courtesy of Sheth BP. Does pregnancy accelerate the rate of progression of diabetic retinopathy? Curr Diab Rep 2002;2:327-30

47. 47 PRE-EXISTING The effects of pregnancy on PRE-EXISTING ocular disorders Diabetic retinopathy 1.Ophthalmic status should be evaluated before pregnancy 2.Good sugar control throughout pregnancy 3.Eye exam every 3 months 4.Treatment by laser photocoagulation before pregnancy may reduce progression by 50% Courtesy of Sheth BP. Does pregnancy accelerate the rate of progression of diabetic retinopathy? Curr Diab Rep 2002;2:327-30

48. 48 PRE-EXISTING The effects of pregnancy on PRE-EXISTING ocular disorders Diabetic retinopathyNormal retina Courtesy of KANSKI : Clinical Ophthalmology

49. 49 PRE-EXISTING The effects of pregnancy on PRE-EXISTING ocular disorders Diabetic retinopathy laser photocoagulation

50. 50 PRE-EXISTING The effects of pregnancy on PRE-EXISTING ocular disorders Diabetic retinopathy Graves’ diseas Glaucoma Uveitis

51. 51 PRE-EXISTING The effects of pregnancy on PRE-EXISTING ocular disorders Diabetic retinopathy Graves’ diseas Glaucoma Uveitis

52. 52 PRE-EXISTING The effects of pregnancy on PRE-EXISTING ocular disorders Graves’ disease Pre-existing hyperthyroidism can be aggravated aggravated in pregnancy. Courtesy of Amino N et al. Aggravation of thyrotoxicosis in early pregnancy and after delivery in Graces’ disease. J Clin Endocr Metab 1982;55:108-12

53. 53 PRE-EXISTING The effects of pregnancy on PRE-EXISTING ocular disorders initial The initial onset of Graves’ disease during pregnancy may occur during pregnancy Courtesy of Amino N et al. Aggravation of thyrotoxicosis in early pregnancy and after delivery in Graces’ disease. J Clin Endocr Metab 1982;55:108-12

54. 54 PRE-EXISTING The effects of pregnancy on PRE-EXISTING ocular disorders Courtesy of KANSKI : Clinical Ophthalmology Thyroid ophthalmopathy

55. 55 PRE-EXISTING The effects of pregnancy on PRE-EXISTING ocular disorders Diabetic retinopathy Graves’ disease Glaucoma Uveitis

56. 56 PRE-EXISTING The effects of pregnancy on PRE-EXISTING ocular disorders Diabetic retinopathy Graves’ disease Glaucoma Uveitis

57. 57 Glaucoma increase in intraocular pressure (increase in intraocular pressure) Courtesy of F. Newell: Ophthalmology principles & concepts leads to:  optic disk atrophy  loss in visual field

58. 58 atrophic glaucomatous optic disk Courtesy of Kanski: CLINICAL OPHTHALMOLOGY NORMAL OPTIC DISK

59. 59 Courtesy of Kanski: CLINICAL OPHTHALMOLOGY visual field loss Progression of glaucomatous visual field loss

60. 60 PRE-EXISTING The effects of pregnancy on PRE-EXISTING ocular disorders During pregnancy occurs decrease in intraocular pressure (temporary control) !!! Courtesy of Johnson SM, Martinez M, Freedman S. Management of glaucoma in pregnancy & lactation. Surv. Ophthalmol 2001;45::449-54

61. 61 PRE-EXISTING The effects of pregnancy on PRE-EXISTING ocular disorders –Diabetic retinopathy –Graves’ disease –Glaucoma –Uveitis

62. 62 PRE-EXISTING The effects of pregnancy on PRE-EXISTING ocular disorders –Diabetic retinopathy –Graves’ disease –Glaucoma –Uveitis

63. 63 PRE-EXISTING The effects of pregnancy on PRE-EXISTING ocular disorders : A non-infectious inflammation of uvea, which sometimes accompanies inflammations of connective tissue: arthritis, spondyloarthritis ….etc Courtesy of F. Newell: Ophthalmology principles & concepts Uveitis

64. 64 PRE-EXISTING The effects of pregnancy on PRE-EXISTING ocular disorders temporary improvement of uveitis !!! During pregnancy also occurs temporary improvement of uveitis !!! Courtesy of Sunness JS, Santos A, Pregnancy & the Mother’s eye: Lippincott Williams & Wilkins;2001

65. 65 PLAN 1.NEURO-OPHTHALMOLOGICAL changes 1.NEURO-OPHTHALMOLOGICAL changes appearing in pregnancy PRE-EXISTING 2.The effects on PRE-EXISTING ocular disorders PREGNANCY-RELATED diseases 3.Ocular disorders associated with PREGNANCY-RELATED diseases DURING PREGNANCY 4.Eye changes developing DURING PREGNANCY

66. 66 PREGNANCY- RELATED diseases Ocular disorders associated with PREGNANCY- RELATED diseases oToxoplasmosis oToxemic retinopathy of pregnancy

67. 67 PREGNANCY- RELATED diseases Ocular disorders associated with PREGNANCY- RELATED diseases oToxoplasmosis oToxemic retinopathy of pregnancy

68. 68 Toxoplasmosis raw or undercooked meat cat feces Is an infection caused by the intracellular protozoon (Toxoplasma gondii), by ingestion of raw or undercooked meat containing oocysts, or by exposure to oocysts in cat feces Fabiana Maria Ruiz Lopes - Toxoplasma gondii infection in pregnancy Brazilian Journal of Infectious Diseases

69. 69 transplacentally It is acquired transplacentally, which may cause: Abortion Miscarriage or stillbirth blindnessChronic chorioretinitis blindness Severe jaundice & hepatosplenomegaly CNS lesions: –Hydrocephalus –Intracerebral calcification –Mental retardation –convulsions Neonatal congenital toxoplasmosis Fabiana Maria Ruiz Lopes - Toxoplasma gondii infection in pregnancy Brazilian Journal of Infectious Diseases

70. 70 Girl with hydrocephalus due to congenital toxoplasmosis. (From Dubey JP, and Beattie CP. Toxoplasmosis of animals and Man. CRC Press, Baca Raton, Florida, 52, 1988.) Brain calcification in congenital toxoplasmosis

71. 71 PREGNANCY- RELATED diseases Ocular disorders associated with PREGNANCY- RELATED diseases Normal retina Toxoplasmosis lesion in center of retina Courtesy of KANSKI : Clinical Ophthalmology

72. 72 Suggestion The serological research for toxoplasmosis in pregnant women should be mandatory by law, as in some countries: France & Austria, Neonatal screening programs for congenital toxoplasmosis should be done routinely as Guthrie test for PKU (phenylketonuria). Courtesy of Fabiana Maria Ruiz Lopes - Toxoplasma gondii infection in pregnancy Brazilian Journal of Infectious Diseases

73. 73 PREGNANCY- RELATED diseases Ocular disorders associated with PREGNANCY- RELATED diseases oToxoplasmosis oToxemic retinopathy of pregnancy

74. 74 PREGNANCY- RELATED diseases Ocular disorders associated with PREGNANCY- RELATED diseases oToxoplasmosis oToxemic retinopathy of pregnancy

75. 75 PREGNANCY- RELATED diseases Ocular disorders associated with PREGNANCY- RELATED diseases Toxemic retinopathy of pregnancy occurs: During pre-eclampsia Premature separation of the placenta (Abruptio placentae) Retention of dead fetus Courtesy of: Sunness JS. The pregnant woman’s eye. Surv of Ophthalmology 1988;32:219-38

76. 76 PREGNANCY- RELATED diseases Ocular disorders associated with PREGNANCY- RELATED diseases Toxemic retinopathy of pregnancy:  Cotton wool spots  Retinal hard exudates  Edema of optic disc  Retinal hemorrhages  Serous chorioretinopathy Courtesy of: Sunness JS. The pregnant woman’s eye. Surv of Ophthalmology 1988;32:219-38

77. 77 Toxemic retinopathy of pregnancy edema of optic disc & retinal hemorrhages & cotton-wool spots & central exudates Courtesy of KANSKI : Clinical Ophthalmology Normal retina

78. 78 Toxemic retinopathy of pregnancy Central serous chorioretinopathy Courtesy of KANSKI : Clinical Ophthalmology Normal retina

79. 79 PLAN 1.NEURO-OPHTHALMOLOGICAL changes 1.NEURO-OPHTHALMOLOGICAL changes appearing in pregnancy PRE-EXISTING 2.The effects on PRE-EXISTING ocular disorders PREGNANCY-RELATED diseases 3.Ocular disorders associated with PREGNANCY-RELATED diseases DURING PREGNANCY 4.Eye changes developing DURING PREGNANCY

80. 80 DURING PREGNANCY Eye changes developing DURING PREGNANCY ON ON: LIDSLIDS CORNEACORNEA TEARS PRODUCTIONTEARS PRODUCTION LENSLENS

81. 81 DURING PREGNANCY Eye changes developing DURING PREGNANCY Chloasma on LIDS Chloasma on LIDS (Chloasma gravidarum) (Mask of pregnancy) Blotchy brown discoloration around lids, due to pigmentation It fades in postpartum period No treatment needed Courtesy of Sushma Sharma - Review: Pregnancy and the eye

82. 82 DURING PREGNANCY Eye changes developing DURING PREGNANCY Due to fluid retention This (edema) causes: change 1.MYOPIC change 2.Intolerance to CL traumatic effects 2.Intolerance to CL due to traumatic effects on corneal surface Corneal edema on CORNEA Normal corneal thickness Increased corneal thickness Courtesy of Sushma Sharma - Review: Pregnancy and the eye

83. 83 DURING PREGNANCY Eye changes developing DURING PREGNANCY Decrease in tears production in 80% of pregnant women It causes Intolerance to wearing CL Courtesy of Sushma Sharma - Review: Pregnancy and the eye

84. 84 Pregnants are advised to avoid wearing CL X = Courtesy of Sushma Sharma - Review: Pregnancy and the eye

85. 85 DURING PREGNANCY 1.Eye changes developing DURING PREGNANCY on lens = increase in lens curvature leads to: Temporary myopia Normal lens curvature Increased lens curvature

86. 86 conclusion 1. Attention to NAUSEA & VOMITTING when accompanied by intracranial disorders 2. SEROLOGICAL RESEARCH for toxoplasmosis in pregnant women. & Neonatal screening for CONGENITAL TOXOPLASMOSIS 3. Good control of SUGAR in diabetic pregnants 4. No CONTACT LENSES during pregnancy

87. 87 THANK YOU