Nw2013 retinopathies inpregnancyfinal

396 views

Published on

retinopathies in pregnancy,
retina problems in pregnancy

Published in: Health & Medicine
0 Comments
1 Like
Statistics
Notes
  • Be the first to comment

No Downloads
Views
Total views
396
On SlideShare
0
From Embeds
0
Number of Embeds
4
Actions
Shares
0
Downloads
27
Comments
0
Likes
1
Embeds 0
No embeds

No notes for slide

Nw2013 retinopathies inpregnancyfinal

  1. 1. Nawat Watanachai Chiangmai University Hospital RCOPT mid 2013
  2. 2. Many emotional and physical changes  including eyes 
  3. 3. Normal eye changes in pregnancy  Pregnancy induced chorioretinopathy  Retinal diseases that are affected by pregnancy 
  4. 4.    Cornea ◦ increase thickness 1 ◦ Increase curvature 2 ◦ Decrease sensitivity 3 Lens ◦ Increase thickness 1 ◦ Increase curvature 1 IOP ◦ Decrease in 3rd trimester 4 1 Riss B, Riss P. Corneal sensitivity in pregnancy. Ophthalmologica 1981; 183:57—62. 2 Weinreb RN, Lu A, Beeson C. Maternal corneal thickness during pregnancy. Am J Ophthalmol 1988; 105:258—260. 3 Park SB, Lindahl KJ, Temnycky GO, Aquavella JV. The effect of pregnancy on the corneal curvature. CLAO J 1992; 18:256—259. 4 Akar Y, Yucel I, Akar ME, et al. Effect of pregnancy on intraobserver and intertechnique agreement in intraocular pressure measurements. Ophthalmologica 2005; 219:36—42.
  5. 5.  Retina ◦ Retinal thickness  slightly increases during 2nd-3rd trimesters 1 ◦ Retinal venous diameter  decreased during the 3rd trimester 2 1. Dinn, Robert B. BS*; Harris, Alon MSc, PhD†; Marcus, Peter S. MD‡. Ocular Changes in Pregnancy. Obstetrical & Gynecological Survey: February 2003 - Volume 58 - Issue 2 - pp 137-144 2. The effect of pregnancy on retinal hemodynamics in diabetic versus nondiabetic mothers ☆ Lisa S Schocket, MDa, Juan E Grunwald, MDa, , , Amy F Tsang, MAa, Joan DuPonta American Journal of OphthalmologyVolume 128, Issue 4, October 1999, Pages 477–484
  6. 6. ● ● Early preg -> hyperdynamic circulation controlled by an autoregulatory mechanism in the retinal vasculature Success  not develop retinopathy – – Failed  increased blood flow velocity  petential damage to capillary endothelium Chen HC et al. Retinal blood flow changes during pregnancy in women with diabetes. Invest Ophthalmol Vis Sci 1994; 35:3199–3208.
  7. 7. Central serous chorioretinopathy (CSCR)  Valsava retinopathy  Purtscher’s retinopathy  Preeclampsia/ eclampsia associated retinopathy ◦ (HT retinopathy)  RAO, RVO  Bullous ERD 
  8. 8. ● ● 10:1 male predominance outside the context of pregnancy closure when women become pregnant Chumbley LC, Frank RN. Central serous retinopathy and pregnancy. Am J Ophthalmol 1974; 77:158—160.
  9. 9. ● CSCR ● ● ● unilateral with or without fibrin formation Most cases ● ● occurred during the 3rd trimester recurring in subsequent pregnancies Sunness JS, Haller JA, Fine SL. Central serous chorioretinopathy and pregnancy. Arch Ophthalmol 1993; 111:360—364. Gass JDM. Central serous chorioretinopathy and white subretinal exudation during pregnancy. Arch Ophthalmol 1991; 109:677—681.
  10. 10. ● Investigations ● ● OCT >>>>>> FA/ICG CSCR ● ● ● spontaneously resolved during the early postpartum not associated with any adverse fetal outcomes C/S Rx conservatives
  11. 11. ● ● ● unilateral or bilateral self limiting increased intra-thoracic or intraabdominal pressure ● ● ●  sharp rise in the intraocular venous pressure  rupture of superficial retinal capillaries Constipation/ delivery
  12. 12. ● No specific treatment is needed ● ● Laser posterior hyaloidotomy the diagnosis should be made only after excluding other causes of retinal haemorrhages
  13. 13. ● (reported) developing after child birth ● ● ● Preeclampsia/ eclampsia compliment activated leuko-embolus formation? No treatment is needed
  14. 14. ● How common ● ● ● ● 25% of the patients with preeclampsia 50% with eclampsia Mostly asymptomatic Few suffers visual disturbance ● blurred vision, diplopia, photopsia, scotomata, amaurosis and chromatopsia and cortical blindness DieckmannWJ (1952) The toxemias of pregnancy, 2nd edn. Mosby, St Louis
  15. 15. ● common ocular findings ● ● ● ● ● Focal/ general constriction or spasm of the retinal arterioles CWS intra retinal haemorrhages, retinal oedema optic nerve oedema in a patient with mild preeclampsia ● Look for cowexisting DM/ chronic HT Jaffe G, Schatz H Ocular manifestations of preeclampsia. Am J Ophthalmol 1987;103:309–315
  16. 16. ● Choroidal involvement ● ● yellow- white focal lesions at the level of the RPE serous retinal detachment ● ● ● often bullous usually bilateral Elschnig’s spots ● ● small, isolated areas of hyperpigmentation surrounding yellow or red halos A.M. Joussen, T.W.Gardner, B. Kirchhof , S.J. Ryan . Retinal Vascular Disease:691-699
  17. 17. ● prognosis ● ● ● Good Generally do not need specific treatment But NEED Systemic treatment ● ● ● antihypertensive therapy magnesium sulfate early delivery of the fetus when indicated A.M. Joussen, T.W.Gardner, B. Kirchhof , S.J. Ryan . Retinal Vascular Disease:691-699
  18. 18. ● ● pre-existing DM preexisting posterior uveitis
  19. 19. ● Changes in hemodynamics increased level of various growth factors and hormones ● DR may start/ progress during pregnancy ● Who will be attacked?  Risk factors ●
  20. 20. DM duration <15 yrs DR Progression 18% > 15 yrs 39% Chew EY, Mills JL, Metzger BE, et al. Metabolic control and progression of retinopathy. The Diabetes in Early Pregnancy Study. DiabetesCare 1995; 18:631—637.
  21. 21. ● The Diabetes in Early Pregnancy Study (DIEP) – Prospective cohort – 140 pregnant diabetic women – Retinopathy was most likely to progress in ● Poorest control at baseline ● largest improvement during early pregnancy Chew EY, Mills JL, Metzger BE, et al. Metabolic control and progression of retinopathy. The Diabetes in Early Pregnancy Study. DiabetesCare 1995; 18:631—637.
  22. 22. Baseline DR progression No DR 10.3% Progression to PDR - Only microaneurysms Mild NPDR 21.1% - 18.8% 6.3% Moderate NPDR 54.8% 29% Chew EY, Mills JL, Metzger BE, et al. Metabolic control and progression of retinopathy. The Diabetes in Early Pregnancy Study. DiabetesCare 1995; 18:631—637.
  23. 23. ● ● additionally hazardous during pregnancy In at least one major study, ● all patients with severe PDR ● ● also had proteinuria indicating a generalized vasculopathy DR in patients with eclampsia/preeclampsia is more likely to progress Phelps RL et al Changes in diabetic retinopathy during pregnancy. Correlations with regulation of hyperglycemia. Arch Ophthalmol 1984; 104:1806–1810
  24. 24. ● rapid normalization of sugar level ● ● ●  hypoglycemia retinal hypoxia and  new CWS and intra retinal microvascular abnormalities Chew EY, Mills JL, Metzger BE, et al. Metabolic control and progression of retinopathy. The Diabetes in Early Pregnancy Study. DiabetesCare 1995; 18:631—637.
  25. 25. Risk factors for the DR progression ● – Duration of DM 1 Poor metabolic control – Baseline severity of DR – HT, PIH and preeclampsia 2,3 – Rapid normalization of glucose levels during pregnancy 1 – 1. 2. ● 1. Chew EY, Mills JL, Metzger BE, et al. Metabolic control and progression of retinopathy. The Diabetes in Early Pregnancy Study. DiabetesCare 1995; 18:631—637. 2. Rosenn B, Miodovnik M, Kranias G, et al. Progression of diabetic retinopathy in pregnancy: association with hypertension in pregnancy. Am J Obstet Gynecol 1992; 166:1214—1218. 8. Loukovaara S, Harju M, Kaaja R, Immonen I. Retinal capillary blood flow in diabetic and nondiabetic women during pregnancy and postpartum period. Invest Ophthalmol Vis Sci 2003; 44:1486—1491.
  26. 26. I know it ● ● ● early education and good counselling of diabetic women in childbearing age good glucose control Treat diabetic retinopathy prior to conception
  27. 27. ● ● DR that progress during pregnancy commonly regress after delivery But somes with rapid progression or high-risk PDR will progress ● Can cause VH/ TRD/ NVG/ blindness ● Should be treated Chan WC, Lim LT, Quinn MJ, et al. Management and outcome of sightthreatening diabetic retinopathy in pregnancy. Eye 2004; 18:826— 832.
  28. 28. ● non-infectious uveitis ● ● ● May flare-up in disease activity within the 1st trimester And then slow down later Rebound within 6 months of delivery. Peter K Rabiah,Albert T Vitale. Noninfectious uveitis and pregnancy. American Journal of Ophthalmology 2003; 136:91-98
  29. 29. ● Most common ● ● VKH and Behcet disease Most flare-ups were effectively treated with observation/corticosteroids Peter K Rabiah,Albert T Vitale. Noninfectious uveitis and pregnancy. American Journal of Ophthalmology 2003; 136:91-98
  30. 30. Central serous chorioretinopathy (CSCR)  Valsava retinopathy  Purtscher’s retinopathy  Preeclampsia/ eclampsia associated retinopathy ◦ (HT retinopathy)  ● ● pre-existing DM preexisting posterior uveitis
  31. 31. We need healthy moms to take care of these guys!

×