This document summarizes various ocular manifestations that can occur during pregnancy and labor, ranging from innocuous and reversible changes to more serious sight-threatening conditions. Some common physiological changes include melasma, mild ptosis, increased corneal thickness and refractive changes, and decreased intraocular pressure. However, pathological conditions like diabetic retinopathy, hypertensive disorders of pregnancy, central serous chorioretinopathy, and pre-eclampsia may affect vision and require urgent ophthalmic referral. Special considerations are also discussed for managing ocular issues during pregnancy.

1. Ocular manifestations in
pregnancy and labour: from the
innocuous to the sight
threatening (TOG July 2020)
PRESENTER : DR THOMAS
SUPERVISOR: DR SIM WEE WEE

2. Occular Adnexae
 Most changes are physiological and reverse post
delivery
 Melasma
 Mild Ptosis

3. Melasma
 Cloasma/ The mask of pregnancy – area of facial skin
hyperpigmentation
 Malar pattern
 Due to increasing in circulating melanocyte stimulating hormones,
estrogen, progesterone
 Occurs in 2nd half of pregnancy in 75% women

4. Ptosis
 Drooping of the eye lid
 Hormonal changes or fluid retention within the levator muscle aponeuresis
 Mild and unilateral
 Rule out : Horner’s Syndrome (smaller pupil), Oculomotor nerve
palsy(diplopia)

5. Cornea and refractive changes
 Fluid retention -> cornea thickness increase 30%
 14% women will develop myopia
 Experience “ tight lens syndrome”
 NOT for laser refractive surgery in pregnancy due to refractive instability –
to delay 12 months after delivery
 Krukenberg spindles (pigmentation of the posterior surface of the cornea)

6. Tear film and ocular surface
 Tear film disturbances due to hormonal changes -> dry eye symptoms
 Foreign body or gritty sensation
 Treatment : ocular lubricants

7. Eye Pressure
 Intraocular pressure drops by 2-3mmHg
 Changes in progesterone cause reduction in episcleral venous pressure
 Return to pre-pregnancy level 2-3 months post delivery
 Improvement in eye pressure control in glaucoma or ocular hypertension
pregnant women

8. Topical medication in prengancy

9. Posterior Segment
 Pathological and require urgent ophthalmology input
 Most common : diabetic eye disease
 Require pupillary dilation for detail examination of the back of
the eye
 Pupillary dilatation drug: tropicamide / cyclopentolate

10. Diabetic eye disease
 Digital photographic screening after first AN appointment
 If normal, repeat at 28 weeks
 If abnormal, repeat at 16-20 weeks
 Diabetic retinopathy : not contraindication for vaginal delivery
 Retinal laser photocoagulation is safe treat proliferative
retinopathy in pregnancy

11. Diabetic maculopathy
 Treated with laser photocoagulation ( focal leak away from
centre of macular)
 In severe cases when centre of the macula involved and is
threatening vision, it is treated by intravitreal injection of anti-
vascular endothelial growth factor (anti-VEGF) drugs
 Anti-VEGF : potential risk of adverse effect on fetal vasculature
-> best avoided in pregnancy / wait 3 months from last dose
if plan to conceive

12. Pregnancy related hypertension
 Occurs in up to 11% of pregnancies
 Diastolic blood pressure correlates more closely with presence
of fundus changes
 Blurred patch in the field of vision when retinal haemmorhage
or cotton wool spot develops in central of retinal
 Cystoid macular edema, serous retinal detachment, optic discs
swelling -> affect vision -> urgent ophthalmic referrals

13. Central serous chorioretinopathy
 Localized serous detachment of the neurosensory retina at the
macula, secondary to leakage from the choriocapillaris from
one or more hyper-permeable retinal pigment
epithelium(RPE) sites
 Micropsia, metamorphopsia, blurred vision
 Most common during the third trimester
 Amsler Grid
 Diagnose with Optical Coherence tomography (OCT) of the
retina

15. Idiopathic intracranial hypertension
(IIH)
 Common in childbearing age and obese women
 Weight gain lead to its onset and exacerbation
 Headache, nausea, vomiting, transient visual obsturations and
pulsatile tinnitus
 Treatment: weight loss (non-pregnant), oral
acetazolamide(best avoided in first trimester)

16. Posterior reversible encephalopathy
syndrome (PRES)
 Hypertensive disorders of pregnancy
 Headache, visual loss, impaired consciousness and seizure
 Diagnosis confirmed by MRI – presence of subcortical white
matter edema typically in parieto-occipital area

17. Sub-conjunctival haemorrhage
 Benign finding during or after delivery – 10% of women
 Can also occur during pregnancy following repeated vomiting,
coughing or eye rubbing

18. Valsalva maculopathy
 Rare occurrence during labour or pregnancy
 Characterized by superficial retinal haemorrhage
 Increased intrathoracic or intraabdominal pressure during
labor is transmitted to the eye -> sharp rise in the intraocular
venous pressure

19. Purtscher’s retinopathy
 Retinal haemorrhages, edema, cotton wool spots,
predominantly located around the optic disc
 May occur in uneventful labour, severe pre-eclampsia or
eclampsia
 Unknown cause, thought to be associated with micro embolic
occlusion of pre-capillaries arterioles

20. Risk of rhegmatogenous retinal
detachment (RRD)
 Retinal detachment secondary to a tear or hole in the retina
with subsequent separation of the retina from the underlying
retinal pigment epithelium
 Save to deliver vaginally

23. THANK YOU