THE OPHTHALMOLOGIC CHANGES IN PREGNANCY

Sophia M. Chung, MD
St. Louis, Missouri

The pregnant woman's body undergoes tremendous

physiologic changes as a result of hormonal influences,
increased maternal blood volume and cardiac output,
coaguktive changes, and immunologic alterations. There are
numerous ophthalmologic changes that result in the normal
and otherwise healthy pregnancy. The clinician should be
familiar with these alterations in order to better understand
the neuro-ophthalmologic manifestations present in the
gravid patient.
EYELID
Ptosis has been reported to occur in pregnancy. Beard
anecdotally reports in his textbook six cases related to
pregnancy3; four were unilateral while two were bilateral.
These cases developed a few days to weeks after delivery.
He theorizes that the high progesterone levels cause
increased fluid content which secondarily weakens the
levator aponeurosis. Sanke subsequently gave a report of
ptosis occurring during the sixth month of pregnancy.67
Horner's syndrome is a more commonly recognized
complication of lumbar epidural analgesia during labor and
deliveiy albeit rare. In this setting, the Horner's syndrome
resultsfrom cephalad spread of anesthetic to the sympathetic
chain. The duration is temporary with resolution typically
within 5 hours. 68
Chloasma, or the "mask of pregnancy" is lid and facial
pigmentation that increases during pregnancy. Melanocyte
stimulating' hormone is considered responsible for these
changes.64
CORNEA
Surprisingly little has been written on the subject of
corneal and lenticular changes during pregnancy. There
appears to be a shift towards myopia mediated by
progesterone or estrogen. These hormones may cause an
increase of the water content of the cornea and/or lens. The
older ophthalmic literature is confusing but newer data by
Park supports an increase in corneal steepening particularly
during the third trimester.56 This steepening is persistent in
nursing mothers and returns to baseline after cessation of
breast-feeding.
Corneal thickness likewise has been
demonstrated to increase in pregnancy.76,77 The optometrie
literature however provides conflicting data suggesting no
change in corneal thickness and refractive error.48
In a recent study by Park, changes in refraction were not
found while conversely Imafidon reports that the refractive
error can change by 1.25 D towards myopia.33,36 Imafidon
attributes the myopic shift directly to lens hydration. Rabbit
studies have shown that progesterone and estradiol increase
the lens membrane permeability with a significant water
gain. 4 4

Corneal sensitivity thresholds are increased particularly

during the last trimester with resolution by the second month
postpartum in 85% patients, 54,63
Contact lens intolerance is reported in as many as 30% of
gravid patients.33 The changes may be attributed to corneal
changes as indicated above, changes in tear production,
alterations in the composition such as increased secretion of
mucin due to the effects of estrogen and progesterone on
goblet cells.33
Duncan found three Krakenberg spindles amongst 100
consecutive pregnant women while he found zero among 120
consecutive nonpregnant women in a family planning clinic.
Eighty-five of the women in the latter group were, however,
on oral contraceptives. Two of the three women with
Krukenberg spindles had significant diminution of the
endothelial pigmentation during the postpartum period. He
suggests that melanocyte-stimulating hormone (MSH),
relaxin, estrogen and progesterone, and/or insulin may all be
related to this change in pigmentation during pregnancy.19
INTRAOCULAR PRESSURE
There is general agreement in the literature that the
intraocular pressure (IOP) falls in pregnant patients.
Numerous reports, both animal 20,46 and human studies
support the decrease. 4,26,30,31,57,60,76 In earlier studies, the fall
in IOP was attributed to increased venous capacitance in the
lower extremities. However, further investigations have
shown the effect of hormones on the IOP by affecting
outflow facility, aqueous formation, and episcleral venous
pressure. Relaxin injected intramuscularly lowered the IOP
in both men and women by increasing facility of outflow.57
Studies using progesterone or estrogen in single preparations
have shown conflicting results withrespectto their influence
on IOP, However, combination preparations can produce
decreases in IOP. 51,52 Grant and Goldmann determined the
normal coefficients of outflow to be 0.22 and 0.33
respectively. In the pregnant women, however, the
coefficients are almost always increased with values of 0.35
to 0.55 with the values normalizing in the postpartum
period 4 These values support the increased facility of
outflow as one reason for the decreased IOP. Recent studies
by Ziai et al confirmed lower IOPs in pregnant women due to
increased outflow facility.
Progesterone levels were
statistically correlated to these changes although a cause and
effect relationship could not be established. The beta-HCG
levels could not be comrfated to the IOP. The data from Ziai
and colleagues can be summarized by Table l, 7 7 Episcleral
venous pressure is also reduced and is consistent with the
generalized reduction in peripheral vascular resistance.

149

Thus, multiple factors may interplay to account for the

decrease in IOP seen in pregnant women.
REPEATED MEASURES ANALYSIS OF STUDY
VARIABLES
Variable

Trimester

Mean

IOP, mm

1
2
3
PP

11.6
10.7
10.3
11.6

Aqueous
flow

1
2
3
PP

2.6
2.6
2.7
2.6

Outflow
facility

3
PP

0.44
0.30

Corneal
thickness

1
2
3
PP

0.538
0.544
0.548
0.540

P
.

<0.01

0.79

<0.01
<0.01

Table 1, Measures of intraocular pressure (IOP), aqueous flow,

outflow facility, and corneal thickness according to trimester of
pregnancy. Abbreviations: PP=pos1partum, Adaptedfrom Ziai N,
et al, Arch Ophthalmol 112:801-806, 1994."

occur during the third trimester. All of the cases reported

have been mild with spontaneous resolution near the end of
the pregnancy or in the postpartum period.
In 1991, Gass reported on six healthy nonwhite pregnant
women with CSR during the third trimester but with focal
areas of white subretinal exudate.25 In addition he reviewed
eight previously reported women who in retrospect
demonstrated the same white subretinal exudates. He also
reviewed previous cases of CSR in nonpregnant patients and
showed a statistically significant higher incidence of these
exudates in pregnancy (90% compared to less than or equal
to 20%). Sunness and coauthors confirmed a higher
incidence of these exudates although without racial
predilection.74 The white subretinal exudates surround and
partly cover the RPE detachment and are associated with
greater than average amount of subretinal fluid. A defect in
the RPE is usually visualized onfluorescein angiogram into
the subretinal fluid. Fibrous strands, as confirmed by
histology, may be left beneath the retina after resolution of
the subretinal fluid. This attests to the marked increase in
permeability of the choriocapillaris.
A number of mechanisms have been proposed for CSR in
pregnancy. Hormonal influences could alter the structure of
vessels or the RPE. The increased blood volume in the
choriocapillaris has been proposed to stress the dynamics
between the choriocapillaris and RPE, The lower colloid
osmotic pressure of plasma with increased capillary
permeability may also contribute; hypercoaguability with
elevated fibrinogen and factors VII, VIII, IX, and X levels
could theoretically lead to microemboli to the choroid.
Collier has experimentally shown in cats that subretinal fluid
transudation occurs with microspheres in the choroidal"
vessels.14 Increased levels of prostacyclin in the second and
third trimester may also predispose these patients, Finally,
changes in the autonomic nervous system regulation could
contribute.22

RETINA
The retinal changes observed in pregnancy are perhaps
the most commonly recognized ophthalmologic alteration.
The neurosensory retina and vessels appear normal
throughout pregnancy. However, pregnancy may render
some women predisposed to central serous chorioretinopathy
or with pre-existing disease, such as diabetes mellitus, to
potentiation of their disease. The choroidal and retinal
The prognosis is good for resolution of the RPE
changes seen in pre-eclatnpsia and eclampsia are the subject
detachment with resolution of the subretinal fluid with most
of another author (See Kathleen Digre, M.D.)
enjoying complete recovery. However, some are left with
permanent scotomas, dyschromatopsia , micropsia and
Central serous chorioretinopathy (CSR) is an idiopathic
metamorphopsia. Central serous retinopathy may recur both
localized serous retinal detachment caused by focal retinal
in the pregnant and nonpregnant state; conversely,
pigment epithelial (RPE) detachments. CSR is commonly
seen in men between the ages of 20-45 years. However, it subsequent pregnancies may not be complicated by the
disease.74
may be seen in women during uncomplicated pregnancies.
Eighteen cases of CSR in nontoxemic pregnant women have
It is important to recognize CSR as benign and not to
been reported to date. 5,13,15 ' 22 ' 24,7 ' 1 Bedrossian reports twomisinterpret these findings as subretinal neovascular
pregnant women with CSR5; Chumbley and Frank report one membranes, areas of retinitis, or retinal ischemia.
woman who experienced CSR during four consecutive
Purtscher's like retinopathy has been reported during or
pregnancies with resolution.'3 Subsequently, Fastenberg and immediately after labor by Blodi and colleagues.6 Purtscher's
Ober reported an additional three patients, all nonretinopathy is typically associated with severe compression
Caucasians suggesting a higher incidence in Orientals or
injury to the head or trunk although it has also been reported
Hispanics.22 Central serous chorioretinopathy may occur with pancreatitis.34 The ophthalmoscopic findings in
anytime during the pregnancy although half of the cases
Purtscher's include multiple patches of superficial retinal
150

occur during the third trimester. All of the cases reported

have been mild with spontaneous resolution near the end of
the pregnancy or in the postpartum period.
In 1991, Gass reported on six healthy nonwhite pregnant
REPEATED MEASURES ANALYSIS OF STUDY
women
with CSR during the third trimester but with focal
VARIABLES
areas of white subretinal exudate,25 In addition he reviewed
Trimester
Mean
Variable
P
eight previously reported women who in retrospect
demonstrated
the same white subretinal exudates. He also
11.6
1
IOP, mm
reviewed
previous
cases of CSR in nonpregnant patients and
<0.01
10.7 .
2
showed
a
statistically
significant higher incidence of these
10.3
3
exudates
in
pregnancy
(90% compared to less than or equal
11.6
PP
to 20%). Sunness and coauthors confirmed a higher
incidence of these exudates although without racial
2.6
1
Aqueous
predilection.74 The white subretinal exudates surround and
flow
2
2.6
0.79
partly cover the RPE detachment and are associated with
2.7
3
greater than average amount of subretinal fluid. A defect in
2.6
PP
the RPE is usually visualized on fluorescein angiogram into
0.44
3
Outflow
the subretinal fluid. Fibrous strands, as confirmed by
<0.01
facility
PP
0,30
histology, may be left beneath the retina after resolution of
the
subretinal fluid. This attests to the marked increase in
1
0,538
Corneal
permeability of the choriocapillaris.
2
0.544
<0.01
thickness
A number of mechanisms have been proposed for CSR in
0.548
3
pregnancy. Hormonal influences could alter the structure of
PP
0.540
vessels or the RPE. The increased blood volume in the
choriocapillaris has been proposed to stress the dynamics
Table 1. Measures of intraocular pressure (IOP), aqueous flow,
between
the choriocapillaris and RPE. The lower colloid
outflow facility, and corneal thickness according to trimester of
osmotic
pressure of plasma with increased capillary
pregnancy. Abbreviations: PP=postpartum. Adaptedfrom Ziai N,
permeability may also contribute; hypercoaguability with
et al, Arch Ophthalmol 112:801-806,1994."
elevatedfibrinogen and factors VII, VIII, IX, and X levels
could theoretically lead to mieroemboli to the choroid.
RETINA
Collier
has experimentally shown in cats that subretinal fluid
The retinal changes observed in pregnancy are perhaps
transudation occurs with microspheres in the choroidal
the most commonly recognized ophthalmologic alteration.
vessels.14 Increased levels of prostacyclin in the second and
The neurosensory retina and vessels appear normal
third trimester may also predispose these patients. Finally,
throughout pregnancy. However, pregnancy may render
changes in the autonomic nervous system regulation could
some women predisposed to central serous chorioretinopathy
contribute.22
or with pre-existing disease, such as diabetes mellitus, to
The prognosis is good for resolution of the RPE
potentiation of their disease. The choroidal and retinal
detachment with resolution of the subretinal fluid with most
changes seen in pre-eclampsia and eclampsia are the subject
enjoying complete recovery. However, some are left with
of another author (See Kathleen Digre, M,D.)
permanent scotomas, dyschromatopsia , micropsia and
Central serous chorioretinopathy (CSR) is an idiopathic
metamorphopsia. Central serous retinopathy may recur both
localized serous retinal detachment caused by focal retinal
in the pregnant and nonpregnant state; conversely,
pigment epithelial (RPE) detachments. CSR is commonly
subsequent pregnancies may not be complicated by the
seen in men between the ages of 20-45 years. However, it
disease.74
may be seen in women during uncomplicated pregnancies.
Eighteen cases of CSR in nontoxemic pregnant women have
It is important to recognize CSR as benign and not to
been reported to date. 5 ' 13 - 15,2 " 4 - 74 Bedrossian reports two misinterpret these findings as subretinal neovascular
pregnant women with CSR5; Chumbley and Frank report one membranes, areas of retinitis, or retinal ischemia.
woman who experienced CSR during four consecutive
Purtscher's like retinopathy has been reported during or
pregnancies with resolution,13 Subsequently, Fastenberg and immediately after labor by Blodi and colleagues,6 Purtschcr's
Ober reported an additional three patients, all nonretinopathy is typically associated with severe compression
Caucasians suggesting a higher incidence in Orientals or
injury to the head or trunk although it has also been reported
Hispanics.22 Central serous chorioretinopathy may occur with pancreatitis.34 The ophthalmoscopic findings in
anytime during the pregnancy although half of the cases
Purtscher's include multiple patches of superficial retinal
Thus, multiple factors may interplay to account for the
decrease in IOP seen in pregnant women,

150

whitening and retinal hemorrhages concentrated about the

q)tic disc. Four women presented with a similar retinopathy
within 24 hours; of childbirth, two requiring oxytocin and one
a Cesarian section.6 Examination showed peripapillary white
retinal patches consistent with arterial occlusion and
infarction. Two of the four had pre-eclampsia; one had
pancreatitis and hypertension but no other collagen vascular
disease. Three of the four patients showed resolution with
significant improvement of vision. Ayaki presented a similar
case of Purtscher's-like retinopathy in a pregnant woman
although she had hyperlipidemia, elevatedfibrinogen and
thrombocytosis. A nonhypertensive 16 year old induced with
oxytocin suffered a similar scenario as described by Gass.25
Although the pathogenesis of Purtscher's retinopathy has
been attributed to lymphatic extravasation of retinal vessels,
and reflux venous shock waves by sudden intrathoracic
pressure elevations, there are clinical features of Purtscher's
retinopathy to support emboli within the retinal arteriolar
system.6 The sudden onset of visual loss, multifocal lesions,
obstruction seen on fluorescein angiography, and the
distribution of ischemic patches are characteristic.6 Fat
emboli 34 , air emboli9, and most recently, leukoemboli from
endothelial damage6-35'70 specifically by C5a activation, have
been proposed as the mechanism.

have not been isolated, they could still be influential by

mechanisms not requiring receptors by exerting indirect
effects.69
The influence of pregnancy on diabetic retinopathy has
been extensively discussed in the literature. The degree of
retinopathy is related primarily to the duration of the disease
and not directly to the pregnancy itself. Therefore, those
women with gestational diabetes are not at great risk;
however, those with the disease for greater than 10-15 years
have 63-82% risk of having retinopathy.
Sunness in an extensive review of the literature relevant
to this issue, consolidated all of the studies analyzing the
changes in diabetic retinopathy in pregnant women,73 Table
2 below summarizes her findings, In short, only 12% of
patients without retinopathy prior to pregnancy showed
progression of their disease with 57% regressing postpartum.
Those with background disease had a greater rate of
progression with 5% developing proliferative retinopathy
requiring laser photocoagulation. Of the 122 women with
proliferative disease early in the pregnancy, 81 had not been
treated with laser therapy. 58% of these patients progressed.
Thirty-five women had received laser photocoagulation and
only 9 (26%) advanced.
The recommendations, therefore, are to examine those
Amniotic fluid embolism is a life-threatening
women with little to no retinopathy in the first and third
complication of pregnancy with an 86% mortality rate. The
trimester, with background disease, each trimester, and
contents of amniotic fluid such as lanugo hair, fat, mucin, finally those at high risk, i.e., proliferative disease, each
bile, and squamous cells are released into the mother's
month.
Panretinal photocoagulation may be safely
arterial system resulting in cardiovascular collapse,
administered during pregnancy.
hemorrhage, cyanosis, disseminated intravascular clotting,
OPTIC NERVE
and ultimately death. Chang and Herbert report the case of
Optic disc edema may be seen in the pregnant patient in
a survivor of amniotic fluid embolism who suffered retinal a variety of settings. Bilateral disc edema may herald the
arterial occlusions.11
presence of intracranial tumors with secondary
Other retinal vascular occlusions have been reported.
hydrocephalus. (The subject of intracranial tumors in
Five cases of retinal arterial obstruction have been reported
pregnancy is covered elsewhere in this syllabus; see Mark
in non-eclamptic pregnant women7-8'27-45; two of the women's Kupersmith, M.D.) It may alsoreflect idiopathic intracranial
histories were complicated by migraines and one of the two hypertension (EH). Digre and colleagues performed an
women had coexisting elevated factor Vffl level. One of the extensive review of patients with EH at the University of
five had concurrent protein S deficiency. Protein S
Iowa spanning from 1939-1982 and highlighted those
deficiency occurs in young patients who present with deep
associated with pregnancy.17 Furthermore, they exhaustively
venous thrombosis and has been associated in a young adult
reviewed the past literature combing for cases reported in
man with a central retinal artery occlusion.27 Central retinal pregnant women. They summarized their results and
vein occlusion has been reported once although it
concluded that IIH occurs in pregnancy at the same rate as
hasbeenassociated with oral contraceptives.12,72 Vasculitis of that in the general population. Idiopathic intracranial
the retinal veins has also been documented.71
hypertension usually appears in thefirst half of pregnancy
Case reports document presentation and/or growth of
although it may occur any time, and the visual outcome is not
choroidal hemangioma, osteoma, and melanoma during
affected by the pregnancy itself.17 Carbonic anhydrase
pregnancy. 23 ' 50 fil 6 9 Debate continues about the mechanism inhibitors have been associated with limb deformities and
although
melanocyte-stimulating hormone (MSH),
therefore are contraindicated in the pregnant woman.66
adrenocorticotropic hormone (ACTH), and the other
In the pregnant woman with diabetes, optic disc edema
hormones have been implicated. Both of these hormones are
may be seen as in Lubow's syndrome, a relatively benign
at increased levels during pregnancy and are responsible for
manifestation of diabetic vasculopathy. Three cases of
melanocyte activity. Although estrogen binding receptors
Lubow's syndrome in pregnancy have been reported. 238 ' 73

Although Lubow and Makley attributed the disc swelling to

ischemic optic neuropathy, the condition is self-limited, with
little to no change in visual acuity. There may be associated
optic nerve-related visualfield defects. Therefore, Barr et al
and Pavan and colleagues attribute the edema to diabetic
vasculopathy.38,73 The relationship of pregnancy to optic disc
edema in juvenile diabetes is not clear although the

progression of diabetic retinopathy in pregnant patients

might be extrapolated to suggest a risk of enhanced
vasculopathy at the disc. Because bilateral disc edema is
present in 60% of cases2, it is important to distinguish optic
disc edema of juvenile diabetes from papilledema secondaty
to increased intracranial pressure.

Degree of Retinopathy

Changes during Pregnancy

Postpartum

Recommendation

No/Little

57/484 (12%)
developed BDR

13/57 (57%)
regressed

Examination in
trimester 1 & 3

1/484 (0.2%)
developed PDR

regressed with
PRP

Background

120/258 (47%)
progressed
14/258 (5%)
developed PDR

Proliferative

56/122 (46%)
progressed

Examination in
each trimester
7 PRP-all
regressed
Examination each month

47/81 (58%) of
untreated progressed
9/35 (26%) of
treated progressed

Table 2. Summary of studiesfrom 1978-1988 examining diabetic retinopathy in pregnant women.10,14 2 8 , 3 7 " 3 9 , 4 3 , 5 3 , 5 5 , 5 9 , 6 3 Information ta
from Sunness, JS, Surv Ophthalmol 32:219-238, 1988.73
Papillophlebitis has been reported in the pregnant
woman.32
Visual evoked potentials in women have demonstrated
shorter PI00 latencies than men with one theory
hypothesizing the steroid hormonal differences as the reason.
The work by Marsh and Smith supports this theory as their
group of pregnant women showed shorter PI00 latencies
when compared to the nonpregnant women. Estrogens cause
inhibition of gamma aminobutyric acid (GABA) synthesis
while progesterones enhance the cellular responses to
GAB A. GABA is an important inhibitory neurotransmitter
in the cerebral cortex particularly in the visual cortex. Their
delicate balance may control the activity in the visual
cortex.49
CRANIAL MONON1UROPATHIES
Jacobson reported three women with decompensated
fourth nerve pareses during their last trimester, two of whom
resolved in the postpartum period.
Mechanisms
hypothesized include expansion of the cavernous sinus to
152

exert mild compression on the fourth nerve within the dural

wall 36
Bell's palsy is three times more common in the pregnant
patient than women in a comparable age with 75% occurring
within the last trimester.29,62 The prognosis and management
remains similar in these patients as in the general population
Transient partial or total loss of accommodation during
pregnancy and delivery has been reported by Duke-Elder."
CONCLUSION
There are a variety of ophthalmologic changes in
pregnancy that may occur although most pregnant women
will remain asymptomatic. Treatment of most of these
conditions is similar to therapy in nonpregnant individuals
taking precautions with medications and interventional
techniques. Awareness of these changes, however, is
important to better understand potential neuroophthalmologic manifestations.

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