Saudi Journal of Ophthalmology (2013) 27, 51–53

Review Article

The eye and visual system in the preeclampsia/eclampsia syndrome:

What to expect?
Khawla Abu Samra, MD ⇑

Abstract

The preeclampsia/eclampsia syndrome is a multisystem disorder that can include cardiovascular changes, hematologic abnormal-
ities, hepatic and renal impairment, and neurologic or cerebral manifestations. It also can affect the eye and visual pathways. Visual
symptoms concern up to 25% of patients with severe preeclampsia and 50% of patients with eclampsia. This review discusses the
ophthalmic complications of preeclampsia/eclampsia with focus on the hypertensive retinopathy, exudative retinal detachment
and cortical blindness.

Keywords: Eclampsia, Preeclampsia, Ocular complications, Visual system, Eye

Ó 2012 Saudi Ophthalmological Society, King Saud University. All rights reserved.
http://dx.doi.org/10.1016/j.sjopt.2012.04.003

Introduction Definition

Pregnancy, being a real challenge to the human body, is
associated with a group of physiologic and pathologic
changes. One of the most important pathologies accompa-
nying pregnancy is the preeclampsia/eclampsia syndrome.
The syndrome is a multisystem disorder that can include
cardiovascular changes, hematologic abnormalities, hepatic
and renal impairment, and neurologic or cerebral manifesta-
tions.1,2 It also can affect the visual pathways, from the
anterior segment to the visual cortex. Improved under-
standing of the nature and pathophysiology of ocular dis-
eases that accompany preeclampsia/eclampsia offer the
opportunity for meaningful counseling and management
of the pregnant women who presents with ocular changes.
This review discusses the ophthalmic complications of pre-
eclampsia/eclampsia with focus on the hypertensive reti-
nopathy, exudative retinal detachment and cortical
blindness.
Preeclampsia is a clinical syndrome that afflicts 3–5% of
pregnancies and is a leading cause of maternal mortality,
especially in developing countries.3,4 It is a multisystem
hypertensive disorder, with the clinical spectrum including se-
vere preeclampsia; eclampsia; hemolysis, elevated liver en-
zymes, and low platelets (HELLP) syndrome; and HELLP
syndrome with eclampsia. Preeclampsia is defined as the
new onset of hypertension and proteinuria during the second
half of pregnancy.1 The diagnosis of preeclampsia requires
blood pressure >140/90 mm Hg on two occasions combined
with urinary protein excretion >300 mg/day1.4,5 Edema is a
classic feature of the disease, however, it is no longer consid-
ered a diagnostic feature given its lack of sensitivity or spec-
ificity.1,2,4,5 Eclampsia is an acute and life-threatening
complication of pregnancy characterized by the appearance
of tonic-clonic seizures, usually in a patient who had devel-
oped preeclampsia.2

Received 20 December 2011; accepted 14 April 2012; available online 23 April 2012.

Ross Eye Institute, 1176 Main Street, Buffalo, NY 14209, United States

⇑ Tel.: +1 631 875 3996.

e-mail address: Khawla.abusamra@gmail.com

Peer review under responsibility Access this article online:

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52
Pathophysiology
Preeclampsia is considered a systemic vascular disorder
where both hypertension and proteinuria implicate the endo-
thelium as the target of the disease. The hypertension of pre-
eclampsia is characterized by peripheral vasoconstriction and
decreased arterial compliance.3,4
In preeclampsia, the refractoriness to vasoactive agents is
lost first followed by the loss of vasoconstriction, which re-
sults in a decrease in intravascular volume, which in turn,
shunts to the extravascular spaces. There is also an imbalance
between proangiogenic and antiangiogenic factors during
preeclampsia. The two important antiangiogenic factors
implicated in preeclampsia are soluble vascular endothelial
growth factor (VEGF) and soluble endoglin. Nitric oxide sig-
naling is involved in vascular relaxation and is reduced in
preeclampsia.4,5
Ocular complications
The complications of preeclampsia extend to involve mul-
tiple systems and organs, the eye and visual system are of no
exception. Visual symptoms concern up to 25% of patients
with severe preeclampsia and 50% of patients with eclamp-
sia.5–7
Preeclampsia/eclampsia has various ocular manifestations.
Blurred vision is the most common visual complaint. Focal or
generalized arteriolar narrowing is the most common ocular
finding in preeclampsia/eclampsia syndrome. Other ocular
manifestations include photopsia, visual field defects, sudden
inability to focus, and in severe cases, complete blindness.5–7
Blindness and preeclampsia/eclampsia
Although visual disturbances are quiet common, complete
blindness is rare, with an incidence of 1–3%.6–8
Blindness in preeclampsia/eclampsia syndrome can be
due to the involvement of the occipital cortex, retina, or optic
nerve. In the past, most cases of blindness in preeclampsia
and eclampsia were commonly attributed to retinal pathol-
ogy including vascular abnormalities, edema or detachment
and acute ischemic optic neuropathy as a result of decreased
blood supply to the prelaminar portion of the optic nerve.
Nowadays, more emphasis is being placed on cortical blind-
ness.6–8
Hypertensive retinopathy
The effect of hypertension extends to involve the vascula-
ture of the retina, choroids and optic nerve head.9 At the
pathophysiologic level, the primary response of the retinal
vasculature to systemic arterial hypertension is vascular nar-
rowing. This response to an increased blood pressure leads
to focal or diffuse vasoconstriction. In addition, extravasation
of fluid to the extravascular spaces occurs as a result of in-
creased vascular permeability. Resultant retinal changes
may manifest as decreased retinal to vein ratio, cotton wool
spots, hemorrhages, Elschnig spots and serous retinal
detachments.9,10 Jaffe and Schatz, found a significant rela-
tionship between reduced arteriole to vein ratio and pre-
eclampsia, suggesting retinal vasospasm and resistance to
blood flow as a possible explanation for visual symptoms.7
K. Abu Samra
A measurable narrowing of the retinal arteries can be
demonstrated in about 50% of uncomplicated pregnancies
with physiologic increase in blood pressure. This narrowing
is functional and disappears with the termination of preg-
nancy. The degree of narrowing ranges from 10% to 40%,
thus it is very difficult to discriminate between a normal and
mild preeclamptic patient based on fundoscopy.9,11
Retinal changes due to severe preeclampsia are similar to
the changes of hypertensive retinopathy without the organic
changes of arteriolosclerosis.9–11
Severe arteriolar spasm is the most common fundoscopic
finding, occurring in 70% of preeclampsia cases. As a result
of this spasm, retinal vessels appear like a corkscrew or a
beaded pearl necklace. Other fundoscopic features include
arteriovenous crossings, hard and cotton-like exudates, reti-
nal hemorrhages and optic head swelling.11,12
The severity of retinal arteriolar changes is more closely re-
lated to the degree of underlying vasospasm. Previous stud-
ies showed that the level of retinopathy in patients with
preeclampsia did not correspond to the severity of hyperten-
sion (systolic or diastolic).9–12 It has been suggested that ret-
inal changes in preeclampsia may indirectly indicate the level
of placental vascular status and, hence, placental insufficiency
and fetal birth weight.9–12
Preeclampsia/eclampsia related retinopathy generally re-
solves soon after delivery and no specific treatment is re-
quired.9–12
Serous retinal detachment (SRD)
SRD is an unusual cause of visual loss in preeclampsia, first
described by von Graefe in 1855. It involves separation of the
neurosensory retina from the pigmented retinal epithelium
(RPE) and is one of the emergency situations in
ophthalmology.12
The exact pathophysiology of SRD in cases of preeclamp-
sia is not well known. It is usually present in patients with se-
vere preeclampsia or eclampsia, and they are usually
observed in the absence of significant retinal vascular abnor-
malities and retinal breaks. Hayreh et al. suggested that SRD
in preeclampsia may be caused by choroidal ischemia sec-
ondary to accelerated hypertension.13
The incidence of SRD is approximately 1% for severe pre-
eclampsia and 10% for eclamptic patients.12,14 Clinically, pa-
tients present with sudden loss of vision. The detachments
are often bullous and bilateral. Although it can be present
at any time during pregnancy, this condition most often ap-
pears before, or soon after, delivery.14,15 Mothers with the
most severe forms of preeclampsia have the worst fundo-
scopic findings.14–17
Conflicting opinions exist on whether maternal or fetal
outcome is worse in patients with fundoscopic signs. Some
studies reported poor fetal prognosis, while others reported
no prognostic implications on the fetus.17 SRD management
in preeclampsia is conservative and involves treating the
underlying condition. Spontaneous resolution usually occurs
within few weeks and visual prognosis is excellent. After
delivery, the subretinal fluid is reabsorbed by the RPE and vi-
sual acuity should return to pre-detachment levels within
weeks.7 However, patients with severe preeclampsia may
be left with permanent visual loss, despite resolution of the
SRD due to extensive RPE necrosis.7
The eye and visual system in the preeclampsia/eclampsia syndrome:
Cortical blindness
Acute cortical blindness is one of the most dramatic pre-
sentations of preeclampsia and is historically known to be
reversible. It is defined as blindness occurring in association
with normal fundoscopy and pupillary function.18
The exact mechanism of cortical blindness in preeclamp-
sia/eclampsia is unclear. It may result from cerebral vaso-
spasm and ischemic injury or it may arise from vasogenic
edema due to increased capillary permeability. Previous re-
ports suggested that cortical blindness in association with
preeclampsia/eclampsia may result from petechial hemor-
rhages and focal edema in the occipital cortex.8 Recently, sin-
gle-photon emission tomography studies supported the
finding that elevated capillary permeability and vasogenic
edema are involved in patients with cortical blindness.18–20
Cortical blindness is manifested in 1–15% of patients with
severe preeclampsia and eclampsia.8 It may occasionally be
the first clinical symptom preceding seizures by 4–7 hours.
Cortical lesions are usually bilateral and is often in the poster-
ior cortical areas.18–20
Neuroimaging findings in cortical blindness range from
normal to typical findings. Typically, there are bilateral corti-
cal occipital lesions with hypodensity on CT or hyperdensity
on T2-weighted MRI.20,21
Fortunately, blindness due to occipital lesions is reversible
and the lost vision is usually regained within 4 hours to
8 days.18–21
Late complications
Permanent ocular changes may develop in patients with
preeclampsia and may be mistaken for hereditary disorders
if discovered later in life. Permanent changes include narrow-
ing of arteriolar caliber, retinal pigment epitheliopathy and
patches of choroidal atrophy.22
Other late complications include proliferative retinopathy
(PR). The occurrence of PR is rare and is thought to be a con-
sequence of ischemia following microthrombus formation in
the periphery of the retinal microcirculation. The latter was
related to hemorrhagic alterations and activation of the
thromboplastin–fibrinogen system that occur in
preeclampsia.23
Other complications
Rare ocular complications of preeclampsia/eclampsia that
have been previously reported include; choroidal infarcts,
papillophlebitis, retinal artery and vein occlusion, ischemic
optic neuropathy, optic atrophy, optic neuritis, thrombosis
of the central retinal artery and purtscher-like retinopa-
thy.24–26
Conclusion
Visual disturbances are very common among pregnant
women with preeclampsia/eclampsia. Physicians should have
a firm understanding of the various ocular conditions associ-
ated with these disturbances. In addition, it is very important
53
to be vigilant about the rare and serious conditions that may
occur in pregnant women with visual complaints. Prompt
evaluation may be required and the immediate transfer of
care of the patient may help saving the lives of both the
mother and the baby.
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