*documenti 2006 imp
Ritenendo di fare cosa utile ai Soci, il CdE ha approvato la pubblicazione in lingua originale di questo articolo di quesitie risposte di interesse pratico per una rapida consultazione “à cahier de chevet” così da fornire spiegazioni osuggerimenti corretti alle mamme in attesa ed alle loro famiglie.
Pregnancy and your eyes
Department Ophthalmology, Rustaq Hospital, Sultanate of Oman
delivery. Lubricating eye drops which are safe to use
find very few women know about the changes their
eyes go through during pregnancy. A lot of changes hap-
during pregnancy can lessen the discomfort of dry eyes.
pen to a woman’s body when she is pregnant. While mostwomen know their feet & hands can swell, they don’t rea-lize their eye can swell as well. During pregnancy, various
Pathological effects of pregnancy
physiological changes take place in your body due to the
on eyes include the following
hormonal effects of the placenta. These hormones have
Diabetic Patients: Pregnancy can have an adverse outco-
effects on most organ systems, including the eyes. Some
me on the state of pre-existing diabetic retinopathy. The
of the effects of pregnancy in eyes are normal physiologi-
worsening of the disease depends on the severity of dia-
cal changes while few are pathological too.
betic retinopathy before pregnancy. Early stages of diabe-tic retinopathy usually stay quite stable, but the moreadvanced stages [especially the proliferative diabetic reti-
The physiological changes in eyes include
nopathy stages] tend to progress fast during pregnancy.
Gestational diabetes poses a very low risk for the deve-
The Intra-ocular Pressure: The normal intra-ocular pres-
lopment of retinopathy. Usually eye examination is not
sure [the fluid pressure within the eye] may decrease sli-
required for pregnant woman who had developed gesta-
ghtly due to certain hormonal and circulatory change1,2.
The decrease in intra ocular pressure may persist for seve-
In patients who had nonproliferative diabetic retino-
ral months post-partum. This could be advantageous to
pathy, studies demonstrated that as many as 50% of
patients suffering from Glaucoma, a condition where the
them may show an increase in their nonproliferative reti-
raised intra-ocular pressure damages the optic nerve that
nopathy, which often improves by the third trimester and
transmits visual information to the brain.
postpartum. Approximately 5-20% of these patients
Contact Lens intolerance: The sensitivity of the pre-
develop proliferative changes, the risk being higher in
gnant mother’s cornea also decreases significantly due to
those patients who had severe nonproliferative retino-
the associated fluid retention of ocular tissues [especially
pathy at beginning of their pregnancy. An ophthalmologic
during the last trimester of pregnancy]1,2 This may cause
examination at least once every trimester is recommen-
problems for contact lens wearers who may traumatize
their corneas more than usual, resulting in red, irritated
Studies on patients with proliferative diabetic retino-
eye and relative contact lens intolerance.
pathy have shown that a progression of disease may
Change in refraction: The tendency of fluid retention
occur in as many as 45% of them. However, in those
affects your refraction. This means that your current spec-
patients who had laser treatment before pregnancy, the
tacles or contact lenses may be temporarily either too
risk of progression was reduced by 50%. Hence; initiation
weak or too strong, depending upon your specific refrac-
of laser photocoagulation is recommended prior to pre-
tive error. It is usually a temporary change, and you need
gnancy. In patients with proliferatve diabetic retinopathy,
not get your eyes re-tested during the later stages of pre-
monthly ophthalmic examinations are warranted.
gnancy and for at least the first 6 weeks after child birth.
Proliferative diabetic retinopathy may regress at the end of
Unless the patient is insisting, it is best to defer prescribing
the third trimester or postpartum. Pan retinal laser photo-
new glasses until several weeks postpartum.
coagulation is effective during pregnancy in inducing
Dry Eyes: Some women experience dry eyes during pre-
regression of proliferative retinopathy. Almost all retinal
gnancy. This is usually temporary and goes away after
specialists would aggressively treat patients with high-risk
characteristics of proliferative retinopathy as defined by
Central serous retinopathy [CSR]: although not typical,
the Diabetic Retinopathy study. In patients with prolifera-
CSR has been reported to occur during pregnancy .
tive diabetic retinopathy that does not meet the high risk
Although more common in third trimester, it has been
criteria, some would treat one or both eyes, given the fact
reported to occur in the first and second trimesters. The
that some patients have progressed rapidly during pre-
diagnosis is clinical one. Observation is the treatment of
gnancy. Patients with proliferative diabetic retinopathy
choice as the condition resolves spontaneously in first few
cesarean section should be considered to prevent vitreous
months postpartum and has been known to occur in futu-
hemorrhage due to Valsalva maneuver used during
re pregnancies. A weak plus lens [hyperopic correction]
labor.Proliferative diabetic retinopathy are definitely not
may provide temporary visual assistance.
an indication to terminate the pregnancy.
Diabetic macular edema may develop or worsen during
Intracerebral and other tumors
pregnancy. It may be reasonable to observe such patientsuntil they reach postpartum, especially given that studies
Pituitary adenomas: With pregnancy, previously asymp-
have shown that most cases have resolved spontaneously
tomatic pituitary adenomas or micro adenomas may
after delivery1,2. It is therefore important for woman with
enlarge and result in various ophthalmic symptoms, such
advanced diabetic eye disease to seriously take their visual
as headache, visual field change, and / or visual acuity
future into consideration when planning their pregnancy
loss. It is recommended that pregnant patients with pitui-
and these decisions should only be made after consulta-
tary adenomas and micro adenomas have monthly
tion with their ophthalmologist. The proliferative or
ophthalmic follow up with visual field assessment to rule
advanced diabetic eye changes should be treated and sta-
out enlargement. Symptomatic pituitary adenomas may
require the combined efforts of an ophthalmologist,obstetrician, neurosurgeon, and endocrinologist to decide
Pregnancy Induced Hypertension [Pre-eclampsia]:
upon medical, surgical, or radiation treatment. One
The onset of hypertension in an otherwise normotensive
potentially visual threatening complication of pituitary
pregnant woman, with generalized edema and/or protei-
adenomas is the sudden increase in pituitary size from
nurea is termed pregnancy induced hypertension [PIH] or
infarction or hemorrhage referred to as pituitary apoplexy.
pre-eclampsia. If these changes are associated with seizu-
This condition may present as a sudden onset of heada-
res, then the disorder is classified as eclampsia.The inci-
che, visual loss, and / or ophthalmoplegia. Pregnancy is
dence of PIH in otherwise healthy women is approxima-
one of several potential risk factors for its occurrence. The
tely 5% and is more common in primigravidas.The onset
management of such patients includes a neurosurgical
of this disorder usually is after 20th week of gestation. PIH
opinion for potential surgical decompression.
has various maternal and fetal consequences, includingocular sequelae in up to one third of cases. The most com-
Meningioma of Pregnancy: Meningiomas are benign,
mon ocular complaint is visual blurring; however other
slow growing tumors. Meningiomas may have a very
symptoms have been reported, including photopsias, sco-
aggressive growth pattern during pregnancy that is diffi-
tomas, and diplopia.The protean ocular manifestations
cult to manage. They may regress postpartum but may
include retinopathy, optic neuropathy, serous retinal deta-
regrow during subsequent pregnancy. Often ophthalmic
chment and occipital cortical changes. The changes that
symptoms of decreased vision or visual field loss are the
occur in PIH induced retinopathy are similar to changes
first manifestations. Since most of these tumors regress in
from hypertensive retinopathy. The most common finding
size postpartum, those patients who are asymptomatic or
is focal arteriole narrowing, which also may be diffuse.
with mild symptoms can be observed and left untreated.
Other changes may include retinal hemorrhages, retinal
For those patients who require it, treatment usually is sur-
edema, cotton wool spots, nerve fiber layer infarcts and
gical. Indications for timing and type of intervention requi-
vitreous hemorrhage and papilledema. A positive correla-
tion exists between the severity of PIH and degree of reti-nopathy, however most changes are reversible once PIH
Occlusive vascular disorders: It is well appreciated that
resolves. Cortical blindness has also been seen in asso-
pregnancy represents a hypercoagulable state in which
ciation with severe preeclamsia/eclampsia around the
both clotting factors and clotting activity are increased,
time of delivery. In the past, changes in retinal vessels
through various changes that occur with platelets, clot-
were considered a risk factor for placental insufficiency
ting factors, and arterio-venous flow dynamics. Such
and fetal mortality and induction for delivery3. Both an
changes may be related to the development of central
old and a recent study of patients with pre-eclampsia and
retinal artery and vein occlusion in eye. Both branch and
eclampsia, found that those patients with retinal
central retinal artery occlusions have been reported to
hemorrhages and cotton wool spots had a higher rate of
occur in pregnancy. Retinal vein occlusions are less com-
Toxoplasmic Retinochoroiditis: Pregnant patients with
the doses used and the topical mode of administration,
old toxoplasmic retinochoroiditis are usually concerned
have not been implicated in an adverse fetal outcome,
about the possibility of transmitting toxoplasmosis to the
thought should go into using drugs only as necessary.
fetus, but in general they need not to be concerned.
However recommendations are summarized as per the
Congenital toxoplasmosis in the fetus generally results
FDA guide lines below for commonly used eye medication.
only from active infection of the mother that developsduring that pregnancy. The presence of toxoplasmic reti-
nochoroiditis or chorioretinal scars in the mother is regar-ded as evidence of congenital infection of the mother her-
Topical Beta blockers: [e.g., timolol eye drops] FDA risk
self, and does not indicate a new active infection of the
category C in first trimester while D in 2nd and 3rd tri-
mother. In recurrent disease, there are usually pre-existing
mester. B blockers can cause intrauterine growth retarda-
maternal antibodies that are believed to protect the fetus.
tion if used in 2nd & 3rd trimester and persistent neonatal
Therefore, the fetus should not be at risk for contracting
blockade if used near term. Should be avoided during pre-
congenital toxoplasmosis and its related birth defects
from a mother with toxoplasmic retinochoroiditis or cho-
Topical and systemic carbonic anhydrase inhibitors
rio-retinal scars. These patients usually are treated in a
[eg, acetazolamide, dorzolamide] are contraindicated
similar fashion to patients who are not pregnant.
during pregnancy because of potential teratogenic
However spiramycin has been recommended as a safer
Prostaglandin analogs [eg, latanoprost] FDA risk cate-gory C. Not well studied, and the reports that do exist are
conflicting. The use of latanoprost / trvoprost is generally
Ptosis [drooping of upper eyelid] has been reported to
contraindicated in pregnant women8,9.
occur during and after normal pregnancy and is usually
Mydriatics [Dilating Drops]: Use of occasional dilating
unilateral. The mechanism is thought to be due to defects
drops during pregnancy for the purposes of ocular exami-
that develop in levator aponeurosis from fluid, hormonal,
nation is safe. However, repeated use is contraindicated
and other changes from the stress of labour and delivery.
because of potential teratogenic effects of both parasym-
Uveitis: The immunosuppressive effects and high steroid
patholytics [eg, atropine] and sympathomimetics [eg, epi-
levels present in pregnant women may cause improve-
ment in uveitis during pregnancy, with exacerbation after
Topical Corticosteroids: [Prednisolone] FDA risk cate-
delivery. This has been noted in patients with sarcoido-
gory B. Although systemic corticosteroids are contraindi-
sus6 and Vogt koyanagi-harada syndrome7.
cated in pregnancy, topical steroids have not been repor-
Conjunctival Blood Vessels: Changes in conjunctival
ted to have an adverse effect on pregnancy10, but the
blood vessels have been described toward the end of pre-
safety of their use has not absolutely been established.
gnancy. These changes include a granularity of conjuncti-
Therefore, use with care during pregnancy. Avoid their
val venules, mild spasm of conjunctival arterioles, and
decreased visualization of conjunctival capillaries.
Excessive vomiting during pregnancy can cause conjuncti-
Topical chloramphenicol: FDA risk category is notavailable. It is used widely to treat superficial eye infec-
Ophthalmic medications in pregnancy
tion because of its spectrum and low cost. Many con-
“Doctor, I am pregnant. Can I still use this eye drops?”
cerns, however, have been documented about this drug’s
This is probably one of the most common questions asked
serious side effects-namely aplastic anemia and ‘grey baby
by pregnant women when they visit not only to their
syndrome’. A review article in 2002 concluded that the
ophthalmologist, but also their obstetrician or even family
risk of these serious side effects is low and they are
physician. Perhaps it is also one of the few questions that
unlikely to occur if patients adhere to the prescribed dose
even ophthalmologist and other doctors of various special-
and duration of the treatment.Chloramphenicol if given
ties might have difficulty in answering, especially when
to mother shortly before labor may cause “grey baby syn-
they have to present evidence to convince their patients.
drome” with cyanosis and hypothermia.Chloramphenicol
Limited data have been published regarding the potential
treatment should be avoided during the last week of pre-
risk of eye medications to the mother and fetus. When
one wishes to administer ophthalmic pharmacologic
Gentamicin eye drops: FDA risk Category C. Should be
agents during pregnancy, there should be a clear indica-
avoided in pregnancy. Drug should be given only if the
tion for them. Although most ophthalmic medications, in
potential benefit outweighs the potential risk8,9.
Ciprofloxacin eye drops: FDA risk category C. should
Most of the retinal specialist avoids fluorescein angio-
be used only if the potential benefit outweighs the poten-
graphy during pregnancy, especially first trimester.
Topical anesthetic: No known contraindications exist to
Tetracycline eye ointment: FDA risk category D.
use of topical anesthetic drops in pregnancy10.
Positive evidence of human fetal risk exists8,9.
Anti-allergic eye drops: Sodium cromoglycate 2%
Topical Erythromycin: FDA risk Category B. Controlled
[FDA risk category B] eye drop is safe to use in pre-
studies done on animals does not indicate risk to fetus.
gnancy while antihistaminic eye drops containing
However no adequate and well controlled studies done
naphazoline [FDA category C] are better avoided8,9.
on pregnant women. Generally considered safe to use in
Little has been published to evaluate the true risk in the
use of eye medication during pregnancy The overall level
Antibiotics which are safe during pregnancy are amoxi-
of evidence for risk giving ophthalmic drugs to pregnant
cillin, ampicilline, benzylpenicilline, cabenicilline, cloxacilli-
women is low. Most of the available evidence is based on
ne, Erythromycine and vancomycin. Antibiotics which
only individual case reports and animal studies.
should be avoided during pregnancy are, gentamycin,
If you are using any other medication during pregnancy,
streptomycin, neomycin, & kenamycin, Flourinated quino-
check with your doctor whether it is safe to continue, and
lones like norfloxacilline and ciprofloxacilline are not con-
always let your eye care practitioner know that you are pre-
gnant when you visit him, so that he may prescribe medi-cations that are safe and harmless to you and your baby.
Antiviral eye preparations [Acyclovir eye ointment]:
The topic of this article provides a practical overview for
FDA risk category B. Topical acyclovir has not been stu-
pregnant women and their treating doctors. Little has
died in pregnant woman. However this medicine has not
been published to evaluate the eye changes in pregnancy;
been shown to cause birth defects or other problems in
however most of the physiological eye changes are rever-
animal studies. So it is considered generally safe for eye
sible and doesn’t warrant urgent ophthalmic help.
application. Systemic acyclovir should only be used
Fortunately the pathological eye changes during pre-
during pregnancy if potential benefit justifies the poten-
gnancy discussed above are extremely rare and occasio-
nally seen in daily ophthalmic practice.
Fluorescein dye: FDA risk category B. No known tera-
Opinions from obstetrician, ophthalmologists, and family
togenic effects of fluorescein during pregnancy exist.
physicians are essential to ensure safe pregnancy.
1. SOHEL SOMANI, IQBAL IKE K AHMED. Pregnancy, Special considerations.
6. CHUMBLEY LC, KEARNS TP. Retinopathy of sarcoidosis. Am J Ophthalmol
, 2005; November 7.
2. JANET S. SUNNESS, ARTURO SANTOS. Pregnancy and the mother’s eye.
7. STEAHLY LP. Vogt-Koyanagi-Harada syndrome and pregnancy. Ann
Duane’s clinical ophthalmology.
1997; 32: 1-19.
3. SADOWSKY A, SERR DM, LANDAU J. Retinal changes and fetal prognosis
8. CHUNG CY, KWOK AKH, CHUNG KL. Use of ophthalmic medications
in the toxemias of pregnancy. Obstet Gynecol
during pregnancy. Hong Kong Med J.
TO M, UEMURA A. Retinochoroidopathy and systemic state in toxemia
of pregnancy. Acta Soc Ophthalmol Jpn
9. Drugs in Pregnancy and Lactation: www.safefetus.com
5. BEDROSSIAN RH. Central serous retinopathy and pregnancy. Am J
10. SAMPLES JR, MEYER SM. Use of ophthalmic medications in pregnant and
nursing women. Am J Ophthalmol
1988; 106 :616-23 [Medline].
British Journal of Guidance & Counselling,Vol. 34, No. 3, August 2006CATHERINE HAKIMDepartment of Sociology, London School of Economics, Houghton Street, London. WC2A2AE, UK; email: email@example.comThere are no sex differences in cognitive ability but enduring sex differences incompetitiveness, life goals, the relative emphasis on agency versus connection. Policy-makers’ andfeminist emph
Publikationen Originalarbeiten Blättner B, Kohlenberg-Müller K, Grewe A: Prävention von Adipositas bei Kindern und Jugendlichen: Neue Strategien sind erforderlich. Prävention 29, 42 – 46, Blättner B, Kohlenberg-Müller K, : Evaluation von zwei Adipositas-Programmen für Kinder und Jugendliche. Public Health Forum (51), 25, 2006 Blättner B, Kohlenberg-Müller K, Grewe A: Adiposi