Surgery for detachment of the retina should not affect a normal delivery

RATES OF RECURRENT RETINAL DETACHMENT AFTER VAGINAL VERSUS CESAREAN DELIVERIES: A Retrospective Analysis and Review of the Literature

PURPOSE

To evaluate the risk of a retinal redetachment in women after vaginal delivery versus cesarean delivery.

METHODS

Retrospective cohort analysis of patients diagnosed with retinal detachment (RD) who had later delivered in one tertiary medical center. Recurrence rates of RD were obtained from medical charts.

RESULTS

A total of 967 women with RDs were evaluated, and 66 patients met the inclusion criteria. The mean age at the time of RD was 22.64 ± 5.81 SD years and 21.75 ± 5.47 SD years in the vaginal delivery group and the cesarean section group, respectively. None of the patients had a history of eye surgery or traumatic eye injury before the event of RD. In all patients, the detached retina was surgically reattached. Retinal detachment was not recorded in the fellow eye during follow-up. We report four cases of redetachment after birth in four women. In our study, there was a 5% rate (n = 2) of RD after a vaginal delivery as compared with a 7.5% (n = 2) redetachment rate for patients after a cesarean delivery ( P = 0.654).

CONCLUSION

The risk of a redetachment of the retina in women is not increased after a vaginal delivery as compared with a cesarean delivery. Therefore, in our opinion, there is no ophthalmic benefit in a cesarean section for a woman with prior RD.

Motherhood: What every ophthalmologist needs to know

The aim of this review article is to summarize the available literature on physiologic and pathologic ocular changes during pregnancy and the effect of diseases in pregnancy. A literature search was conducted using PUBMED, MEDLINE, and Cochrane library in English. In addition, the cited references in the published articles were manually reviewed for the relevant results. Pregnancy encompasses a multitude of changes in all body systems, including the visual system of the female. The changes can be physiological, i.e., changes occurring in the lids and adnexa, cornea, conjunctiva, changes in tear film composition and intraocular pressure, retina, choroid, and visual field. Pathological changes in a pregnant woman's eye include changes related to preeclampsia and eclampsia, central serous chorioretinopathy, retinal artery or vein occlusions, and disseminated intravascular coagulation. Preexisting diseases like diabetic retinopathy, Graves' disease, idiopathic intracranial hypertension, various inflammatory conditions can undergo changes in their course during pregnancy. Ophthalmic medications can have an effect on both mother and the baby and hence should be used cautiously. In addition, intrauterine infections play a major role in causing inflammation in the eye of the baby. Hence, vaccination of the mother prior to pregnancy plays an important role in preventing intrauterine infections in the neonate. A regular eye examination in the perinatal period plays a vital role in recognizing ophthalmic pathologies which might require a prompt medical intervention. Pathological ocular diseases should be discriminated from physiologic changes to establish an individualized treatment or preventive plan. This approach to ocular benefits of treatment to the mother should always weigh against the potential harm to the fetus.

Glaucoma in pregnancy: an update

PURPOSE OF REVIEW

Glaucoma management during pregnancy is a complex challenge, which requires balancing the clinical disease of the mother with the potential risks of therapy to the developing child. Because systematic studies are lacking in the pregnant population, this review aims to collect the array of available data from observational studies and case reports to provide the reader with guidance and context for the safety of glaucoma interventions during pregnancy.

RECENT FINDINGS

Surgical glaucoma is a rapidly expanding field with many new technologies and procedures. We review the surgical options for the gravid patient with reference to traditional procedures like trabeculectomy and tube-shunts, and newer MIGS procedures. When indicated, orphan trabeculectomy, or with collagen matrix implant may be a viable solution for severe glaucoma during pregnancy. Newer MIGS procedures such as the gelatin stent may also provide minimally invasive options for pregnant patients. Two new medications, Vyzulta and Rhopressa, were recently released in 2018 and have limited data to support their safety for use during pregnancy.

SUMMARY

The careful consideration of fetal health in the management of glaucoma during pregnancy is best done as a part of a multidisciplinary team including obstetrics and neonatology. When medication is necessary, steps to minimize systemic absorption should be employed. Surgical management should not be excluded for pregnant patients and may be considered before medical management in some cases to prevent fetal exposures and maternal harm.

Ocular Changes During Pregnancy

Pregnancy is needed for the perpetuation of the human species, and it leads to physiological adaptations of the various maternal organs and systems. The eye, although a closed space, also undergoes some modifications, most of which are relatively innocuous, but they may occasionally become pathological. For women, pregnancy is a susceptibility period; however, for many obstetricians, their knowledge of the ocular changes that occur during pregnancy tends to be limited. For this reason, this is a important area of study as is necessary the development of guidelines to approach those changes. Of equal importance are the knowledge of the possible therapies for ophthalmological problems in this period and the evaluation of the mode of delivery in particular conditions. For this article, an extensive review of the literature was performed, and a summary of the findings is presented.

Delivery recommendations for pregnant females with risk factors for rhegmatogenous retinal detachment

OBJECTIVE

High-risk pathologies for rhegmatogenous retinal detachment (RRD) in otherwise healthy pregnant females are not contraindications for spontaneous vaginal delivery. However, 74% of European obstetrician-gynecologist (OBGYN) respondents in 2008 recommended operative delivery for females at risk for RRD. This discrepancy is likely due to an older study suggesting a causal relation between Valsalva-like manoeuvres and RRD. The purpose of this study is to determine current delivery recommendations for healthy pregnant females with high-risk pathologies for RRD among Canadian ophthalmologists and OBGYNs.

METHODS

Anonymous prospective cross-sectional survey sent via electronic link in 2013. χ(2) test of proportions was used to compare delivery recommendations between the 2 specialties. Multinomial logistic regression was used to identify predictors for recommendations.

RESULTS

A total of 356 participants responded including 92 ophthalmologists and 27 trainees, and 185 OBGYNs and 52 trainees. For healthy pregnant females with previously treated retinal hole/tear or treated RRD, significantly more OBGYNs recommended cesarean section and significantly more ophthalmologists recommended spontaneous vaginal delivery. Length of practice and type of practice setting were significant predictors among obstetricians in their delivery recommendations.

CONCLUSIONS

This study is the first to include obstetricians, ophthalmologists, and their trainees in a survey of the recommended mode of delivery for pregnant females with risk factors of RRD. Our results suggest that obstetricians concerned about potential RRD in pregnant patients may be unnecessarily recommending operative management. Educational sessions on the risk for RRD with spontaneous vaginal delivery may reconcile the current differences in recommendations between ophthalmologists and obstetricians.

Obstetric opinions regarding the method of delivery in women that have had surgery for retinal detachment

Objectives

We sought to determine international obstetric opinions regarding the influence of a history of rhegmatogenous retinal detachment on the management of labour and to review the evidence base.

Design

A questionnaire containing closed questions, with pre-coded response opinions, was designed to obtain a cross-section of the obstetric opinions.

Setting

Questionnaires were distributed at the 20th European Congress of Obstetrics and Gynaecology in Lisbon, Portugal.

Participants

One hundred questionnaires were distributed among obstetricians attending the congress and 74 agreed to participate.

Main outcome measures

Participants were asked to state their preferred method of delivery in such patients and the reasons for their recommendation. Furthermore, we questioned whether there was any difference in opinions depending on generation.

Results

The majority of respondents (76%) would recommend assisted delivery (either Caesarean section or instrumental delivery), whereas the remaining 24% would advise normal delivery. Generation is not a factor influencing this decision. The majority (58%) based their decision to alter the management of labour on their personal opinion of standard of care.

Conclusion

The literature shows that there is little evidence to support the belief that previous retinal surgery increases the risk of re-detachment of the retina during spontaneous vaginal delivery. This short survey shows that the majority of an international sample of obstetricians questioned does not share this viewpoint. Therefore, unnecessary interventions may be occurring in otherwise fit women with a history of retinal detachment.

The effect of normal childbirth on eyes with abnormalities predisposing to rhegmatogenous retinal detachment

BACKGROUND

Pregnant women who have high myopia, a history of retinal detachment or retinal holes, or have known lattice degeneration are frequently referred to an ophthalmologist for advice concerning the management of pregnancy and labor, i.e. whether a spontaneous vaginal delivery can be allowed and whether prophylaxis for high-risk retinal pathology is indicated. Many obstetricians still believe that pregnant women with ocular abnormalities predisposing to rhegmatogenous retinal detachment should have an instrumental delivery, and a few even advocate cesarian section. Very little has been written about the management of pregnant women with high-risk retinal pathology, and opinions differ considerably. Patient data on this subject are scarce.

METHODS

We studied 10 women who had 19 deliveries (10 prospective and 9 retrospective) and who had a history of retinal detachment, had been diagnosed as having extensive lattice degeneration, or had been treated for symptomatic retinal holes or breaks. The women were followed from the third trimester of pregnancy through labor and delivery into the postpartum period, looking for changes in the retinal status.

RESULTS

We found no changes in the retinal status in the postpartum examination.

CONCLUSION

We conclude that prenatal treatment of asymptomatic retinal pathology is not indicated and that spontaneous vaginal delivery may be allowed to take place in women with high-risk retinal pathology.