Retinal and Choroidal Presentations in Pregnancy

During an instruction course at AAO 2019, researchers discussed how retinal and choroidal symptoms manifest in the presence of other conditions, including pregnancy.

Ocular changes commonly occur in pregnancy, and while most revert back, they could sometimes be permanent. Changes during pregnancy could be attributed to new conditions or exacerbation of preexisting ones. Ocular effects that could manifest during pregnancy are categorized by physiologic changes, pathologic conditions, or modifications of preexisting conditions.

Physiologic changes include intraocular pressure, which is known to decrease during the second half of pregnancy. This change is largely attributed to an increase in the facility of outflow and uveoscleral outflow and a decrease in episcleral venous pressure. Intraocular pressure normally returns to normal two months postpartum.

Pathologically, pregnancy-induced hypertension (PIH)—which includes preeclampsia and eclampsia—affects about 5% of pregnancies. Common symptoms of PIH include blurred vision, photopsias, scotomata, and diplopia; ocular signs include retinal arteriolar abnormalities, serous retinal detachments, and ischemic optic neuropathy. About 10% of patients with severe PIH will develop the HELLP syndrome (hemolysis, elevated liver enzymes, and a low platelet count), which is typically associated with poor outcomes for the mother and fetus. Ocular signs of the HELLP syndrome include bilateral serous retinal detachments with yellow-white subretinal opacities and vitreous hemorrhage. Visual and retinal abnormalities are less common due to advances in PIH medical management, and most of those that do occur can be improved with proper management.

Central serous chorioretinopathy (CSC), although typically more common in males than females (male:female ratio, 8-10:1), can also manifest during pregnancy. Its etiology in pregnancy is unclear, and it can develop during any trimester. Research suggests that CSC during pregnancy may be associated with hormonal, coagulation, and hemodynamic changes. The presence of subretinal exudates, white or gray-white in appearance, with serous retinal detachment is more common in pregnancy-associated CSC (90%) than in nonpregnant men and women (> 20%). A diagnosis can usually be made based on physical symptoms. Serous detachment and subretinal exudates typically clear up on their own toward the end of pregnancy or during the postpartum period. Pregnant women who develop CSC may be more likely to experience it again outside of pregnancy or in a subsequent pregnancy.

Several occlusive vascular disorders have been known to occur during pregnancy, including Purtscher’s-like retinopathy, disseminated intravascular coagulation, thrombotic thrombocytopenic purpura, and amniotic fluid embolism. Preexisting conditions could also progress during pregnancy, including diabetic retinopathy and intraocular tumors.