• Treating Retinal Disease in the Pregnant Patient

    The myriad physiologic, hormonal, and metabolic changes that occur in pregnancy can have an impact on the retina, Mark W. Johnson, MD, said during Retina Subspecialty Day on Friday.

    Diseases induced by pregnancy. These include hypertensive retinopathy, choroidopathy, exudative retinal detachment, and retinal vascular occlusive disease. In pregnancy-induced hypertension syndromes (such as preeclampsia), fundus findings include retinal arteriolar constriction, cotton-wool spots, retinal hemorrhages, and retinal edema—and, in most cases, these changes reverse after delivery and normalization of blood pressure.

    Diseases exacerbated by pregnancy. These include idiopathic central serous chorioretinopathy (ICSC) and diabetic retinopathy (DR). ICSC is probably triggered by the rise in serum cortisol levels that occurs during pregnancy and is characterized by subretinal fibrin formation. As for DR, retinopathy progression occurs at double the rate in pregnant women compared with their nonpregnant counterparts, Dr. Johnson said.

    General management approach. “Triamcinolone is likely safe during pregnancy,” Dr. Johnson said. Regarding anti-VEGF injections, he said that “while several small case series indicate that these drugs are safe, it would be prudent to use them only when absolutely necessary.” He also recommended pregnancy testing for patients who are of childbearing age before beginning anti-VEGF treatment.

    With regard to angiography and imaging, the dye used in fluorescein angiography crosses the placenta, although no adverse fetal events have been reported. Indocyanine green dye does not cross the placenta—and, again, no adverse fetal effects have been noted. But to reduce the odds of adverse outcomes, he recommended using optical coherence tomography (OCT) or OCT angiography whenever possible.

    When you are faced with a pregnant patient with DR, Dr. Johnson recommended that you follow the Academy’s updated Preferred Practice Pattern for the disease.

    What about surgery? Ideally, retinal surgery should be delayed until after labor and delivery. However, if surgery is necessary, involve the obstetrical team to minimize operative risks, Dr. Johnson said. Finally, local anesthesia is preferable to general anesthesia. Among the specific anesthetic agents, lidocaine is considered safe for use, but bupivacaine and mepivacaine should be avoided.—Jean Shaw

    Financial disclosures: Dr. Johnson: Hoffman La Roche, Ltd.: S; Tyrogenex: C. 

    Disclosure key. C = Consultant/Advisor; E = Employee; L = Speakers bureau; O = Equity owner; P = Patents/Royalty; S = Grant support.