Glaucoma in pregnancy: an update

Abstract

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.

Glaucoma Progression after Delivery in Patients with Open-Angle Glaucoma Who Discontinued Glaucoma Medication during Pregnancy

“…If patients are reluctant to use glaucoma medication, laser or surgery may be a reasonable alternative. A case series of selective laser trabeculoplasty (SLT) found the procedure to be effective in eliminating the need for glaucoma medications before pregnancy [ 2 ]. SLT is also conceivable for patients during their pregnancy since it would impose minimum risks to the fetus and help avoid the addition of perioperative and postoperative medications at the same time.…”

“…The recent introduction of minimal invasive glaucoma surgery (MIGS) provides clinicians with an option that is simple and safe while eliminating risks associated with anesthesia. In addition, in the case of glaucoma patients who have a high risk of deterioration during pregnancy or are already at an advanced stage, it would be desirable to achieve a stable IOP through surgery before conception [ 2 , 22 , 23 ].…”

“…Despite the challenge, there exist only a few systematic studies that investigated glaucoma progression or the safety of intervention during pregnancy. Thus far, clinicians rely on a limited number of case series studies or personal experiences for the management of glaucoma patients during their pregnancy [ 1 , 2 ]. Understandably, a randomized comparative study to determine the safe drugs and the extent to which they are suitable in pregnant patients may be ethically difficult.…”

A Narrative Review of the Complex Relationship between Pregnancy and Eye Changes

“…Laser peripheral irritodomy or laser iridoplasty is a safe treatment and can be performed as a prophylaxis of acute closure of the chamber angle in pregnant women without real effects on the fetus [41].…”

“…Cyclophotocoagulation is performed under intracameral, suportonian, or retrobulbar anesthesia as an alternative to classical incisional surgery [41]. In some cases, micropulse and cyclophotocoagulation laser therapy can be performed [41].…”