Evidence-Based Approaches to Glaucoma Management During Pregnancy and Lactation

Abstract

With increasing maternal age in this decade, there is a parallel rise in the number of pregnant and lactating women affected by glaucoma worldwide. Understanding the diagnosis and management of glaucoma during pregnancy and lactation is essential to preventing blindness from glaucoma in this vulnerable population. This report provides a review of the current literature and offers effective strategies that will overcome the challenges in managing glaucoma during pregnancy and lactation. Practically, glaucoma management during pregnancy and lactation presents a unique challenge for the physician, as the benefit of any treatment must be weighed against the potential risks to the fetus. Prior to initiating or continuing treatment, the physician should be familiar with the various treatment options to manage intraocular pressure during pregnancy and lactation, including the safety of various anti-glaucoma medications as supported by the existing literature and based on the food and drug administration guidelines. A collaborative team effort between the ophthalmologist, obstetrician, and neonatologist in high-risk pregnancies is recommended to optimize care for the mother and fetus.

Introduction

Glaucoma is the leading cause of permanent blindness worldwide, with primary open-angle glaucoma(POAG) as the most common type. Indeed, the total number of people with glaucoma is predicted to rise from60.5million in 2010 to 79.6 million in 2020 [1••]. Although POAG demonstrates no clear sex predilection, there exist a higher number of glaucoma cases in women due to greater longevity; additionally, women are 24 %less likely to be treated despite reporting a higher rate of visual impairment by glaucoma [1••]. Although glaucoma is seen more commonly in the elderly population, Werner et al. [2] has estimated the prevalence to be 0.5 %of the population under age 40, while Yoshida et al. [3] has reported the prevalence to be 0.48, 0.42, and 0.72 % among women aged 15–24, 25–34, and 35–44, respectively. For women of reproductive age, the most common manifestations of elevated intraocular pressure (IOP) include ocular hypertension, congenital glaucoma, juvenile open-angle glaucoma, and various secondary glaucomas, including uveitic, post-traumatic, post-surgical (post-penetrating keratoplasty or retinal surgery), and pigment dispersion.

The Challenge

Glaucoma is rarely diagnosed during pregnancy, and most cases are actually well tolerated during pregnancy. Despite the fact that glaucoma is uncommon in the younger age group, it is possible that physicians and eye care providers will have to face the treatment of glaucoma during pregnancy due to increased maternal age in this decade. Indeed, National Statistic data showed that the number of older mothers has been increasing, specifically by 90 % during ages 35–39 and by 50 % during ages 45–54 [4].

Although most cases of glaucoma in pregnancy are well tolerated, several reports of challenging cases with IOP during pregnancy have been described. When there is evidence of uncontrolled glaucoma during pregnancy and/or lactation, the physician must weigh the benefits of treatment against the potential teratogenic risks of IOP-lowering medications and risks of laser or surgical treatment. It is crucial for the physician to address childbearing plans with women of reproductive age prior to conception and to provide education regarding benefits and risks of various treatments. In order to assess risk of observation off treatment versus continuing or advancing treatment, it is wise to obtain baseline IOP levels and fluctuations, optic nerve head imaging, and visual field evaluation to evaluate baseline disease status.

Understandably due to ethical and legal considerations, the existence of clinical trials in this population regarding management is limited, and most of our knowledge regarding management comes from case reports and animal studies. Due to a lack of management guidelines for pregnant and nursing females, most physicians and patients are concerned about unknown potentially adverse effects of treatment. In 2007 a study conducted in the United Kingdom by Vaideanu et al. [5••], all consultant ophthalmologists in the United Kingdom (UK) were sent a questionnaire survey and asked if they had previous experience treating pregnant women with glaucoma, what management they used, what management they would currently employ, and their first choice medical agent. Of the 282 (out of 605) questionnaires that were returned, only 26 % (73 consultants) had experience treating glaucoma in pregnant women. Of these, most (71 %) continued the current therapy, 34 % chose observation, and only a small percentage (12 %) performed more aggressive therapy such as laser or surgery. When the ophthalmologists were asked what they would do given evidence of glaucoma progression during pregnancy, 31 % were unsure of which treatment to use, 40 % would continue the pre-pregnancy treatment, 17 % would observe off treatment, 8 % would pursue laser trabeculoplasty, and 4 % would perform surgery. Of those who chose medical treatment, 45 % would use topical beta-blockers, 33 % surprisingly chose topical prostaglandins, and 22 % would use other medications. This survey study therefore indicates a general level of uncertainty among ophthalmologists regarding management of glaucoma during pregnancy.

Glaucoma and Pregnancy

The role of female sex hormones on the risk of glaucoma in that estrogens are neuroprotective has been elucidated [1, 6•]. Specifically, Vajaranant et al. have shown that estrogen deficiency may accelerate aging of the optic nerve and thus increases risk for glaucoma [1••]. For instance, several population-based studies suggested that a lifetime decrease in estrogen exposure, as indicated by late menarche, early menopause, or a shorter length of time from menarche to menopause was associated with an increased risk for glaucoma [7–10]. Furthermore, a large claims database showed that each additional month of hormone therapy containing estrogen, but not a combination of estrogen and progesterone, was associated with a 0.4 % reduced risk for open-angle glaucoma [11]. The role of estrogen exposure in glaucoma can also be correlated clinically, in that post-menopausal women tend to have higher IOP, and hormone replacement therapy (HRT) causes modest IOP reduction (1–4 mmHg), improves retinal blood flow, and preserves the retinal nerve fiber layer (RNFL) [12•]. On the whole, these studies lend credibility to the hypothesis that perhaps the hyperestrogenemia of pregnancy may be protective against the development or progression of glaucoma.

Pregnancy-Related IOP Changes

At a biomolecular level, estrogen may regulate IOP by affecting aqueous production and outflow through receptors in the nonpigmented ciliary epithelium [13]. The hyperestrogenemic state of pregnancy has indeed been found to be associated with a 10 % decrease in IOP [14], which is more pronounced in the second and third trimesters and persists for several months postpartum. Qureshi et al. showed that in ocular hypertensive patients, the largest IOP decline occurred between 24th and 30th week of pregnancy, compared to 12th and 18th weeks in nonglaucomatous patients [15], and that the ocular hypotensive effect of late pregnancy is significantly greater in multigravidae than in primigravidae women [16]. Qureshi et al. also showed that the mean diurnal IOP variation was 2.3 and 1.1 mmHg in control and third trimester subjects, respectively, and that this reduced diurnal variation of IOP in pregnant patients with glaucoma may play a protective effect [17]. Various mechanisms have been proposed to explain the decrease in IOP during pregnancy which may be multifactorial, involving hormonal and second-messenger mechanisms [18]: First, there is increased outflow facility and changes in estrogen, relaxin, beta-hCG, and especially a rise in progesterone result in an overall increase in uveoscleral outflow [19]. A decrease in IOP with use of either progesterone or combination progesterone/estrogen at pharmacologic doses has been described [20], with the hypothetical mechanism that progesterone could act as a glucocorticoid receptor antagonist in the outflow apparatus and inhibit the ocular hypertensive effect of endogenous steroids [20]. A second mechanism to explain IOP decrease during pregnancy is that there is a generalized decrease in upper extremity venous pressure and peripheral vascular resistance that can lead to a decrease in episcleral venous pressure; [21•] Finally, maternal metabolic acidosis results in an IOP decrease. Aqueous humor flow rate, however, remains unchanged [21•].

To evaluate whether this IOP decrease is true or simply due to corneal biomechanical changes during pregnancy, Weinreb et al. [14] measured central corneal thickness using ultrasound pachymetry in 89 pregnant women and found it to be 3 % (16 microns) higher than compared to control eyes, a change that is independent of trimester and returns to baseline after delivery. Although IOP could theoretically be falsely low by applanation tonometry due to physiological softening of ligaments in late pregnancy which may reduce corneoscleral rigidity [22•], Weinreb et al. [14] found no correlation between corneal thickness and IOP. Indeed, there is a true IOP reduction during pregnancy. Efe et al. [21•] also evaluated the effect of pregnancy on IOP and CCT in a prospective cohort study involving 25 pregnant women with no prior history of glaucoma. There was a statistically significant IOP decrease in the second and third trimesters (p = 0.001), with a reciprocal increase in CCT during the same time frame (p < 0.001). Both IOP and CCT returned to first trimester values at 3 months postpartum. Hormonal changes during pregnancy have been suggested to cause estrogen-induced up-regulation of the renin–aldosterone system and systemic water retention, which causes corneal fluid retention and thus thick corneas. Kara et al. also investigated the effect of different body positions on IOP measurements taken during the third trimester in healthy nonglaucomatous pregnant women and reported that IOP is lowest in the sitting position compared to supine or lateral decubitus [23].

Pregnancy-Related Visual Field Changes

Visual field is also sensitive to female sex hormones, in that mean visual sensitivity thresholds during the luteal phase (low estrogen state) when compared with a follicular phase (high estrogen state) in normal menstruating women [24]. In terms of pregnancy-specific effects on the visual field, although there is no study on visual sensitivity during pregnancy, there are reports of asymptomatic visual field changes [25], including bitemporal restriction, concentric contraction, and enlarged blind spots. Most cases reverse by 10-day postpartum. These reversible visual field changes are hypothesized to be due to a nearly 120 % increase in the size of the pituitary gland during normal pregnancy, which may cause chiasmal compression and transient nonglaucomatous visual field changes [22•].

The Clinical Course of Glaucoma During Pregnancy

The clinical course of glaucoma during pregnancy including IOP and visual field changes has been retrospectively studied in two small case series. Mendez-Hernandez et al. [26•] published a retrospective case series to evaluate IOP and visual field progression in 13 eyes of 8 pregnant women with pre-existing glaucoma and found that 6 of 8 women required medication to control IOP but that in most patients (7 of 8), the disease remained stable throughout pregnancy. Brauner et al. [27•] also reported a retrospective case series of 28 eyes (15 women) with glaucoma and evaluated IOP fluctuations and visual field changes throughout the course of pregnancy. In 16 (57.1 %) of 28 eyes, IOP was stable with no progression of visual field loss; in 5 eyes (17.9 %), visual field loss progressed while IOP remained stable or increased; and in 5 eyes (17.9 %), there was no visual field progression despite an IOP increase. These results demonstrate that despite the trend of lower IOP during pregnancy, eyes with pre-existing glaucoma do behave differently than healthy eyes. Therefore, measurement of IOP fluctuations, visual field testing, and optic nerve imaging is needed to closely monitor for glaucomatous progression during pregnancy.

Management of Glaucoma During Pregnancy and Lactation

Ideally, physicians should discuss glaucoma management goals and options with all women of childbearing age prior to conception. The potentially harmful effects of medications vary depending on the stage of embryogenesis during which the fetus is exposed, drug characteristics, drug dosage, duration of exposure, and the genetic makeup of mother and fetus [28]. Nearly eighty percent of the volume in a certain eye drop drains to the nasolacrimal duct and is absorbed systemically due to high blood flow to this area, therefore altogether bypassing metabolism by the hepatic cytochrome P450 system [22•]. In the first trimester, maximal susceptibility to teratogens occurs between embryonic weeks 3–8 during organogenesis, the process of organ differentiation [29]. It is during this stage of pregnancy, when most women may not even realize that they are pregnant, then teratogen exposure can lead to major morphological abnormalities. After organogenesis, embryonic development is characterized mainly by an increase in organ size, such that exposure of a teratogen in the second trimester can affect the growth of the embryo and/or the size of a specific organ [29]. During the third trimester, teratogen exposure may lead to premature labor and affect final fetal maturation and development [29].

Selecting Anti-Glaucoma Medications During Pregnancy and Lactation

From a pharmacologic standpoint, the deleterious effects of a compound depend on its ability to traverse the placenta to reach the fetus. Lipid-soluble, nonionized, low molecular weight (< 700 daltons) drugs will readily cross the placenta and enter the fetal circulation. Since most anti-glaucoma medications have a molecular weight of 90–390 Daltons, there will usually be no impediment to transfer across the placenta [30•]. Drugs are only able to cause harm to the fetus if it is not bound to plasma protein [30•]. Fetal factors that may increase toxicity include smaller blood volume, immature hepatic and kidney for drug metabolism and excretion, and excretion into the amniotic fluid from the kidneys, lungs, or skin. Prolonged exposure to the drug can occur as a result of recirculation of drug via swallowing and breathing movements of the fetus and re-excretion by fetal kidneys [30•]. Most medications that are present in the maternal circulation are in fact transferred to breast milk, but the maximum amount of drug that is secreted into milk is usually 1–2 % of the total administered maternal dose. Unionized, lipid-soluble agents with molecular weights < 200 Daltons enter milk easily, and basic compounds may become slightly more concentrated in breast milk given the slightly more acidic contents of milk (pH 7 to 7.6, mean 7.2) compared to plasma (pH 7.4) [30•].

Treatment options during pregnancy for glaucoma are similar to that for nonpregnant patients. In nonurgent cases, the physician may choose to observe since young pregnant women often will tolerate slight increases in IOP well and treatment may be deferred until after delivery [31]. The rapidity of any glaucomatous progression must be taken into consideration to decide on the urgency with which treatment should be initiated or altered. Medication treatment of glaucoma during any trimester is controversial due to lack of management guidelines, which should be emphasized during discussion with the patient. As such, the physician should consider discontinuing these medications temporarily, if possible, during the first trimester when teratogenic risk is greatest. The food and drug administration (FDA) classifications of anti-glaucoma medications are outlined in Table 1. The only two medications that are categorized as Class B (i.e., no adverse effects have been demonstrated in animal studies) are Brimonidine and Dipivefrin. Most anti-glaucoma medications, including prostaglandin analogues, beta-blockers carbonic anhydrase inhibitors, epinephrine, apraclonidine, and parasympathetics are Class C (i.e., animal studies have shown teratogenic effects on the fetus but use is justified only if the benefits of the mother outweigh potential harm to the fetus). The following summarizes safety and reported adverse reactions for commonly used anti-glaucoma medications by the FDA classification.

Table 1.

FDA’s classification of glaucoma medications’ teratogenic risk [38]

FDA Class	Description	Medications
A	Risk for the fetus in controlled studies in humans has not been demonstrated	None
B	Risk for the fetus in animal studies has not been demonstrated, or the risks which were   demonstrated were not confirmed in human studies	Brimonidine dipivefrin
C	Teratogenic effect on the fetus has been demonstrated in animal studies, thus use is only   justified if the benefits of the mother exceed potential risks to the fetus	Prostaglandin analogues β-blockers Carbonic anhydrase inhibitors Epinephrine and apraclonidine Parasympathomimetics
D	Clear evidence of teratogenic risk. Benefits could make its use acceptable during   pregnancy despite risk only in the case of severe disease and in the absence of   alternative treatments	None
X	Anomalies have been demonstrated in human or animal fetuses. The use of these   medications is absolutely contraindicated during pregnancy

Brimonidine

Brimonidine should be considered as the safest medication for use during pregnancy given that it is Class B—animal studies on rats and rabbits at doses 190 and 100 times or 120 and 60 times higher, respectively, than the exposure seen in humans following multiple ophthalmic doses (0.1 or 0.15 %) did not reveal impaired fertility or fetal damage [22•]. However, brimonidine must be discontinued prior to delivery as it has been shown to traverse the hematoencephalic barrier and produce CNS depression and apnea in infants less than 2 months old. This suggests potential toxicity if it is excreted into breast milk, so the general consensus is to avoid it in nursing mothers [32].

Beta-Blocker

As illustrated by the UK questionnaire survey [5••], beta-blockers are the most commonly used anti-glaucoma medication during pregnancy and is most preferred by obstetricians for treatment of any concurrent systemic hypertension. Indeed, topical timolol is 10–12 times more potent compared to propranolol in its cardiac chronotropic and inotropic effects [33], and levels may easily approach toxicity as 80 % is absorbed by the nasal mucosa and thus bypasses hepatic metabolism. Furthermore, the half-life of timolol in the fetus is nearly 4–6 times longer than that of adults due to smaller blood volumes and immature metabolic mechanisms [34]. Therefore, it can have potentially serious adverse effects: Wagenvoort et al. reported a 21-week-old fetus with bradycardia and arrhythmia, while another study reported apnea in a neonate after topical timolol therapy [35]. However, Brauner et al. [27•] did not report any significant side effects with timolol use during the entire course of pregnancy, while a population-based study by Ho et al. [36] reported no significant difference in the risk of low-birth-weight infants between mothers who were taking topical beta-blockers compared to the control group. A further consideration in glaucoma treatment during lactation is that timolol has a low molecular weight of 316 Daltons and not only is filtered into breast milk from the blood, but is also actively secreted, with levels in breast milk approaching six times that of serum levels [37]. The hypothesized mechanism is that beta-blockers are weak bases and may accumulate in the acidic environment of breast milk [37]. Of note, although timolol may be concentrated in breast milk, the actual level obtained from a mother’s milk is only 1/80 of cardiac-effective dose and will probably not cause major concern unless the infant’s hepatic or renal function is impaired [37]. Regardless, Lustgarten et al. [37] do not recommend giving timolol to a nursing mother unless treatment is absolutely necessary. In the case that treatment must be initiated, use of low-dose (0.1 %) Timolol gel once daily is recommended, followed by effective punctual occlusion to minimize systemic absorption [38]. Since drug level in breast milk is often highest 30–120 min after the dose [39], it is prudent to administer the medication right after nursing. For use during lactation, only timolol and acetazolamide are approved by the American Academy of Pediatrics [40].

Carbonic Anhydrase Inhibitor

The use of oral acetazolamide during pregnancy is not recommended in given previous case reports of sacrococcygeal teratoma and transient renal tubular acidosis [41, 42]. However, in an observational case series, 12 pregnant women used 1 g/day of oral acetazolamide for treatment of idiopathic intracranial hypertension without maternal or fetal complications [43]. Overall, topical carbonic anhydrase inhibitors are well tolerated during pregnancy. However, although Brauner et al. [27•] reported no adverse effects with the use of topical carbonic anhydrase inhibitors as a third-line agent in treating glaucoma during pregnancy, there was one reported case of metabolic acidosis with the use of topical dorzolamide in a neonate with bilateral Peters anomaly [44]. There was also a report of intrauterine growth retardation in a woman treated with combination topical timolol–dorzolamide that required cesarean section [26•]. Although topical carbonic anhydrase inhibitors are generally well tolerated during pregnancy, these case reports illustrate the need for caution and close monitoring if treatment is initiated. In terms of use during lactation, Soderman et al. [45] showed that infants exposed to acetazolamide via breast milk actually have low plasma concentration of this medication. Acetazolamide appears in breast milk at one-third of the maternal plasma level and can potentially cause respiratory distress and renal or hepatic dysfunction. However, plasma levels of this medication in infants have shown to be very low [45]. Indeed, the American Academy of Pediatrics approves the use of acetazolamide during lactation [40].

Prostaglandin Analogue

Prostaglandin analogues are Class C medications due to animal studies showing that one quarter of pregnant rabbits exposed to 80 times the human dose of latanoprost delivered nonviable fetuses [22•]. Although prostaglandins increase uterine tone, the dosage needed to stimulate abortion would be 400 cc of the ocular formulation of latanoprost [46•], and the plasma concentration after topical use does not reach a sufficient level to stimulate nonocular receptors. Additionally, De Santis et al. reported no adverse systemic side effects threatening abortion or preterm delivery as a consequence of once daily topical latanoprost in a small series of 11 pregnant women [46•]. However, the use of prostaglandin analogues has been advised against in all stages of pregnancy as they may cross the blood-placental barrier and can theoretically induce miscarriage or premature labor. Additionally, there is no evidence to support the use of these medications during lactation.

Cholinergic Agonist

Cholinergic agonists, such as pilocarpine, are Class C medications. Although there were no adverse effects from use of cholinergic agonists in Brauner et al’s [27•] retrospective case series, they have been associated with neonatal hyperthermia, restlessness, seizures, and diaphoresis when given to women who are near term [27•]. Thus, pilocarpine can be a useful alternative or an additive medical therapy option but should be avoided near term. In terms of lactation, there is no evidence to support its use during this period.

Practical Guides to Selecting Anti-Glaucomatous Medications During Pregnancy and Lactation

To summarize anti-glaucoma therapy recommendations based on reviewed data (see Table 2), all topical anti-glaucoma medications should ideally be avoided during the first trimester when teratogenic risk is greatest. Brimonidine is recommended as the first line agent given that it is Class B, but it should be discontinued prior to delivery as it can cause CNS depression in neonates. Beta-blockers are the recommended second line agents and are the most commonly chosen medications during pregnancy but should be used with caution, as they are Class C. The recommended third-line agents are topical carbonic anhydrase inhibitors, and alternative topical medications include Pilocarpine and Prostaglandin analogues. Overall, the risk of systemic absorption of these medications and thus potential toxicity to the neonate can be mitigated via punctual occlusion immediately after administration, substitution with sustained release gel form (i.e., Timolol 0.1 % gel) and discontinuation prior to delivery. For use during lactation, the only two medications that are currently approved by the American Academy of Pediatrics are Timolol and oral Acetazolamide (see Table 2). Toxicity risks can be minimized by administration immediately after breast-feeding.

Table 2.

Summary of recommendations during pregnancy and lactation

Pregnancy	Lactation
1st line: Brimonidine (Class B)	1st line: Topical carbonic anhydrase inhibitor
2nd line: Beta-blocker (Class C)	Alternative: Timolol and prostaglandin
3rd line: Topical carbonic anhydrase inhibitor (Class C)	Timolol and acetazolamide (approved by the academy of pediatrics)
Alternatives: Pilocarpine, prostaglandin

Punctal occlusion and pumping can be applied during lactation

Special Considerations for Laser and Surgery During Pregnancy and During Lactation

Of all treatment modalities, laser exposes the fetus to the least amount of risk and may be a reasonable alternative to anti-glaucoma medications or a temporizing method to control IOP. Selective laser trabeculoplasty is overall safe, but given its delayed onset of action, may not be a good choice if urgent IOP lowering is required. One study of selective laser trabeculoplasty on 40 pregnant or lactating females showed successful IOP lowering with a mean decrease in the number of anti-glaucoma medications used post-operatively [47]. However, the physician must keep in mind that laser trabeculoplasty may not be as effective in young patients and in cases due to angular alterations inherent to the disease or to the presence of synechiae [48]. The use of diode cyclophotocoagulation has also been described an alternative to medication and may be more effective than selective laser trabeculoplasty. Wertherim et al. [49] reported a case of a patient with aphakic glaucoma for which cyclodiode laser therapy was performed in anticipation of pregnancy. Two sessions of cyclodiode laser were performed prior to pregnancy under peribulbar anesthesia and one session was done during pregnancy, following which IOP was persistently well controlled.

When IOP is not adequately controlled with medications or laser treatment, surgical intervention may be pursued with careful consideration of its unique set of challenges, including anesthesia risks, patient positioning during surgery, and use of certain medications during and after the surgery. Overall, it is recommended to defer surgery until after the first trimester to avoid potentially teratogenic anesthesia medications. The use of general anesthesia is overall discouraged as it can cause intraoperative hypoxemia and asphyxia due to decreased uterine blood flow, maternal hypotension, depression of fetal cardiovascular and central nervous system from placental transfer of anesthetic agents, exposure to potentially teratogenic anesthetic agents, and premature delivery [32] In terms of local anesthesia, Heinonen et al. reported no increased incidence of fetal malformation in a large multicenter retrospective study [50]. Indeed, safety has been reported with the use of retrobulbar block. In terms of anesthetic choice, bupivacaine use in dentistry during pregnancy has been associated with fetal bradycardia, but lidocaine has not shown any adverse effects. Thus, use of retrobulbar block with lidocaine or local anesthesia with lidocaine gel or subconjunctival administration may be safer anesthetic options if surgery is pursued. In regard to patient positioning during surgery, surgical risk to the mother increases with larger fetal size in the second and third trimesters, which may compress maternal aorta and vena cava and induce profound systemic hypotension [32]. Placing the pregnant patient in a left lateral decubitus position may mitigate this risk [22•]. Especially in the later stages of pregnancy, weight gain, laryngeal edema, and higher risk of gastric acid aspiration due to decreased gastroesophageal sphincter tone and delayed gastric emptying time are additional challenges that must be considered [32]. It is thus crucial to have available emergency intubation staff and instrumentation as well as continued intraoperative maternal and fetal monitoring if glaucoma surgery is to be performed at a later stage in pregnancy. When considering which surgery to choose, the physician must keep in mind that not only is there a higher failure rate of trabeculectomy in the young age group, but that antimetabolites mitomycin C and 5-fluorouracil are Class D medications that should be avoided in all stages of pregnancy. Thus in the case that surgery might be necessary, tube shunt surgery may be a better alternative. For postoperative management, corticosteroids are commonly used in pregnancy to treat maternal asthma to stimulate fetal lung maturation and are considered Class A medications. Erythromycin is a Class B antibiotic medication and an ointment base may be used to decrease systemic absorption. For pain control, acetaminophen is the medication of choice as it is Class B.

Practical Guides to Laser and Surgery During Pregnancy and Lactation

Considering all therapeutic options during pregnancy and lactation, laser presents the least possible risk to the fetus and is thus recommended as a temporizing measure in the case of uncontrolled intraocular pressure. Surgery should be considered in some cases to reduce adverse effects from medication therapy, but should be performed with caution in view of heightened anesthesia and systemic intraoperative risks during pregnancy.

Conclusions

As one can see, glaucoma management during pregnancy and lactation presents a unique challenge for the physician. Importantly, the goal of treatment during pregnancy is to find a temporalizing measure to minimize glaucoma progression, and the benefit of any treatment must be weighed against potential risks to the fetus. Sometimes, treatment may not be necessary given that IOP is usually lower during the hyperestrogenemic state of pregnancy. And even if IOP is higher than desired, most pregnant women would rather risk their own health for the well-being of their unborn child and may choose to defer treatment during pregnancy. Prior to initiating or continuing treatment, the physician should be familiar with the different ways to manage IOP during pregnancy, including the safety of various anti-glaucoma medications as supported by the existing literature and based on FDA guidelines. It is also essential to assess the urgency of glaucoma treatment and to set a target IOP goal. Ideally, planning before conception can minimize the need for treatment during pregnancy and thus bring less risk to the fetus. If treatment is to be pursued, efforts can be made to reduce systemic absorption, including punctual plugging, nasolacrimal duct occlusion, and timing of medication to reduce exposure to the fetus. Lastly, the ophthalmologist should work closely with a multidisciplinary team involving a glaucoma specialist, obstetrician, and neonatologist to optimize care for the mother and fetus in any high-risk pregnancy.