In this issue of Retina Today, Eugene W. Ng, MD, MBA; Karl Waite, MD; and Michael Bennett, MD, discuss clinical pearls for managing preeclamptic retinal findings in pregnant patients.
We extend an invitation to readers to submit pearls for publication in Retina Today. Please send submissions for consideration to Dean Eliott, MD (deliott@doheny.org); or Ingrid U. Scott, MD, MPH, (iscott@psu.edu). We look forward to hearing from you.
—Dean Eliott, MD; and Ingrid U. Scott, MD, MPH
BACKGROUND
Pregnancy can affect the visual pathways, from the anterior
segment to the visual cortex. Posterior segment complications
include worsening of diabetic retinopathy, and
development of central serous chorioretinopathy, hypertensive
retinopathy, retinal vascular occlusion, and retinal
complications of preeclampsia-eclampsia syndrome.1,2
Preeclampsia-eclampsia syndrome may result in life-threatening
complications. In fact, the maternal mortality rate
in preeclampsia and eclampsia
is up to 1.8% in developed
countries.3
Preeclampsia is defined by the development of proteinuria in a patient with gestational hypertension. Preeclampsia has an incidence of approximately 5% and typically occurs after 20 weeks gestation. 4 Eclampsia is heralded by the onset of seizures in the setting of preeclampsia. Preeclampsia-eclampsia syndrome is a multisystem disorder that can include cardiovascular changes, hematologic abnormalities, hepatic and renal impairment, and neurologic or cerebral manifestations.
Ocular sequelae are observed in 30% to 100% of patients with preeclampsia-eclampsia syndrome.5 Blurred vision is the most common visual complaint, and focal or generalized arteriolar narrowing is the most common ocular finding in preeclampsia-eclampsia syndrome. Areas of nonperfusion or arterial and venous occlusive disease may also develop.1,2
Preeclampsia and eclampsia have been associated with severe retinopathy similar to hypertensive retinopathy, with serous retinal detachments, yellow, opaque retinal pigment epithelial (RPE) lesions, and cortical blindness.6 Choroidal dysfunction, primarily choriocapillaris ischemia, is the underlying mechanism which leads to the serous retinal detachments and yellow RPE plaques.7
While most patients recover normal vision within a few weeks of delivery, some have residual RPE changes in the macula that appear as Elschnig spots or that mimic macular dystrophy or tapetoretinal degeneration.8 Although rare, optic atrophy may develop if chorioretinal atrophy is widespread. Permanent blindness from retinal vascular changes is rare, and cortical blindness is generally reversible.9
CASE PRESENTATION
An optometrist called our practice regarding a
43-year-old pregnant woman who had blurry vision in
both eyes for 3 days. We requested that the patient
come to our office immediately.
The patient stated that she was 20 weeks pregnant, had delivered three children without any previous pregnancyrelated complications, and had not received prenatal care during this pregnancy.
On examination, visual acuity with correction was 20/80 in her right eye and 20/400 in her left eye. Anterior segment examination was unremarkable. Dilated fundus examination disclosed bullous, inferior, serous retinal detachments in both eyes. Multiple yellow retinal pigment epithelial plaques, scattered intraretinal hemorrhages, and florid cystoid macular edema were also present (Figures 1 and 2). The patient's blood pressure was 261/140. We also noted pitting edema of her ankles.
We diagnosed the patient with presumed preeclampsia and suggested that she take an ambulance to the maternity hospital nearby. Soon after she presented to the emergency room, the patient developed convulsions and required immediate airway stabilization. Subsequently, the patient underwent emergent Caesarean section to deliver the baby. It was discovered that the patient was actually 33 weeks pregnant.
The patient was diagnosed with HELLP syndrome and eclampsia. HELLP is an obstetric complication characterized by hemolysis, elevated liver enzyme levels and a low platelet count. During the seizure, the patient bit her tongue and thus required admission to the intensive care unit for airway management on a ventilator. A cranial computed tomography scan showed cerebral ischemia in the watershed zone of her occipital lobes.
FOLLOW-UP FINDINGS
A follow-up examination was performed 3 days after
admission and delivery while the patient was sedated in the
intensive care unit. Conscious sedation precluded testing of
visual acuity. Indirect ophthalmoscopy disclosed resolution
of the bilateral serous retinal detachments. Bilateral macular
edema was still present.
The patient was discharged from the hospital several days later and returned to our office for follow-up 3 weeks after delivery. At this time, visual acuity with correction was 20/20 in each eye. Anterior segment findings were unremarkable. Dilated fundus examination revealed complete resolution ofserous retinal detachments and cystoid macular edema (Figures 3 and 4). The scattered intraretinal hemorrhages that were prominent on the original examination had mostly resolved, with only a few remaining. The multiple yellow pigment epithelial plaques had resolved, leaving multiple areas of mottled RPE. The MP-1 MicroPerimeter (Nidek Co., Gamagori, Japan) showed subtle macular functional changes in the right and left eyes (Figure 5).
CLINICAL PEARL
This case illustrates the importance of being vigilant
about the rare and serious conditions that may occur in
pregnant women with visual complaints. Prompt evaluation
may be required. The immediate transfer of care of the
patient in this case may have saved the lives of both her and
her baby boy. In this patient, prompt treatment of
preclampsia-eclampsia syndrome, namely delivery of the
fetus, resulted in reversal of the ocular manifestations and
visual sequelae associated with this condition.
Eugene Ng, MD, MBA, is a vitreoretinal surgeon at the Retina Institute of Hawaii. Dr. Ng has no financial interests in the product or company mentioned in this article. He may be reached at +1 808 955 0255; or via e-mail at gng@retinahawaii.com.
Karl Waite, MD, is a vitreoretinal fellow at the Retina Institute of Hawaii in Honolulu. Dr. Waite has no financial interests in the product or company mentioned in this article. He may be reached at kwaite@retinahawaii.com.
Michael D. Bennett, MD, is a vitreoretinal surgeon at the Retina Institute of Hawaii and an Associate Professor in the Department of Surgery at the University of Hawaii, John A. Burns School of Medicine. Dr. Bennett is a Retina Today Editorial Board member. Dr. Bennett has no financial interests in the product or company mentioned in this article. He can be reached at +1 808 955 0255.
Dean Eliott, MD, is a Professor of Ophthalmology and Director of Clinical Affairs, Doheny Eye Institute, Keck School of Medicine at USC, and is a member of the Retina Today Editorial Board. He may be reached by phone: +1 323 442 6582; fax: +1 323 442 6766; or via e-mail: deliott@doheny.org.
Ingrid U. Scott, MD, MPH, is a Professor of Ophthalmology and Public Health Sciences, Penn State College of Medicine, Department of Ophthalmology, and is a member of the Retina Today Editorial Board. She may be reached by phone: +1 717 531 4662; fax: +1 717 531 8783; or via e-mail: iscott@psu.edu.
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