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Abstract #19097 Published in IGR 3-1
Management of glaucoma in pregnancy and lactation
Johnson SM; Martinez M; Freedman SSurvey of Ophthalmology 2001; 45: 449-454
This is an excellent review of our present knowledge on the management of glaucoma in pregnancy and lactation. This is a subject that concerns all those treating young females with glaucoma. The review centers around a case report: a 30-year-old pregnant woman with secondary chronic open-angle glaucoma became pregnant. In her right eye, she had sustained a trauma with subsequent keratoplasty. She developed glaucoma at the age of 19 years. As treatment, she received timolol, latanoprost and brimonidine. All these medications were discontinued at ten weeks' gestation. At 7.5 pregnancy, she had ALT. When she was examined again at seven months' gestation, she had a pressure of 45 mmHg in the right eye and 14 mmHg in the left. There was a large visual field defect in the right eye. Further, the eye had a corneal graft and aphakia. The discussion centers on the question of whether medical treatment should be reinstated in this patient or whether surgical treatment is to be preferred. In fact, in this case, it was decided to use timolol, dorzolamide, and brimonidine. It is known that timolol may cause bradycardia. Brimonidine was chosen since it has been categorized as class B, i.e., controlled studies have shown no risks to fetuses. With this medication, pressure was 50 mmHg after six weeks. The commenting experts suggested that, at this stage, tube shunt surgery would be the preferred procedure. The patient did not receive latanoprost since prostaglandins are involved in the physiology of labor and delivery. She received echothiophate. A first attempt was made to induce labor. The pressure again rose to 42 mmHg. A second induction of labor was attempted. Following a successful delivery of a healthy infant, the pressure remained high. The patient refused to discontinue lactation, and despite various combinations of topical medication, the pressure remained high. The patient was given her medication immediately after nursing, because it is known that drug levels in milk are often highest 30 - 20 minutes after drug dose. She finally received a Achmed valve. Unfortunately, the pressure rose again to the low twenties and the patient was started on timolol and dorzolamide. The child has experienced no health problems. The choice in this case is between medical treatment and surgery. The risks of surgery include anesthesia, supine positioning, and postoperative medications. It has been estimated that 11-23% of pregnancies involve prenatal, non-labor, local-anesthetic exposure. In a large multicenter retrospective study, no significant increase in the amount of malformations was found. The authors feel that lidocaine would be the best solution for local anesthesia. The use of antimetabolites is not recommended. Postoperative medications should perhaps not include an antibiotic. The problem with all glaucoma medications is the absence of any large-scale controlled trials. Information must be gathered from case studies, with the limitation of non-applicability to other cases. Some medications have shown adverse effects to animal fetuses, and therefore belong to class C. Among these are beta-blockers, epinephrine, apraclonidine, carbonicanhydrase inhibitors, parasympathomimetics, and prostaglandin analogues. The experts believe that incisional glaucoma surgery offers a relatively low fetal and neonatal risk and is to be preferred to medical treatment. Furthermore, the authors discuss the potential effect of glaucoma medication during lactation. In the case of brimonidine, a warning was issued by the manufacturer. Finally, the authors put forward the following principles: 1. pregnancy is usually a period of lower intraocular pressure; 2. ALT may be of help; 3. a higher intraocular pressure may be tolerated for the period of gestation and lactation; 4. the minimum amount of medical treatment should be prescribed; 5. the lowest drug dose possible should be used; 6. punctal occlusion should be employed. 7. FDA categories should be consulted when choosing medical therapy; 8. incisional surgery can be considered; 9. early surgery may be indicated in these cases.
Dr S.M. Johnson, Department of Ophthalmology, University of North Carolina Hospitals, Chapel Hill, NC, USA
Classification:
11.1 General management, indication (Part of: 11 Medical treatment)