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Refractive changes in pregnancy. (PMID:12736728)

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Pizzarello LD Department of Ophthalmology, Southampton Hospital, Southampton, New York, USA. bythebay@hamptons.com Graefe's Archive for Clinical and Experimental Ophthalmology = Albrecht von Graefes Archiv fur Klinische und Experimentelle Ophthalmologie [2003, 241(6):484-488] Type: Journal Article DOI: 10.1007/s00417-003-0674-0 Abstract Highlight Terms
Gene Ontology(2) OBJECTIVE: To determine the causes of any vision change reported during pregnancy. SETTING: An obstetrical practice in Southampton, New York. STUDY POPULATION: Two hundred forty pregnant women were asked whether they had any alteration in vision. Those who agreed to take part in the study (83) and who complained of vision changes (12) were Diseases(2)

matched with the next patient seen in the practice who was asymptomatic. OBSERVATION. All patients underwent a complete ophthalmic examination, including refraction. Those who had alterations in vision status were seen again after delivery. MAIN OUTCOME MEASURES: Changes in visual acuity and refractive error during pregnancy. RESULTS: All women who complained of visual changes were found to have experienced a myopic shift from pre-pregnancy levels. (0.87+/-0.3 diopters in the right eye ( P<0.0001) and 0.98+/-0.3 diopters in the left eye ( P<0.0001). Post partum, all subjects returned to near pre-pregnancy levels of myopia. CONCLUSIONS: This report links worsening of myopia to pregnancy. The causes of this myopic shift are not readily evident and merit further investigation.

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Adult Case-Control Studies Female Humans Myopia Postpartum Period Pregnancy Pregnancy Complications Recovery of Function Refraction, Ocular Visual Acuity

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Limits Advanced Journal list Help Journal List > JRSM Short Rep > v.2(4); Apr 2011 > PMC3085969

JRSM Short Rep. 2011 April; 2(4): 24. Published online 2011 March 31. doi: 10.1258/shorts.2011.010107 PMCID: PMC3085969

Obstetric opinions regarding the method of delivery in women that have had surgery for retinal detachment
Esther Papamichael,1 George William Aylward,2 and Lesley Regan3 Author information Copyright and License information

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Abstract
Objectives

We sought to determine international obstetric opinions regarding the influence of a history of rhegmatogenous retinal detachment on the management of labour and to review the evidence base.
Design

A questionnaire containing closed questions, with pre-coded response opinions, was designed to obtain a cross-section of the obstetric opinions.
Setting

Questionnaires were distributed at the 20th European Congress of Obstetrics and Gynaecology in Lisbon, Portugal.
Participants

One hundred questionnaires were distributed among obstetricians attending the congress and 74 agreed to participate.
Main outcome measures

Participants were asked to state their preferred method of delivery in such patients and the reasons for their recommendation. Furthermore, we questioned whether there was any difference in opinions depending on generation.
Results

The majority of respondents (76%) would recommend assisted delivery (either Caesarean section or instrumental delivery), whereas the remaining 24% would advise normal delivery. Generation is not a factor influencing this decision. The majority (58%) based their decision to alter the management of labour on their personal opinion of standard of care.
Conclusion

The literature shows that there is little evidence to support the belief that previous retinal surgery increases the risk of re-detachment of the retina during spontaneous vaginal delivery. This short survey shows that the majority of an international sample of obstetricians questioned does not share this viewpoint. Therefore, unnecessary interventions may be occurring in otherwise fit women with a history of retinal detachment.
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Introduction
Frequent inquiries to one of the authors (a retinal surgeon) from pregnant women with a history of surgery for retinal detachment, drew our attention to the possibility that this condition influences the management of labour. In retinal detachment fluid collects in the potential space between the sensory retina and the retinal pigment epithelium. By far the most common cause is the presence of a retinal break which allows fluid from the vitreous cavity into the subretinal space. If a break is present the diagnosis is rhegmatogenous retinal detachment (RRD). These breaks occur spontaneously, and when detected they are treated with retinal surgery. In the past it was believed that labour exerts pressure on the eye and increases the possibility of retinal detachment. Although the association between serous (exudative) retinal detachment and eclampsia during pregnancy is well documented, there have been no convincing reports of the occurrence of RRD in pregnancy. Pregnant women with a history of surgery for RRD usually disclose this information at the antenatal booking visit. Two surveys conducted in the UK suggest that obstetricians may recommend either an assisted vaginal delivery with forceps, vacuum extraction, or a Caesarean section to women who had surgery for RRD. The reason for this decision is fear of retinal re-detachment,1,2 a viewpoint that is not shared by retinal detachment surgeons. Our objective was to determine whether the view, that vaginal delivery is contraindicated in such patients, is prevalent among obstetricians from an international audience, and to review the evidence base. We also aimed to determine which method of delivery obstetricians would recommend for these patients, and the reasons for their recommendation. Furthermore, due to the recent shift towards more conservative management for degenerative retinal holes and tears, we questioned whether there was any difference in opinions depending on generation.
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Methods
A questionnaire containing closed questions, with pre-coded response opinions, was designed to obtain a cross-section of the obstetric opinions. The layout of the questionnaire was clear and simple in an effort to facilitate quick and comprehensive reading. A questionnaire was given to obstetricians selected randomly, at the European Congress of Obstetricians and Gynaecology (ECOG) in 2008 held in Lisbon, Portugal. Information about the aim of the study, as well as potential benefits, was given to each participant. Once the data had been collected, a comparison was made between the responses provided by two generations of obstetricians, namely those practising obstetrics for less than 20 years (group 1), and those practising for more than 20 years (group 2). The 2 test for proportions was used and statistical significance was implied if the P value was less than or equal to 0.05.
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Results
One hundred obstetricians were approached and 74 agreed to participate, producing 74 usable data-sets. The majority (76%) of responders reported that a history of surgery for RRD would influence their management of delivery in an otherwise normal pregnant woman. More than

half (54%) would recommend delivery by Caesarean section. The remaining 22% would recommend either Caesarean section or instrumental delivery. The reasons for their choice are shown on the chart of Figure 1.

Figure 1 Reasons that influence the decision for management of labour in the 76% of obstetricians that would be influenced by a history of RRD

The majority (58%) based their decision to alter the management of labour on their personal opinion of standard of care. A further 18% based their decision on local guidelines. The same proportion (18%) was influenced by what they read in obstetric textbooks and a small proportion (6%) stated that medicolegal reasons influenced their decision. More than one-third (35%) of the obstetricians that would be influenced by a history of RRD suggested that such a patient should not be allowed to push during the second stage of labour due to fears of increasing intraocular pressure causing re-detachment of the retina. As indicated in the free comments section, 13% of these obstetricians would ask for ophthalmological advice. Among obstetricians practising for more than 20 years (group 1, mean 28 6 years experience) 76% would recommend assisted delivery (either Cesarean section and/or instrumental delivery), and among obstetricians practising for less than 20 years (group 2, mean 10 6 years experience) 74% would recommend intervention to a patient with a past history of RRD. Analysis of results by groups showed no difference in opinions.
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Discussion
The results of this survey indicate that three-quarters of obstetricians that attended the ECOG in 2008 may choose to intervene in the delivery of women who have had surgery for RRD because of the perception that spontaneous delivery is likely to cause a re-detachment of the retina. Only one-quarter considered that this condition would not pose a risk of further detachment. Generation is not a factor influencing this decision. While previous surveys have looked at the perception of obstetricians in the UK, our survey looked at the opinions of an international obstetric audience. Our survey, as well as the two previously published surveys, are small and only offer a cross-section of obstetric opinions.1,2 They do not indicate the proportion of interventions that occur due to ocular indications. Inglesby et al. sent questionnaires to randomly selected obstetricians across the UK. Threequarters of the responders considered a history of retinal detachment surgery an indication for obstetric intervention during labour.1 More recently Elsherbiny et al. surveyed the opinions of obstetricians in the West Midlands region of the UK. Participants were asked to stratify high myopia, previous retinal detachment, family history of retinal detachment and previous laser treatment into no, low-, moderate or high-risk categories for occurrence of

retinal detachment during labour. The majority stratified high myopia in the no or low-risk categories (59%), previous retinal detachment in the moderate or high-risk categories (71%), family history of retinal detachment in the low- or moderate risk categories (73%) and previous laser treatment in the moderate or high-risk categories (56%). When asked which eye condition, if any, would affect their clinical choice between vaginal delivery and Caesarean section, only 14% of responders indicated that, no ocular condition would affect their choice. A similar proportion (13.6%) answered that their choice would be affected by a history of retinal detachment. Sixty-one percent chose not to answer the question, indicating that the majority of the population surveyed is confused as to what is best practice.2 Furthermore, 48% identified previous retinal detachment as an indication for Caesarean section. The results of our survey are in line with the UK-based data and possibly indicate that this viewpoint is currently slightly more prevalent internationally. As shown by the obstetricians' comments, in this survey, the rationale for this belief is based on a misunderstanding of the pathophysiology of RRD. The comments were all very similar in explaining that spontaneous delivery should be avoided due to the perceived increased risk of detachment resulting from a rise in the intraocular pressure secondary to Valsalva-like manoeuvres during the second stage of labour. There is no evidence suggesting that increasing the intra-abdominal pressure also increases the intraocular pressure. The latter can only be caused by conditions that affect aqueous drainage in the anterior chamber of the eye, such as glaucoma. In addition, increased intraocular pressure is not a risk factor for RRD. There is no reason why the physiological stresses of labour should increase the likelihood of RRD in these women. The need to moderate the management of labour to reduce the risk of retinal detachment in high-risk women was advocated in earlier studies.35 The authors recommend caution in the management of labour in women with high myopia, known retinal holes and lattice, and previous retinal detachment. It is suggested that such women undergo induction of labour, to minimize the duration of the second stage of labour, or instrumental delivery and in some cases Caesarean section. On reviewing the literature we identified three prospective observational studies that investigated the effects of labour in women with the relevant retinal changes. The largest study by Neri et al. reported no retinal changes in the 50 myopic women (4.515D myopia) that were fundoscopically examined pre- and post-delivery, despite the identification of retinal degenerative changes (lattice-like degeneration and retinal breaks).6 A more recent study of similar design by Prost et al. also reported no progression of retinal changes.7 A smaller study by Landau et al. examined 10 women (19 deliveries) with more serious risk factors for RRD and found no signs of change postpartum.8 A recent retrospective study by Socha et al. in Poland found that, in the nine-year study period, 100 out of the 4895 (2.04%) Caesarean sections were performed due to an ocular indication. The most common ocular indications included myopia, retinopathy, glaucoma, imminent retinal detachment and past retinal detachment.9 These data suggest that interventions due to ocular indications may occur in other countries as well. The proportion is probably small but unnecessary procedures should be avoided due to the associated medical and psychological consequences they may have.
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Conclusion
The literature shows that there is little evidence to support the belief that previous retinal surgery increases the risk of re-detachment of the retina during spontaneous vaginal delivery. This short survey shows that the majority of an international sample of obstetricians questioned does not share this viewpoint. This may suggest that unnecessary interventions, including surgery, may occur during labour in otherwise fit women. A history of retinal detachment should not be considered an indication for instrumental delivery or Caesarean section.
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DECLARATIONS
Competing interests

None declared
Funding

None
Ethical approval

Not applicable
Guarantor

LR
Contributorship

All authors contributed equally

Acknowledgements

None
Reviewer

Kausik Das
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References
1. Inglesby DV, Little BC, Chignell AH Surgery for detachment of the retina should not affect a normal delivery. BMJ 1990;300:980.

2. Elsherbiny SM, Benson MT Retinal detachment and the second stage of labour: a survey of regional practice and literature review. J Obstet Gynaecol 2003;23:11417. [PubMed] 3. Schenk H The effect of pregnancy and labor on myopia and retinal detachment. Gynakol Rundsch 1975;15:3014. [PubMed] 4. Ivanov IP, Butskikh TP, Kas'ianova NS [Procedure for managing pregnancy and labor in certain forms of pathology of the organ of vision]. Akush Ginekol (Mosk) 1978;(2):325. [PubMed] 5. Stolp W, Kamin W, Liedtke M, Borgmann H Eye diseases and control of labor. Studies of changes in the eye in labor exemplified by subconjunctival hemorrhage (hyposphagmas). Geburtshilfe Frauenheilkd 1989;49:35762. [PubMed] 6. Neri A, Grausbord R, Kremer I, Ovadia J, Treister G The management of labor in high myopic patients. Eur J Obstet Gynecol Reprod Biol 1985;19:2779. [PubMed] 7. Prost M Severe myopia and delivery. Klin Oczna 1996;98:12930. [PubMed] 8. Landau D, Seelenfreund MH, Tadmor O, Silverstone BZ, Diamant Y The effect of normal childbirth on eyes with abnormalities predisposing to rhegmatogenous retinal detachment. Graefes Arch Clin Exp Ophthalmol 1995;233:598600. [PubMed] 9. Socha MW, Piotrowiak I, Jagielska I, et al. Retrospective analysis of ocular disorders and frequency of cesarean sections for ocular indications in 2000-2008our own experience. Ginekol Pol 2010;81:18891. [PubMed]

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The effect of normal childbirth on eyes with abnormalities predisposing to rhegmatogenous retinal detachment. [Graefes Arch Clin Exp Ophthalmol. 1995] Surgical repair of rhegmatogenous retinal detachment after treatment for retinoblastoma. [Ophthalmology. 1998] Retinal detachment and the second stage of labour: a survey of regional practice and literature review. [J Obstet Gynaecol. 2003] Retinal detachment in myopic eyes after laser in situ keratomileusis. [J Refract Surg. 2002] Asymptomatic rhegmatogenous retinal detachment. [Curr Opin Ophthalmol. 1996]

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Review Retinal detachment and the second stage of labour: a survey of regional practice and literature review. [J Obstet Gynaecol. 2003] Review Retinal detachment and the second stage of labour: a survey of regional practice and literature review. [J Obstet Gynaecol. 2003] Review Retinal detachment and the second stage of labour: a survey of regional practice and literature review. [J Obstet Gynaecol. 2003] [The effect of pregnancy and labor on myopia and retinal detachment]. [Gynakol Rundsch. 1975] [Eye diseases and control of labor. Studies of changes in the eye in labor exemplified by subconjunctival hemorrhage (hyposphagmas)]. [Geburtshilfe Frauenheilkd. 1989] The management of labor in high myopic patients. [Eur J Obstet Gynecol Reprod Biol. 1985]

[Severe myopia and delivery]. [Klin Oczna. 1996] The effect of normal childbirth on eyes with abnormalities predisposing to rhegmatogenous retinal detachment. [Graefes Arch Clin Exp Ophthalmol. 1995] [Retrospective analysis of ocular disorders and frequency of cesarean sections for ocular indications in 2000-2008--our own experience]. [Ginekol Pol. 2010]

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Europ. J. Ohsrer. Gynec. reprod. Biol., 19 (1985) 277-279 Elsev*ier EJO 00196

The management of labor in high myopic patients

A. Neri, I, R. Grausbord, i, I. Kremer, 2, J. Ovadial and G. Treister 3
Department of Ohstetrrcs and Gynecoloa, Department of Ophthalmology, Beilmson Medical Center, Perah Tiqua, and Department of Ophrhalmologv, Sheba Medical Center, Tel Hashomer, Israel Accepted for publication 16 October 1984 NERI, A., GRAUSBORD, R., KREMER, I., OVADIA, J. and TREISTER, G. (1984): The management of labor in high myopic patients. Europ. J. Obstet. Gynec. reprod Biol., 19, 2717219. The routine in our department for years used to be: prevention of bearing down during the end of the 2nd stage of labor in high myopic parturients, by forceps delivery, with the assumption that this will prevent increased intraocular pressure-thus preventing deterioration or increased damage to the eyes. The goal of this study was to challenge our theory and thus we decided to re-evaluate this approach. Various obstetrical data were recorded in 50 women with myopia from 4.5 to 15.0 diopters who were admitted in labor to our department. Fundus examination was performed in all of them before and after delivery. Various types of retinal degeneration and retinal breaks were observed in most of them at their arrival but no deterioration of these retinal defects was observed in any of the cases at the later examination. In view of our results, it is recommended to let high myopic patients deliver spontaneously. labor; myopia

Retinal detachment occurs mainly in myopic eyes. The higher the myopia, the greater is the tendency to develop this condition at an earlier age. Predisposing

factors are: peripheral retinal degeneration, mainly lattice-like and retinal breaks (Duke-Elder, 1967). On the premise that increased ocular pressure from the stress of labor (valsalva mechanism) represents a potential threat to the retina, it has been the policy in our department to terminate delivery of myopic parturients by forceps or vacuum extraction. Posterior poles with lacquer cracks may also predispose to bleeding or subretinal neovascularization due to the valsalva mechanism. Therefore, we investigated possible changes during labor in the retinal condition of 50 highly myopic mothers who gave birth in our department. The few papers discussing the problem of myopia and labor point out that no deterioration could be observed in the condition of the retina during delivery
Reprint requests: Dr. A. Neri, Department of Obstetrics and Gynecology, Beihnson Medical Center, Petah Tiqva, 49 100, Israel. 00282243/85/$03.30 Q 1985 Elsevier Science Publishers B.V. (Biomedical Division) 277

278

(Schenk, 1975; Link and Hindemann, 1974). However, the same authors recommend termination of labor in highly myopic mothers instrumentally (Link and Hindemann, 1974). Since forceps delivery is associated with a higher incidence of birth-related injuries (Kendall and Moloshin, 1952; Rubin, 1964), the decision about the method of delivery is very important, since the affected babies have been found to have lower scores on the Stanford-Binet I.Q. test later (during childhood). Fifty women with myopia of 4.5 diopters and above were selected for this study. All these women were twice subjected to refraction and fundus examination. The first examination was within 4 wk before labor, and the second, between 2 and 14 days after delivery. Since the study reflects the effects of bearing down during delivery on eye fundus, only spontaneous deliveries were included in the study. All deliveries were between the 37th and 42nd wk of pregnancy. Infant birth-weight was between 2500 and 4000 g. Sixty eyes had refraction between 4.7 and 7.5, while 38 eyes had refraction between 8 and 15.0. Table I presents the pre-labor eye fundus condition in correlation with the duration of bearing-down during labor. Repeated examination of the patients, 2 to 14 days after delivery, did not reveal any change in the individual patients eye background. An important factor in changing retinal tears and holes to ablatio retina is the vitreous body retractions on the degenerated retinal surface (Duke-Elder, 1967). During the end of the second stage of labor, the parturients have episodes of increased intraocular pressure due to the valsalva maneuvers. It is assumed that this pressure spreads equally to all directions as in a closed eyeball. This pressure cannot be responsible for the vitreous retraction movement to a particular direction which would cause retinal tears or retinal detachment. In view of our findings and the physical principle described before, there is no reason why delivery should cause deterioration of previous retinal conditions in myopic women. The main finding of the present study is that normal spontaneous delivery can be carried out in myopic women even in cases associated with retinal degeneration or retinal tears.
TABLE I Pre-labor eyeground examination, in correlation with duration of bearing down Bearing Normal down (min) fundus Lattice-like degeneration Other degenerative changes a 3-10 4 5 11 3

11-30 2 7 11 4 31-60 1 1 2 1 Instrumental labor 1 2 4 1 Cesarean section 0 2 4 2 Includes: (1) white without pressure; (2) cobble stones; (3) snail tracks. Retinal breaks

References
Duke-Eider. S. (1967): System of Ophthalmology Volume X, Disease of the Retina, pp. 783-792. Henry Hampton, London. Kendall, N. and Woloshin, H. (1952): Cephalohematoma associated with fracture of the skull. p = Pediatrics, 41, 125. Link, M. and Hindemann, B. (1974): Geburten bei Augenerkrankungen. Zentrallel-Gynaekol., 96, 1226. Rubin. A. (1964): Birth injuries: Incidence mechanisms and end results. Obstet. and Gynec., 23, 218. Schenk, H. (1975): Uber den Einfluss von Schwangerschaft und Geburt auf Kurzsichtig und Netzhautabhebung. Gynaekol. Eit, Rundsch. 15, 301. 279