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    Managing glaucoma in women

    Gender and hormones may play a bigger role than previously thought

     

    Effects of pregnancy

    It is imperative to look at the pregnant state both as a factor in glaucoma diagnosis and treatment. As women delay pregnancy to their late 30s and 40s and glaucoma has a known propensity to affect us as we age, the initial glaucoma diagnosis may occur during pregnancy. However, studies have shown that during the second trimester, normal patients have a 10 to 20 percent reduction in IOP. Ocular hypertensive patients have an even higher reduction, 25 percent during Weeks 24 to 30. There are several theories as to why this may occur. Perhaps hormonal changes increase uveo-scleral flow. We know that other ligaments soften as women prepare to deliver, and perhaps this mechanism applies to aqueous outflow.11,12

    More glaucoma: How patients percieve their glaucoma matters

    Treatment during pregnancy

    This finding offers the patient some protection during pregnancy and may be a safeguard to delay management. If it is decided that the patient needs to start or continue treatment, the potential teratogenic effects need to be considered. As most glaucoma treatment is topical, recall that 80 percent of the drop drains into the nasolacrimal duct and leads to systemic absorption. All steps should be taken to reduce this, such as punctual occlusion, wiping excess, and closing eyes for a few minutes after instillation.

    The only true Category B glaucoma agent is brimonidine; however, many glaucoma specialists concur that the risk-benefit ratio would allow other medications, such as timolol, to be used during pregnancy. Many will discontinue a few weeks prior to delivery to reduce any potential effects to the baby. Topical carbonic anhydrase inhibitors may be indicated, but orals should be avoided. Theoretically, the prostaglandin category is contraindicated due to the potential to induce premature labor, yet these drugs are safe during lactation. Remember that all drops will end up in breast milk, so it is best to administer single daily-dose medications just before the longest sleep interval for the infant. If multiple doses are needed, recommend the patient breast feed immediately before instillation. Finally, many women suffer from severe dry eye, so the use of beta- blockers may be prohibited, making it more difficult to get adequate IOP control and needing more surgical intervention for the disease.13,14

    Ophthalmology Times: 2015's glaucoma therapy advances

    Of concern is the patient at risk for acute angle closure because labor can precipitate an angle closure. A laser peripheral iridotomy (LPI) can be safely performed during pregnancy with topical anesthesia and an upright position during the procedure. For those who have a pre-existing condition of glaucoma prior to pregnancy, this may be a more severe form due to earlier age of onset. IOP is slightly elevated during natural childbirth, therefore a Cesarean section delivery should be discussed if control is questionable.13,14

    Next: The role of estrogen

    Louise Sclafani, OD, FAAO
    Dr. Sclafani is clinical associate of ophthalmology and visual science and director of optometric services The University of Chicago ...

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    Optometry Times A/V