Ординатура / Офтальмология / Английские материалы / Clinical Pathways in Glaucoma_Zimmerman, Kooner_2001

510 Management of Cataract and Glaucoma

22.McCarty CA, Wood CA, Fu CL, et al: Schizophrenia, psychotropic medication, and cataract. Ophthalmology 1999;106:683–687.

23.Klein BE, Klein R, Linton KL, et al: Cigarette smoking and lens opacities: the Beaver Dam Eye Study. Am J Prev Med 1993;9:27–30.

24.Jacques PF, Chylack LT Jr, McGandy RB, et al: Antioxidant status in persons with and without senile cataract. Arch Ophthalmol 1988;106:337–340.

25.Leske MC, Chylack LT Jr, Wu SY: The Lens opacities case-control study. Risk factors for cataract. Arch Ophthalmol 1991;109:244–251.

26.Cumming RG, Mitchell P: Medication and cataract. The Blue Mountains Eye Study. Ophthalmology 1998;105:1751–1778.

27.Kupfer C: Bowman lecture: the conquest of cataract: a global challenge. Trans Ophthalmol Soc UK 1984;104:1.

28.U.S. Department of Health and Human Services. The National Advisory Eye Council: Vision Research: a national plan 1983–1987: 1987 Evaluation and Update. NIH publication no. 872755. Washington, DC: USDHHS, 1987.

29.Steinberg EP, Javitt JC, Sharkey PD, et al: The content and cost of cataract surgery. Arch Ophthalmol 1993;111:1041–1049.

30.Kobelt G, Jonsson L, Gerdtham U, et al: Direct costs of glaucoma management following initiation of medical therapy: a simulation model based on an observational study of glaucoma treatment in Germany. Graefes Arch Clin Exp Ophthalmol 1998;236:811–821.

31.Nardin GF, Zimmerman TJ: Ocular cholinergic agents. In: Ritch R, Shields MB, Krupin T (eds): The Glaucomas. Vol. 3, 2nd Ed. St. Louis: Mosby, 1996;399–1407.

32.Brint SF: Small incision Intraocular lens implantation. In: Nordan LT, Maxwell WA, Davison JA (eds): The surgical rehabilitation of vision. New York: Gower, 1992;15.1–15.14.

33.Fine IH, Masket S: Small pupil phacoemulsification techniques. In: Nordan LT, Maxwell WA, Davison JA (eds): The surgical rehabilitation of vision. New York: Gower, 1992;14.1.

34.Skuta GL, Beeson LL, Higginbotham EJ, et al: Intraoperative mitomycin versus postoperative 5-fluorouracil in high-risk glaucoma filtering surgery. Ophthalmology 1992;99:438–444.

35.Kolker AE, Kass MA, Rait JL: Trabeculectomy with releasable sutures. Arch Ophthalmol 1994;112:62–66.

36.Hoskins HD Jr, Migliazzo C: Management of failing filtering blebs with the argon laser. Ophthalmic Surg 1984;15:731–733.

37.Carpel EF: Pupillary dilation in eyes with pseudoexfoliation syndrome (letter). Am J Ophthalmol 1988;105:692–694.

38.Guzek JP, Holm M, Colter JB: Risk factors for intraoperative complications in 1,000 extracapsular cataract cases. Ophthalmology 1987;94:461–466.

39.Weinstein GW: Cataract surgery In: Tasman W, Jaeger EA (eds). Duane’s Clinical Ophthalmology, Revised Ed. Philadelphia: JB Lippincott, 1992;1–46.

40.Asbell PA, Chiang B, Amin A, et al: Retinal acuity evaluation with the potential acuity meter in glaucoma patients. Opthalmology 1985;92:764–767.

41.Steward WC, Connor AB, Hunt HH: Prediction of postoperative visual acuity in patients with total glaucomatous cupping using the potential acuity meter and automated perimetry. Ophthalmic Surg 1993;24:730–734.

42.Hiller R, Sperduto RD, Krueger DE: Pseudoexfoliation, intraocular pressure and senile lens changes in a population based survey. Arch Ophthalmol 1982;100:1080–1082.

43.Roth M, Epstein DL: Exfoliation syndrome. Am J Ophthalmol 1980;89:477–481.

44.Lumme P, Laatikainen L: Exfoliation syndrome and cataract extraction. Am J Ophthalmol 1993;116:51–55.

45.Liesegang TJ: Clinical features and prognosis in Fuchs’ heterochromic cyclitis. Arch Ophthalmol 1982;100:1622–1626.

46.Foster CS, Fong LP, Singh G: Cataract surgery and intraocular lens implantation in patients with uveitis. Ophthalmology 1989;96:281–288.

47.Younge BR: Chorioretinal field defects. In: Walsh TJ (ed): Ophthalmology Monographs 3. Visual Fields Examination and Interpretation. San Francisco: American Academy of Ophthalmology, 1990;123–135.

48.Anderson DR: Automated static perimetry. St. Louis: CV Mosby, 1992;80–82.

49.Glaucoma Laser Trial Study Group: GLT handbook. Accession # PB 86 - 101037. Springfield, VA: National Technical Information Service, 1985.

50.McCluskey DJ, Douglas JP, O’ Connor PS, et al: The effect of pilocarpine on the visual field in normals. Ophthalmology 1986;93:843–846.

51.Nduaguba C, Ugurlu S, Caprioli J: Acquired pits of the optic nerve in glaucoma: prevalence and associated visual field loss. Acta Ophthalmol Scand 1998;76:273–277.

52.Tuulonen A, Takamoto T, Wu D-C, et al: Optic disk cupping and pallor measurements of patients with a disk hemorrhage, Am J Ophthalmol 1987;103:505–511.

53.Chen HSL, Steinmann WC, Spaeth GL: The effect of chronic miotic therapy on the results of posterior chamber intraocular lens implantation and trabeculectomy in patients with glaucoma. Ophthalmic Surg 1989;20(11):784–789.

54.Ruiz RS, Wilson CA, Musgrove KH, Prager TC: Management of increased intraocular pressure after cataract extraction. Am J Ophthalmol 1987;103:487–491.

55.McGuigan LJB, Gottsch J, Stark WJ, et al: Extracapsular cataract extraction and postrerior chamber lens implantation in eyes with preexisting glaucoma. Arch Ophthalmol 1986;104:1301–1308.

56.Gross JG, Meyer DR, Robin AL, et al: Increased intraocular pressure in the immediate postoperative period after extracapsular cataract extraction. Am J Ophthalmol 1988;105:466–469.

57.Hopkins JJ, Apel A, Trope GE, et al: Early intraocular pressure after phacoemulsification combined with trabeculectomy. Ophthalmic Surg Lasers 1998;29(4):273–279.

58.Kooner KS, Dulaney DD, Zimmerman TJ: Intraocular pressure following extracapsular cataract extraction and intraocular lens implantation. Ophthalmic Surg 1988;19:570–575.

59.Krupin T, Feitl ME, Bishop KI: Postoperative intraocular pressure rise in open-angle glaucoma patients after cataract or combined cataract-filtration surgery. Ophthalmology 1989;96: 579–584.

60.Vu MT, Shields MB: The early postoperative pressure course in glaucoma patients following cataract surgery. Ophthalmic Surg 1988;19:467–470.

61.Naeser K, Thim K, Hansen TE, et al: Intraocular pressure in the first days after implantation of posterior chamber lenses with the use of sodium hyaluronate (Healon). Acta Ophthalmol 1986;64:330–337.

62.Berson FG, Patterson MM, Epstein DL: Obstruction of aqueous outflow by sodium hyaluronate in enucleated human eyes. Am J Ophthalmol 1983;95:668–672.

63.Savage JA, Thomas JV, Belcher CD III, et al: Extracapsular cataract extraction and posterior chamber intraocular lens implantation in glaucomatous eyes. Ophthalmology 1985;92: 1506–1516.

64.Spaeth GL, Fellman RL: Cataract extraction in patients with glaucoma. In: Tasman W, Jaeger EA (eds). Duane’s Clinical Ophthalmology, Vol. 6, Revised Ed. Philadelphia: JB Lippincott, 1995; ch. 16:1–23.

65.Brown SV, Thomas JV, Budenz DL, et al: Effect of cataract surgery on intraocular pressure reduction obtained with laser trabeculoplasty. Am J Ophthalmol 1985;100:373–376.

66.Richter CU, Shingleton BJ, Bellows AR, et al: The development of encapsulated filtering blebs. Ophthalmology 1988;95:1163–1168.

67.Feldman RM, Gross RL, Spaeth GL, et al: Risk factors for the development of Tenon’s capsule cysts after trabeculectomy. Ophthalmology 1989;96:336–341.

68.Campagna JA, Munden PM, Alward WL: Tenon’s cyst formation after trabeculectomy with mitomycin C. Ophthalmic Surg 1995;26:57–60.

69.Schwartz AL, VanVeldhuisen PC, Gadsterland DE et al: The Advanced Glaucoma Intervention Study (AGIS): 5 Encapsulated bleb after initial trabeculectomy. Am J Ophthalmol 1999;127:8–19.

70.Steuhl KP, Marahrens P, Frohn A: Intraocular pressure and anterior chamber depth before and after extracapsular cataract extraction with posterior chamber lens implantation. Ophthalmic Surg 1992;23:233–237.

71.Kim CC, Doyle JW, Smith MF: Intraocular pressure reduction following phacoemulsification cataract extraction with posterior chamber lens implantation in glaucoma patients. Ophthalmic Surg Lasers 1999;30(1):37–40.

72.Storr-Paulsen A, Pedersen JH, Langesen C: A prospective study of combined conventional phacoemulsification in cataract patients with coexisting open angle glaucoma. Acta Ophthalmol Scand 1998;76(6):696–699.

73.Liebmann JM, Ritch R: Complications of glaucoma filtering surgery. In: Ritch R, Shields MB, Krupin T (eds): The Glaucomas, 2nd ed. St. Louis: CV Mosby, 1996;1703–1730.

74.Simmons ST, Litoff D, Nichols DA, et al: Extracapsular cataract extraction and posterior chamber intraocular lens implantation combined with trabeculectomy in patients with glaucoma. Am J Ophthalmol1987;104:465–470.

75.Gandolfi SA, Vecchi M: 5-Fluorouracil in combined trabeculectomy and clear-cornea phacoemulsification with posterior chamber intraocular lens implantation. A one-year randomized, controlled clinical trial. Ophthalmology 1997;104:181–186.

76.Shin DH, Hughes BA, Song MS, et al: Primary glaucoma triple procedure with or without adjunctive mitomycin. Prognostic factors for filtration failure. Ophthalmology 1996;103: 1925–1933.

77.Wishart PK, Austin MW: Combined cataract extraction and trabeculectomy: phacoemulsification compared with extracapsular technique. Ophthalmic Surg 1993;24(12):814–821.

78.Shingleton BJ, Jacobson LM, Kuperwaser MC: Comparison of combined cataract and glaucoma surgery using planned extracapsular and phacoemulsification techniques. Ophthalmic Surg Lasers 1995;26(5):414–419.

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79.Shields MB: Another reevaluation of combined cataract and glaucoma surgery. Am J Ophthalmol 1993;115:806–811.

80.Cashwell LF, Shields MB: Surgical management of coexisting cataract and glaucoma. In: Ritch R, Shields MB, Krupin T (eds): The Glaucomas, 2nd Ed. St. Louis: CV Mosby, 1996;1745–1752.

81.Wedrich A, Menapace R, Hirsch U, et al: Comparison of results and complications following combined ECCE-trabeculectomy versus small-incision trabeculectomy and posterior chamber lens implantation. Int Ophthalmol 1996–97;20:125–129.

82.Lyle WA, Jin JC: Comparison of a 3 and 6 mm incision in combined phacoemulsification and trabeculectomy. Am J Ophthalmol 1991;111:189–196.

83.Anders N, Pham T, Holschbach A, et al: Combined phacoemulsification and filtering surgery with the no-stitch technique. Arch Ophthalmol 1997;115(10):1245–1249.

84.Gayton JK, Van der Karr MA, Sanders V: Combined cataract and glaucoma procedures using temporal cataract surgery. J Cataract Refract. Surg 1996;22(10):1485–1491.

85.Kosmin AS, Wishart PK, Ridges PJ: Silicone versus polymethylmethacrylate lenses in combined phacoemulsification and trabeculectomy. J Cataract Refract Surg 1997;23(1):97–105.

86.Dittmer K, Quentin CD: Intraocular pressure regulation after combined glaucoma and cataract operation. Ophthalmology 1998;95(7):499–503.

87.Mamalis N., Lohner S, Raud AN, et al: Combined phacoemulsification, intraocular lens implantation and trabeculectomy. J Cataract Refract Surg 1996;22(4):467–473.

88.Derick FJ, Evans J, Baker D: Combined phacoemulsification and trabeculectomy versus trabeculectomy alone: a comparison study using mitomycin-C. Ophthalmic Surg Lasers 1998;29: 707–712.

89.Naveh N, Kotass R, Glovinsky J, et al: The long-term effect on intraocular pressure of a procedure combining trabeculectomy and cataract surgery, as compared with trabeculectomy alone. Ophthalmic Surg 1990;21(5):339–345.

90.Park HJ, Weitzman M, Caprioli J: Temporal corneal phacoemulsification combined with superior trabeculectomy. A retrospective case-control study. Arch Ophthalmol 1997;115(3):318–323.

91.Kass MA: Cataract extraction in an eye with a filtering bleb. Ophthalmology 1982;89:871–874.

92.The Fluorouracil Filtering Surgery Study Group: Three-year follow-up of the Fluorouracil Filtering Surgery Study. Am J Ophthalmol 1993;115:82–92.

93.Palmer SS: Mitomycin as adjunct chemotherapy with trabeculectomy. Ophthalmology 1991;98:317–321.

94.Shin D, Simone PA, Song M: Adjunctive subconjunctival mitomycin-C in glaucoma triple procedure. Ophthalmology 1995;102:1550–1558.

95.O’Grady JM, Juzuch MS, Shin D, et al: Trabeculectomy, phacoemulsification and posterior chamber lens implantation with and without 5-fluorouracil. Am J Ophthalmol 1993;116: 594–599.

96.Shin DH, Kim YY, Ren J, et al: Decrease of capsular opacification with adjunctive mitomycin C in combined glaucoma and cataract surgery. Ophthalmology 1998;105:1222–1226.

97.Burratto L, Ferrari M: Extracapsular cataract surgery and intraocular lens implantation in glaucomatous eyes that had a filtering bleb operation. J Cataract Refract Surg 1990;16(3): 315–319.

98.Spaeth GL: Glaucoma surgery. In: Spaeth GL (ed). Principles and Practice of Ophthalmic Surgery. Philadelphia: WB Saunders, 1990;319–335.

99.Shin HD, Kim YY, Sheth N, et al: The role of adjunctive mitomycin C in secondary glaucoma triple procedure as compared to primary glaucoma triple procedure. Ophthalmology 1998;105:740–745.

100.Joseph JP, Grierson I, Hitchings RA: Chemotactic activity of aqueous humor. A cause of failure of trabeculectomies? Arch Ophthalmol 1989;107:69–74.

101.Shin DH, Juzych MS, Oh YH, et al: Ascorbic acid is cytotoxic to dividing human Tenon’s capsule fibroblasts: a possible contributing factor in glaucoma filtration surgery success. Arch Ophthalmol 1991;109:318–319.

102.Shields MB: Cyclodestructive surgery for glaucoma: past, present and future. Trans Am Ophthalmol Soc 1985;83:285–303.

103.Melamed S, Cahane M, Gutman I, et al: Postoperative complications after Molteno implant surgery. Am J Ophthalmol 1991;111:319–322.

104.Fellenbaum PS, Almeida AR, Minckler DS, et al: Krupin disc implantation for complicated glaucoma. Ophthalmology 1994;101:1178–1182.

105.Siegner SW, Netland PA, Urban RC, et al: Clinical experience with the Baerveldt glaucoma drainage implant. Ophthalmology 1995;102:1298–1307.

106.Huang MC, Netland PA, Coleman AL, et al: Intermediate-term clinical experience with the Ahmed glaucoma valve implant. Am J Ophthalmol 1999;127:27–33.

107.Rosenberg LF, Krupin T: Implants in glaucoma surgery. In: Ritch R, Shields MB, Krupin T (eds). The Glaucomas, 2nd Ed. Philadelphia: CV Mosby, 1996;1783–1807.

108.Katz LJ: Tube shunts for refractory glaucomas. In: Tasman W, Jaeger EA (eds). Duane’s Clinical Ophthalmology, Vol. 6, Revised Ed. Philadelphia: JB Lippincott, 1993;1–14.

109.Gagnon MM, Boisjoly HM, Brunette I, et al: Corneal endothelial cell density in glaucoma. Cornea 1997;16:314–318.

110.Kooner KS, Dulaney DD, Zimmerman TJ: Intraocular pressure following secondary anterior chamber lens implantation. Ophthalmic Surg 1988;19:274–276.

111.Wyse T, Meyer M, Ruderman JM, et al: Combined trabeculectomy and phacoemulsification: a one-site versus a two-site approach. Am J Ophthalmol 1998;125:334–339.

112.Murchison FJ Jr, Shields MB: Limbal-based versus fornix-based conjunctival flaps in combined extracapsular cataract surgery and glaucoma filtering procedure. Am J Ophthalmol 1990;109:709–715.

113.Stewart WC, Crinkley CM, Carlson AN: Fornixversus limbus-based flaps in combined phacoemulsification and trabeculectomy. Doc Ophthalmol 1994;88:141–151.

114.Lemon LC, Shin DH, Kim C, et al: Limbus-based versus fornix-based conjunctival flap in combined glaucoma and cataract surgery with adjunctive mitomycin C. Am J Ophthalmol 1998;125:340–345.

115.Kupin TH, Juzych MS, Shin DH, et al: Adjunctive mitomycin C in primary trabeculectomy in phakic eyes. Am J Ophthalmol 1995;119:30–39.

116.Aasved H: The geographical distribution of fibrillopathia epitheliocapsularis. Acta Ophthalmol 1969;47:792–810.

117.Mizuno K, Muroi S: Cycloscopy of pseudoexfoliation. Am J Ophthalmol 1979;87:513–518.

118.Miller KM, Keener GT Jr: Stretch pupilloplasty for small pupil phacoemulsification (letter). Am J Ophthalmol 1994;117:107–108.

119.Fishkind W, Koch PS: Managing the small pupil. In: Koch PS, Davison JA, (eds). Textbook of Advanced Phacoemulsification Techniques. Thorofare, NJ: SLACK, 1991;79–90.

120.De Juan E Jr, Hickingbotham D: Flexible iris retractors (letter). Am J Ophthalmol 1991;111:- 776–777.

121.Belyea DA, Dan JA, Lieberman MF, et al: Midterm follow-up results of combined phacoemulsification, lens implantation and mitomycin C trabeculectomy procedure. J Glaucoma 1997;6:90–98.

122.Jacobi PC, Dietlein TS, Krieglstein GK: Bimanual trabecular aspiration in pseudoexfoliation glaucoma. Ophthalmology 1998;105:886–894.

123.Teekhasaenee C, Ritch R: Combined phacoemulsification and goniosynechialysis for uncontrolled chronic angle-closure glaucoma after acute angle-closure glaucoma. Ophthalmology 1999;106:669–675.

124.Hollick EJ, Spalton DJ, Ursell PG, et al: The effect of polymethylmethacrylate, silicone and polyacrylic intraocular lenses on posterior capsular opacification 3 hours after cataract surgery. Ophthalmology 1999;106:49–55.

125.Hettlich HJ, Lucke K, Asiyo-Vogel M, et al: Experimental studies of the risks of endocapsular polymerization of injectable intraocular lenses. Ophthalmology 1995;92:329–334.

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516 Management of Glaucoma in Pregnancy

glaucomatous disorders adds to the difficulty in determining confusion over prevalence data in this group of young females. The term glaucoma refers not to one entity, but to a large group of diverse disorders with the common features of ocular hypertension, visual field loss, and optic neuropathy. In addition,there is increasing evidence that primary open-angle glaucoma (POAG), the most common glaucoma diagnosis, may be a genetically heterogeneous collection of clinically similar or even indistinguishable diseases. The general demographic and socioeconomic characteristics of POAG and other forms of glaucoma are discussed elsewhere in this text, but such data should be interpreted cautiously in addressing glaucoma issues in women of reproductive age. Unfortunately, there is remarkably little pregnancy-specific epidemiologic data available regarding the various glaucomas, but some conclusions can be drawn from existing knowledge of glaucoma and pregnancy demographics.

Because POAG is associated with aging and the elderly, the disease is generally considered uncommon in pregnancy. The prevalence of POAG increases with age,1 and it is very uncommon under age 40. Of one series of young glaucoma patients between ages 10 and 35, only 25% had the diagnosis of POAG.2 However, POAG occurring in younger patients has been observed to be associated with high initial intraocular pressure (IOP) and may represent a more severe form of the disease.3 Therefore, POAG that is coincident to the condition of pregnancy, although rare, may require relatively aggressive management.

Has the Incidence of Glaucoma in Pregnancy Increased in Recent Years?

Currently there are no data available supporting an increasing coincidence of pregnancy and glaucoma. It might be suggested that the clinical scenario of POAG during pregnancy could become more common in association with increasing childbearing in middle adulthood. There is a national trend of increase of births in women who have delayed starting their families until later in their careers,4 but the incidence of glaucoma has not yet been studied in this population of mothers.

What Type of Glaucoma Occurs During Pregnancy?

In the general population, POAG is the most common form of glaucoma, but, for the reasons discussed above, this observation cannot be extrapolated when considering the population of young women. It has been suggested that juvenile open-angle glaucoma is the predominant type of glaucoma occurring among women of childbearing potential.5 Glaucoma that occurs during adolescence and young adulthood often is also the result of underlying ocular or systemic disease, and in many cases abnormalities of the anterior chamber angle can be identified. Therefore, when referring to women of childbearing age, the developmental and secondary glaucomas are of increasing significance, particularly those associated with inflammatory ocular diseases, chronic steroid use, prior intraocular surgery, and/or trauma. It should be noted that there are no reported cases of pregnancy-induced open-angle glaucoma, and there are no forms of secondary glaucoma unique to pregnancy. Narrow-angle glaucoma may worsen with advancing pregnancy complicated by preeclampsia,6 but this

relationship has not been clearly established by published findings. Acute- angle-closure glaucoma has been reported in one case to be precipitated by labor, perhaps triggered by emotional and physical stress at delivery.7 However, acute angle closure more typically occurs past the fifth and sixth decades of life, and this problem is rare in young females.

Is There a Relationship Between Glaucoma and Pregnancy-Induced Hypertension in Preeclampsia or Eclampsia?

The positive correlation between ocular hypertension and systemic hyperten- sion8–10 is an issue worthy of consideration in addressing glaucoma in pregnancy because the incidence of pregnancy-induced or -aggravated hypertension has been reported to be as high as 5 to 10% of a general population of pregnant women, and over 20% in nulliparous women.4 It has been observed by Qureshi et al11 that ocular tensions of third trimester hypertensive women were significantly higher than tensions of third trimester nonhypertensives. In this report, a total of 200 women were studied, including 40 nonpregnant controls. A difference of mean IOP of 0.6 mm Hg, measured by Goldmann applanation, was found between late pregnancy normotensives and hypertensives, and, although small, this difference was found to be statistically significant. However, this study contradicted earlier work by Phillips and Gore12 demonstrating no significant difference of mean IOP between third trimester hypertensive and nonhypertensive women. In their report, hand-held Perkins applanation tensions were obtained in a total of 97 women including 25 nonpregnant normotensive controls. Mean late pregnancy IOP was 12.1 and 12.4 mm Hg among normotensives and hypertensives, respectively, and the small difference was not found to be statistically significant. A finding of pregnancy-induced lowering of IOP in the third trimester was observed in both hypertensive and nonhypertensive groups in both of the above studies. In both reports the drop was found to be statistically significant, and the mean decrease in IOP ranged between 2.0 and 2.7 mm Hg (13–18%). This interesting phenomenon is further discussed below.

Does Pregnancy-Induced Diabetes Mellitus Affect IOP?

An increased prevalence of POAG and ocular hypertension in general populations of diabetics has also been suggested,8,13–15 but this relationship has not been demonstrated in pregnancy-induced diabetes mellitus.

Could Additional Epidemiologic Data Improve

Patient Care?

The currently available information is of insufficient quality to estimate incidences of various types of glaucoma in women during reproductive years. It can only be stated that glaucoma during pregnancy is considered uncommon. As childbearing at older maternal age becomes more frequent, it is not known if the coincidence of glaucoma and pregnancy is increasing accordingly. Advanced age has not yet been identified as a risk factor for glaucoma during the condition of pregnancy, and the significance of other glaucoma risk factors

518 Management of Glaucoma in Pregnancy

in pregnancy is unclear. IOP normally decreases during pregnancy, and it is unlikely that systemic hypertension during pregnancy affects IOP in a clinically significant manner. Further epidemiologic study could enable better glaucoma management decisions for the patient who is pregnant or at risk of pregnancy. Determination of pregnancy-specific prevalences, risks, and prognostic factors would be useful for improved glaucoma assessment, and possibly in avoiding unnecessary and potentially hazardous treatment.

Diagnosis and Differential Diagnosis

How Are Various Glaucomas Diagnosed in the

Pregnant Patient?

Assessment of glaucoma in the pregnant patient involves application of the same clinical principles as in any patient with suspected glaucoma. Such evaluation should include appropriate classification and diagnosis of the type of glaucoma, and determination of the stage of the disease by optic nerve examination and perimetric analysis. Potential risk factors must be identified including IOP, refractive error, other ocular disease, age, race, family history, and systemic disease. In the young female patient, a particular effort should be made to elicit histories of prior glaucoma or ocular hypertension, nonglaucomatous ocular disease, and eye trauma. A review of records from previous eye examinations is important to characterize the duration and progression of the disorder. Medical history and review of systems are also pertinent, particularly in cases of secondary glaucoma.

Features of the glaucoma exam are discussed in more detail elsewhere in this text, and, although younger and healthier, the pregnant woman should be evaluated equally as thoroughly as the more typical elderly glaucoma patient. Careful examination of pupils, external features, anterior segment, and posterior segment should be performed with particular attention to intraocular tension, gonioscopy, and optic nerve appearance. The optic nerve exam should be detailed to include characteristics of cupping, color, contour, vascular changes, and disc hemorrhages. Any asymmetric findings should be carefully noted.

Classification of glaucoma in any patient is based on the underlying mechanisms leading to the common pathways of optic neuropathy and visual field loss. Discrimination should be made between openand closed-angle glaucoma with attention to identifying any underlying ocular, systemic, or genetic disorders. In dealing with glaucoma in younger ages associated with pregnancy, one must be mindful that the relative occurrences of developmental glaucomas and secondary glaucomas are likely to be higher than that of POAG in women of childbearing years.2 In cases of suspected or known secondary glaucoma, it is important to document all orbital and ocular abnormalities, especially inflammatory, posttraumatic, and neovascular findings. Pregnant or potentially pregnant patients with uveitis of unknown etiology should always undergo extensive systemic evaluation using laboratory and other ancillary

studies to rule out identifiable underlying conditions that could threaten the welfare of mother, fetus, or nursing infant.

In Addition to Physical Examination,

What Other Studies Are Useful?

Because progressive loss of visual field is a common potential outcome for all forms of glaucoma, visual field testing is the most important adjunctive diagnostic tool in detecting and following the disease. In managing the pregnant glaucoma patient, perimetry remains equally invaluable because it is a safe, sensitive, and noninvasive test. Because various forms of glaucoma do not characteristically worsen at an accelerated rate during pregnancy, it is not usually necessary to obtain serial perimetry data in greater frequency than in the nonpregnant glaucoma patient. Visual field screening during pregnancy may also yield results atypical for glaucoma, and the reported findings have been well discussed in a review of the effects of pregnancy on the eye.16

Nonglaucomatous visual field loss in pregnancy has been described in older literature as early as 1923,17–19 but contemporary reports are surprisingly lacking. The reported abnormalities include the findings of bitemporal or concentric field loss, usually detected near term. Other studies failed to verify such findings.19 Such changes, when discovered, are usually asymptomatic and usually resolve shortly after delivery.16 Initial investigators suggested that the field defects might be attributed to physiologic enlargement of the pituitary gland during normal pregnancy. However, in pregnancy, the degree of enlargement of an otherwise normal pituitary gland is insufficient to affect the chiasm, and visual field abnormalities are not explained by this mechanism.19 It is recommended, therefore, that any woman who demonstrates unexplained visual field abnormalities during pregnancy should undergo further evaluation for underlying disease affecting the visual sensory system, particularly central nervous system lesions.

Other ancillary tests, which may also be helpful in evaluating glaucoma disorders, include optic nerve photography, and computerized disc and nerve fiber layer analysis.

Does Pregnancy Have Any Effect on IOP?

The interpretation of IOP during pregnancy warrants additional discussion. It has been demonstrated that in all trimesters of pregnancy, intraocular tensions are lower than in nonpregnant controls. The ophthalmology literature consistently describes a trend of decreasing IOP with advancing pregnancy, especially in the second and third trimesters.12,16,20,21 Using applanation tonometry, Phillips and Gore12 and Qureshi et al11 recorded IOP data in totals of 97 and 200 women, respectively. Both reported third trimester drops in IOP ranging between 13% and 18% compared to nonpregnant controls, with a lesser degree of decrease of mean IOP in hypertensive patients.12 Additionally, the finding of decreased IOP has been observed to persist for several months after delivery.22 Wilke23 observed reduced episcleral venous pressure in pregnancy by measur-