DOI: 10.1111/tog.

12670 2020;22:217–26
The Obstetrician & Gynaecologist
Review
http://onlinetog.org

Ocular manifestations of pregnancy and labour:

from the innocuous to the sight threatening
Ajay D Patil MA (Cantab) FRCOphth,a Abdallah A Ellabban FRCS MSc PhD,*b,c Dilip B Patil MRCOG,d
David Yorston FRCOphth,e Thomas H Williamson FRCOphth,f David A Laidlaw FRCOphth,f
Colin J Vize FRCOphth,b Melanie Hingorani FRCOphth,g Edward P Morris FRCOGh
a
Specialty Trainee Year 7, Department of Ophthalmology, Leeds Teaching Hospitals, Great George St, Leeds LS1 3EX, UK
b
Consultant Ophthalmologist, Department of Ophthalmology, Hull and East Yorkshire Foundation Trust, Anlaby Rd, Hull HU3 2JZ, UK
c
Lecturer of Ophthalmology, Suez Canal University, Ismailia, Egypt
d
Consultant Obstetrician and Gynaecologist, Bedford Hospital NHS Trust, Bedford MK42 9DJ, UK
e
Consultant Ophthalmologist, Gartnavel General Hospital, Glasgow G12 0YN, UK
f
Consultant Ophthalmologist, Guy’s and St Thomas’ NHS Foundation Trust, London SE1 7EH, UK
g
Consultant Ophthalmologist, Moorfield’s Eye Hospital, London EC1V 2PD, UK
h
Consultant Obstetrician and Gynaecologist, Norfolk and Norwich University Hospital, Norwich NR4 7UY, UK
*Correspondence: Abdallah A Ellabban. Email: ellabbanabdallah@gmail.com

Accepted on 9 December 2019. Published online 6 July 2020.

Key content Learning objectives

 Pregnancy may precipitate several physiological changes that can
have ocular consequences; many of these are innocuous and
require little more than reassurance for the patient.
 There are uncommon instances of new sight-threatening pathology
that necessitate a prompt approach.
 Pregnant women presenting to the ophthalmologist with ocular
symptoms can cause concern because alternative differentials may
need to be considered; and the potential teratogenic or fetotoxic
effects of investigations or treatment mean that management
decisions may, in some cases, differ to those of the
nonpregnant patient.
 To be aware of both physiological and pathological ocular changes
that may occur during pregnancy.
 To develop a greater understanding of investigations and
management of ophthalmic and neuro-ophthalmic disorders
in pregnancy.
 To develop an understanding of referral pathways, enabling an
optimal outcome for both mother and baby.
Keywords: diabetic retinopathy / eye changes in pregnancy and
labour / ophthalmic drugs in pregnancy and breastfeeding /
pre-eclampsia / retinal detachment

Please cite this paper as: Patil AD, Ellabban AA, Patil DB, Yorston D, Williamson TH, Laidlaw DA, Vize CJ, Hingorani M, Morris EP. Ocular manifestations of
pregnancy and labour: from the innocuous to the sight threatening. The Obstetrician & Gynaecologist 2020;22:217–26. https://doi.org/10.1111/tog.12670

nonpregnant women must also be considered by

Introduction
Pregnancy is a unique state involving changes in the
hormonal profile, blood circulation and metabolism.
Several ocular changes may occur during pregnancy,
although most are transient and rarely cause problems.
Pregnant women are often concerned about the effect of
pregnancy on their pre-existing ocular condition, or the
use of ocular drugs during pregnancy. The obstetrician
or midwife is often the first port of call for
these women.
This article aims to put clinicians at greater ease when
encountering such ocular complaints and enable them to
differentiate between innocuous physiological changes, the
exacerbation of pre-existing ocular pathology and new
systemic disorders with visual manifestations. While
pregnancy increases the likelihood of certain ocular
disorders, other ocular conditions that can affect
the clinician.
Ophthalmic disorders during pregnancy
Ocular changes during pregnancy can affect different
structures of the eye, leading to visual symptoms. The
common physiological and pathological changes are
summarised in Table 1. For some conditions, referral to an
ophthalmologist, community optometrist or other clinicians
may be required. The referral route and key investigations are
summarised in Table 2.
Ocular adnexae
Most changes affecting the ocular adnexae (tissues
surrounding the eye) are physiological and reverse
after delivery.

ª 2020 Royal College of Obstetricians and Gynaecologists 217

 Ocular manifestations of pregnancy and labour

Table 1. Summary of ocular changes in pregnancy

Pathological changes

Physiological Referral route

changes Clinical finding Symptoms (referral urgency)**

Ocular adnexae  Melasma

(chloasma)

 Mild ptosis*

Anterior segment  Refractive changes  Dry eyes Gritty, foreign body sensation Community optometrist
(routine)
 Increased
corneal thickness  Subconjunctival Localised redness  foreign Not required
haemorrhage body sensation
 Reduced
intraocular Pressure

 Krukenberg
spindles

Posterior segment  Diabetic eye disease Blurred vision Ophthalmology

(1–2 weeks, same day if acute visual
loss)

 Pregnancy-related Visual symptoms possible Refer urgently if visual symptoms

hypertension

 Central serous Blurred vision, occasional Ophthalmology

chorioretinopathy image distortion (2–4 weeks)

Neuro-ophthalmic  Pituitary disorder Headache, blurred vision Ophthalmology/neurology 

unilateral or bilateral neurosurgery
(<24 hours)

 Migraine Bilateral visual symptoms  GP  neurology

headache/prodrome/aura

 Idiopathic Headache  double vision  Neurology  ophthalmology

intracranial intermittent blurring/loss of (<24 hours)
hypertension vision

GP = general practitioner.
*If ptosis is associated with any pupillary abnormality or a neurological cause is suspected, urgent ophthalmology referral is required.
**This is guidance for referral urgency. The referral decision should be made by the clinician on the basis of the clinical findings and the severity of
visual symptoms, on a case-by-case basis.

Melasma (chloasma) Ptosis

Melasma, previously termed chloasma and often referred to
as ‘the mask of pregnancy’, is an area of facial skin
hyperpigmentation. The malar pattern is most common,
but it may also affect the eyelids. It occurs in the second half
of pregnancy in up to 75% of women. Its development is
accounted for by the increase in circulating melanocyte-
stimulating hormone, estrogen and progesterone. It usually
fades with time and, at 12 months postpartum, has regressed
in 90% of women.1,2
Ptosis (drooping of the eyelid) may be seen during
pregnancy, secondary to hormonal changes or fluid
retention within the levator muscle aponeurosis. It is
usually mild and often unilateral. Mild ptosis without any
other associations or pupillary abnormalities does not require
treatment and often resolves following delivery.
The clinician must also be aware of the rare possibility
of Horner’s syndrome, in which the ptosis is associated
with a smaller pupil. This would require further

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 Patil et al.

Table 2. Summarised symptom-based approach to managing ocular pathologies that are more frequent in pregnancy when presenting to the
antenatal clinic*

Symptom Differential Referral route Key investigations

Unilateral blurred  Refractive changes Community optometrist Refraction

vision
 Central serous chorioretinopathy Ophthalmology Amsler grid
Retinal examination
OCT scan

 Diabetic eye disease Ophthalmology  endocrinologist Retinal examination

OCT scan
Blood sugar
HbA1C

Bilateral blurred vision  Refractive changes Community optometrist Refraction

without headache
 Acephalgic migraine GP  neurology Clinical diagnosis

 Diabetic eye disease Ophthalmology  endocrinologist Retinal examination

OCT scan
Blood sugar
HbA1C

 Pituitary disorder Ophthalmology  neurology Blood pressure

(within 24 hours if suspicion of pituitary disorder) Visual fields
Retina and optic
nerve examination
OCT scan
Neuroimaging

 Pre-eclampsia/eclampsia Ophthalmology Visual fields

Retina and optic
nerve examination
Blood pressure
Urine dipstick

Bilateral blurred vision  Migraine** GP  neurology Clinical diagnosis

with headache  neuroimaging

 Pituitary disorder Ophthalmology/neurology  neurosurgery Blood pressure

(within 24 hours) Visual fields
Retina and optic
nerve examination
OCT scan
Neuroimaging

 Pre-eclampsia/eclampsia Ophthalmology Visual fields

Retina and optic
nerve examination
Blood pressure
Urine dipstick

GP = general practitioner; HbA1c = glycated haemoglobin; OCT = optical coherence tomography.

*Other causes of ocular manifestations that could affect nonpregnant women must also be considered by the clinician.
**Migraine may cause headaches with or without visual disturbances. The pattern or frequency of migraine may change during pregnancy.
Acephalgic migraine is a form of migraine that may occur without headache.

ª 2020 Royal College of Obstetricians and Gynaecologists 219

 Ocular manifestations of pregnancy and labour
investigation,3 primarily neuroimaging of the
oculosympathetic pathway, including the chest where the
sympathetic chain lies. Ptosis associated with diplopia, with
or without a dilated pupil, is suggestive of an oculomotor
nerve palsy, which would require urgent ophthalmology
referral and neuroimaging.
Anterior segment and ocular surface
Most anterior segment and ocular surface changes in
pregnancy are physiological and innocuous. Unless
presenting with an acutely painful, red eye, women can be
seen by their community optometrist (optician).
Cornea and refractive changes
Fluid retention during pregnancy means that the corneal
thickness may increase by up to 30%.4 Coupled with the
retention of water in the clear crystalline lens, refractive
(focus) changes may result. About 14% of pregnant women
may experience increased myopia (become more short-
sighted) and therefore report blurred vision – particularly for
distance.5 This can be diagnosed by an optometrist, who will
perform a subjective refraction to identify any need for
spectacles. However, it is advisable to avoid prescribing new
glasses during pregnancy, unless required.
Similarly, pregnant women who use contact lenses –
particularly rigid lenses – may experience ‘tight lens
syndrome’, in which increased corneal thickness causes
removal to become difficult, leading to pain and redness. The
consequently compromised cornea may swell even further,
thus exacerbating the problem.6 Refractive instability in
pregnancy makes it a contraindication to laser refractive
surgery. It is advised that any refractive surgical procedure
should be delayed until at least 12 months after delivery.7
Krukenberg spindles (pigmentation of the posterior
surface of the cornea) may be seen in the first and second
trimesters of pregnancy in 3% of women. However, unlike in
nonpregnant women, they are not associated with increases
in intraocular pressure and spontaneously disappear in the
third trimester or postpartum.8,9
Tear film and ocular surface
Tear film disturbances may occur during pregnancy,
secondary to hormonal changes, causing dry eye symptoms.
Pregnant women often present with a foreign body or gritty
sensation, which transiently improves with blinking.5 Ocular
lubricants can be obtained over the counter.
Eye pressure
During pregnancy, intraocular pressure often drops slightly,
by 2–3 mmHg. This is thought to be associated with changes
in progesterone levels that cause a reduction in episcleral
venous pressure. This reduces resistance to the flow of
220
aqueous humour exiting the eye, in turn leading to a slight
reduction in intraocular pressure.8 This slight change in eye
pressure requires no treatment and has no effect on ocular
haemodynamics. Pregnant women with pre-existing
glaucoma or ocular hypertension may experience modest
improvement in eye pressure control during pregnancy. Eye
pressure changes usually return to the pre-pregnancy level
within 2–3 months of delivery.
Women who are on regular topical treatment to control
intraocular pressure should seek advice from an
ophthalmologist regarding the safety of these eye drops
during pregnancy or breastfeeding.
As with all drugs in pregnancy, it is important to ensure that
the potential benefits outweigh any possible risk to the fetus.
There are limited data about the use of many drugs during
pregnancy. It must be emphasised that, in a sight-threatening
situation, there must be very good reason why a required
treatment is not used. Therefore, a full discussion with the
woman about the benefits and risks of any medication is
encouraged, in the context of available information.
For many topical medications, there is little evidence of
harm since systemic absorption is low, but systemic
medications should be used with caution. It is prudent to
advise pregnant or breastfeeding women that using the index
fingers to apply gentle pressure over the lacrimal punctum for
2 minutes after instilling the eye drops can minimise
systemic absorption of any topical medication (Figure 1).
In selective cases, temporary punctal plugs can be inserted by
the ophthalmologist.
Posterior segment
Unlike anterior segment manifestations of pregnancy, most
posterior segment changes are pathological and require
ophthalmology input. The most common of these is the
progression of diabetic eye disease. Other posterior segment
conditions are uncommon.10
Figure 1. Punctal occlusion. This can be achieved by using both index
fingers to apply pressure over the inside corners of the eye for about
2 minutes. This simple manoeuvre blocks the lacrimal drainage of the
topical medication and hence its passage to the systemic circulation. It
can limit the risk of systemic side effects of topical medications. It is
recommended for all pregnant or breastfeeding women who may
instil eye drops associated with potential risks.
ª 2020 Royal College of Obstetricians and Gynaecologists
 Patil et al.

Detailed examination of the back of the eye often requires

pupillary dilatation. There is a lack of detailed data on the
effects of dilating drops in pregnancy, but occasional use is
thought to be safe. If possible, phenylephrine is best avoided
because of the association of the systemic delivery of this
drug with birth defects and fetal cardiovascular effects.11,12
Therefore, anti-muscarinics, such as tropicamide or
cyclopentolate, are preferred for pupillary dilatation.13

Diabetic eye disease

Pregnancy is an independent risk factor for the progression of
diabetic eye disease and, therefore, individuals with pre-
existing diabetes should have digital photographic screening
after the first antenatal appointment.14 If this is normal, it
should be repeated at 28 weeks of gestation, but, if abnormal,
another assessment should be made at 16–20 weeks of
gestation.15 For high-risk women, such as those with severe
nonproliferative or proliferative diabetic retinopathy, more
frequent examination is recommended, according to severity
and the likelihood of rapid progression.15 It is important to
note that the presence of diabetic retinopathy is not a Figure 3. Proliferative diabetic retinopathy. The retina shows
contraindication for a vaginal delivery, regardless of severity. proliferative changes with the development of new blood vessels on
the retina (yellow arrow) and on the optic nerve head (white arrow).
Diabetic retinopathy is classified as either nonproliferative
diabetic retinopathy (NPDR), which is subdivided into mild,
moderate or severe stages, or proliferative diabetic retinopathy retinopathy before pregnancy, progression may occur in up to
(PDR), in which the retina develops abnormal new blood 54.8% of cases. Development of proliferative disease occurs in
vessels.16 In pregnancy, there is a risk of progression of the only 6.3% of those with mild NPDR and in up to 29% of those
retinopathy; for example, from moderate to severe NPDR with moderate to severe NPDR.17 For the latter high-risk
(Figure 2), or even to proliferative stage (Figure 3). The cohort, multidisciplinary collaboration involving the
Diabetes in Early Pregnancy Study17 showed that pregnant endocrinologist, obstetrician and ophthalmologist is advised
women with little or no diabetic retinopathy before or at the for optimal control of diabetes.
onset of pregnancy are unlikely to have significant progression Duration of diabetes, high glycated haemoglobin (HbA1c)
of retinopathy and mild progression occurs only in 10–20%. and an advanced level of diabetic eye disease are additional
However, in those with moderate to severe nonproliferative risk factors for progression of retinopathy during

Figure 2. Nonproliferative diabetic retinopathy (NPDR). A 34-year-old pregnant woman known to have type 1 diabetes mellitus. (a) At screening
during her first gestational month, the retina showed moderate NPDR changes (left). (b) When reviewed at 7 months of gestation, the retina
showed progression of her retinopathy (white arrow) to severe NPDR with the development of new haemorrhage (yellow arrow) and yellowish
hard exudates (black arrow).

ª 2020 Royal College of Obstetricians and Gynaecologists 221

 Ocular manifestations of pregnancy and labour

pregnancy.15 Paradoxically, a rapid improvement in control

of blood glucose levels can lead to progression of retinopathy.
This rapid improvement in control is not contraindicated in
pregnancy as long as a retinal assessment has been
performed.15 Women with moderate or severe NPDR who
are diagnosed during pregnancy should have at least
6 months of ophthalmic follow-up after delivery.
When proliferative retinopathy occurs during pregnancy,
it is treated by the ophthalmologist. Retinal laser
photocoagulation may be performed to induce regression
of the new vessels. Retinal laser treatment is safe during
pregnancy. In more severe cases, the new retinal blood vessels
(proliferations) may bleed, leading to vitreous haemorrhage.
Vitreous haemorrhage will usually clear spontaneously and
vitrectomy surgery may be delayed until after delivery.
Urgent vitrectomy may occasionally be indicated if the
abnormal fibrovascular tissue contracts, causing a traction
retinal detachment that affects central vision. Review and
monitoring by the ophthalmologist will be required.
Diabetic maculopathy, or diabetic macular oedema, can
also be treated with laser photocoagulation, but only if there
is focal leak away from the centre of the macula. In most
cases when the oedema involves the centre of the macula and
is threatening vision, it is treated by intravitreal injection of
anti-vascular endothelial growth factor (anti-VEGF) drugs.
However, the potential risk of adverse effects on the
developing vasculature of the fetus means that anti-VEGF
agents are best avoided in pregnancy. Women of childbearing
age are advised to wait 3 months after the last dose before
conceiving.18 For pregnant women who develop signficant
macular oedema and are at risk of irreversible vision loss,
ophthalmology review and counselling regarding the
potential risks versus benefits is mandated.19,20 If anti-
VEGF drugs are to be used, then ranibizumab may be
preferable to bevacizumab or aflibercept because it suppresses
plasma VEGF levels to a lesser degree.21
Alternatively, an intravitreal steroid implant (0.7 mg
dexamethasone) may be considered.22 Intravitreal steroids
do not cause the systemic side effects associated with
systemic corticosteroids.23
As reported by Czeizel and colleagues in a large
population-based study, the use of oral or topical
corticosteroids in pregnancy does not appear to noticeably
increase the risk of congenital abnormalities in human
beings.24 However, they should be selectively used with
caution, when required.
The risk of developing advanced retinopathy as a result of
gestational diabetes only is low and, if there are any concerns,
the woman should be referred for an ophthalmology opinion.25
Pregnancy-related hypertension
Pregnancy-related hypertension occurs in up to 11% of
pregnancies.26 The incidence of fundus changes in
Figure 4. Severe hypertensive retinopathy. Fundus photograph of the
right eye, depicting severe hypertensive retinopathy changes,
narrowing of arterioles (red arrow), disc swelling (black arrow) and
multiple retinal haemorrhages. Note the discrepancy of the calibre of
the retinal artery (red arrow) compared with the retinal vein (blue
arrow); the normal artery-to-vein (A/V) calibre ratio is 3:4.
pregnancy-related hypertension is proportional to the
severity of hypertension. Diastolic blood pressure correlates
more closely with the presence of fundus changes than
systolic blood pressure.27–29 Most cases are mild and may
exhibit retinal arteriolar attenuation or, occasionally, subtle
superficial retinal haemorrhage and cotton wool spots (CWS;
small yellowish-white fluffy spots in the superficial retina,
which are caused by accumulation of neuronal debris
following ischaemic disruption of the superficial nerve
axons).30 If the CWS or retinal haemorrhage develops in
the central retina, the pregnant woman presents with a
blurred patch in the field of vision.
Rarely, in severe pre-eclampsia or eclampsia, cystoid
macular oedema, serous retinal detachment or optic disc
swelling (Figure 4) may occur. This can affect vision and is an
indication for immediate ophthalmic referral.31 Double
vision, scotoma and photopsia may also be reported.32
Ophthalmology referral is required for pregnant women who
develop visual disturbances in the context of pregnancy-
related hypertension (Table 2).
Central serous chorioretinopathy
Central serous chorioretinopathy (CSCR) is characterised by
localised serous detachment of the neurosensory retina at the
macula, secondary to leakage from the choriocapillaris from
one or more hyper-permeable retinal pigment epithelium
(RPE) sites. In female individuals, it is most likely to occur

222 ª 2020 Royal College of Obstetricians and Gynaecologists


Figure 5. Amsler grid. The grid is composed of a 10-cm square with a
central black dot. The patient is asked to cover one eye and to look at
the central dot on the grid placed at reading distance (around 30 cm)
and to report any discontinuity or kinks in the lines, or distortion. The
grid assesses the central 20° of vision centred on fixation.
during reproductive years. It can occur in 0.008% (4 in
17 000) of women in the course of uneventful pregnancy.33
The cause of CSCR is unknown, but it can be precipitated
in pregnancy by multiple factors, such as high cortisol levels,
increased vascular permeability, decreased colloidal osmotic
pressure, changes in prostaglandin levels and parenteral
steroid intake.34,35
CSCR presents with micropsia (images appear smaller),
metamorphopsia (image distortion), or blurred vision. It is
most common during the third trimester. The symptoms can
be easily characterised with the Amsler grid, by asking the
woman to fixate on the central dot and to draw or describe
any anomalies on the grid (Figure 5). Ophthalmology referral
is required for diagnosis and further management.
Figure 6. Central serous chorioretinopathy. (a) Fundus photography of the left eye showing a localised area of serous detachment of the retina
(white arrowheads). (b) Cross-sectional optical coherence tomography scan of the retina (indicated by the green line in (a)) showing accumulation
of fluid under the retina.
ª 2020 Royal College of Obstetricians and Gynaecologists
Patil et al.
Ophthalmic examination reveals elevation of the
neurosensory retina – most commonly at the macula.
Optical coherence tomography (OCT) of the retina is key
for diagnosing and monitoring the condition. It is a non-
invasive imaging modality, which renders a high-resolution
cross-sectional image of the retina and takes seconds to
acquire in an outpatient setting (Figure 6).
CSCR does not usually require treatment and resolves
towards the end of pregnancy or a few weeks or months after
delivery. However, it may recur in subsequent pregnancies, or
at any point in the woman’s lifetime.35–37
Neuro-ophthalmic disorders
Assessment of central nervous system disorders will, broadly
speaking, not differ from assessment of the nonpregnant
patient. Early involvement of a neurologist is advisable, as
well as an ophthalmologist to assess optic nerve function and
appearance if visual symptoms are present.
Pituitary disorders
Physiological enlargement of the pituitary gland may occur in
pregnancy as a result of lactotroph hyperplasia secondary to
estrogen stimulation. This process is usually
asymptomatic.38,39,40 Pre-existing adenomas may increase in
size, and proximity to the optic chiasm can unilaterally or
bilaterally compromise the visual field. Ophthalmology
referral for optic nerve function assessment and formal
visual field testing can identify any damage to the visual
pathway. A bitemporal visual field defect is the classic
finding, but other field defects can be seen. If the visual field
suggests a neurological abnormality (i.e. involvement of the
visual pathway), neuroimaging and neurology input are
required.41 Alongside visual fields, optic nerve and macular
ganglion cell layer OCT scans can be performed to assess for
evidence of optic nerve compromise.42 Repeated visual fields
and OCT scans can be used for monitoring progression
during pregnancy.
It is prudent to take a detailed history to help to exclude
migraine, which may cause headaches with or without visual
223
 Ocular manifestations of pregnancy and labour
disturbances. The pattern or frequency of migraine may
change during pregnancy.43,44
Rarely, pregnant women who report a sudden onset
‘thunderclap’ headache and visual disturbance may be
experiencing pituitary apoplexy. This occurs when
enlargement of the pituitary gland causes an increase in
intracapsular pressure within the confined sella turcica,
leading to ischaemia and thrombosis. Once infarction has
occurred, haemorrhage may ensue. Apoplexy is a medical
emergency because impaired pituitary function will
necessitate the replacement of pituitary hormones.41
Idiopathic intracranial hypertension
Idiopathic intracranial hypertension (IIH) predominantly
occurs in women of childbearing age and has a strong
association with obesity.45 Weight gain in pregnancy can lead
to its onset or exacerbation. IIH is characterised by increased
intracranial pressure (ICP) without localising signs. Pregnant
women may present with headaches, nausea and vomiting,
transient visual obscurations and pulsatile tinnitus.
Symptoms are often worsened by lying flat, or by valsalva
manouevres. Papilloedema (swelling of the optic nerve head
secondary to increased ICP) is usually seen, and unilateral or
bilateral sixth nerve palsy is possible. Given that pregnancy is
a pro-thrombotic state, urgent neuroimaging is mandatory to
exclude venous sinus thrombosis or a space-occupying lesion.
To exclude the former, a magnetic resonance venogram
(MRV) or computed tomography venogram (CTV) is
required. A neurology referral is required and a lumbar
puncture may be performed to measure the ICP for
diagnosis. Although possible, lumbar puncture can be
challenging in obese pregnant women.46 Ophthalmology
input is required to assess optic nerve function and
appearance, including visual acuity, formal visual fields,
colour vision, OCT scanning and ophthalmoscopic
assessment of the optic nerve head.
First-line treatment for IIH in the nonpregnant patient
involves a multidisciplinary approach to weight loss. Oral
acetazolamide is generally the first-line medical agent, but
there is limited evidence of safety in pregnancy and the
manufacturer recommends avoiding use in pregnant
women.47 Therefore, it is best avoided, particularly in the
first trimester, unless there is a clear risk of sight loss. If used,
there must be detailed discussion with the pregnant woman
regarding risks and benefits.48,49 Targeted weight loss in
pregnancy that is appropriate for gestational age of the fetus
may warrant referral to a specialist weight service.50 If
surgical management is required to prevent visual loss in
pregnancy, this may entail repeated lumbar punctures or
cerebrospinal fluid diversion procedures.46
Severe pre-eclampsia may also lead to raised intracranial
pressure; this should be investigated by checking for high
blood pressure, proteinuria, evidence of systemic involvement
224
(renal, hepatic, neurological or haematological manifes-
tations) and fetal growth restriction. 51
Posterior reversible encephalopathy syndrome
In the context of pregnancy, posterior reversible
encephalopathy syndrome (PRES) may complicate
hypertensive disorders of pregnancy. This comprises
headache, visual loss, impaired consciousness and seizure
activity. Diagnosis is confirmed on magnetic resonance
imaging (MRI) by the presence of subcortical white matter
oedema – typically in the parieto-occipital area. PRES is rare
during pregnancy and the prognosis is generally favourable if
the underlying cause is treated.52
Other rare neurological manifestations
Venous sinus thrombosis may occur during pregnancy. There
is an increased risk associated with increasing maternal age,
hyperemesis gravidarum, pre-eclampsia and caesarean
section. The pregnant woman may present with headaches,
paresis, seizures, or blurred vision, and papilloedema may be
evident on fundus examination.53,54
Other neuro-ophthalmic conditions in pregnancy may
affect the visual pathway. Rarely, cortical blindness or
ischaemic optic neuropathy may complicate severe cases of
eclampsia. A nutritional optic neuropathy has been reported
in cases of hyperemesis gravidarum.55 Ophthalmology
referral is indicated if visual symptoms develop, to assess
optic nerve function and perform visual field testing.
Ophthalmic disorders during labour
The most common ocular finding following labour is
subconjunctival haemorrhage, which is harmless. Other
ocular complications during labour are rare.
Subconjunctival haemorrhage
Subconjunctival haemorrhage is an innocuous finding during
or after delivery in up to 10% of women. It can also occur
during pregnancy following repeated vomiting, coughing or
eye rubbing. In the nonpregnant patient, repeated episodes
warrant a blood pressure assessment and clotting screen.
However, a one-off episode during or after delivery merely
requires reassurance that the haemorrhage will spontaneously
resorb over a period of weeks.56
Valsalva maculopathy
Valsalva maculopathy is a rare occurrence during labour or
pregnancy. It is characterised by superficial retinal
haemorrhages, with a predilection for the macula. Increased
intrathoracic or intra-abdominal pressure during labour is
transmitted to the eye and can cause a sharp rise in the
intraocular venous pressure, which may rupture superficial
retinal capillaries.57–59
ª 2020 Royal College of Obstetricians and Gynaecologists

Women usually give a history of sudden visual blurring,
usually central, following labour or any episode of straining,
coughing or vomiting.
Ophthalmology referral is required to confirm the
diagnosis by retinal examination. The prognosis is variable
depending on the severity of the haemorrhage. In most cases,
the haemorrhage is mild and spontaneously resolves over few
months. However, in some cases, if there is dense or
persistent pre-macular haemorrhage, the toxic effect of
blood byproducts can damage the photoreceptors or retinal
pigment epithelium.59–61
Purtscher’s retinopathy
Purtscher’s retinopathy is characterised by retinal
haemorrhages, oedema and CWS, predominantly located
around the optic disc. It may occur in uneventful labour or in
cases of severe pre-eclampsia or eclampsia. The cause is
unknown, but it is thought to be associated with micro-
embolic occlusion of pre-capillary arterioles.62,63
Risk of rhegmatogenous retinal detachment
The term ‘rhegmatogenous’ retinal detachment (RRD) refers to
retinal detachment occurring secondary to a tear or hole in the
retina, with subsequent separation of the retina from the
underlying retinal pigment epithelium. It is commonly known
in clinical practice as ‘retinal detachment’. Some obstetricians
are concerned that forcible pushing during labour can cause
RRD, particularly in women who have a previous history of
retinal surgery, or who have risk factors that may predispose to
RRD, such as high myopia, peripheral retinal degeneration or a
previously treated retinal break. This has led some obstetricians
to advocate for assisted delivery.64–67
Previous studies have investigated the risk of RRD during
labour, and no correlation between labour and the risk of
RRD has been shown. RRD develops secondary to a tear or
hole in the retina and is not related to forcible pushing or
changes in the eye pressure.68–70 There is no requirement for
pregnant women with risk factors or a history of retinal tears
or detachments to be assessed by an ophthalmologist before
labour. Such women can safely deliver vaginally.
Conclusion
The complex physiological transformation of pregnancy
precipitates innocuous changes in the eye and vision, but
may also cause serious ocular pathology requiring urgent
ophthalmic or neurology input. Recognition of these
disorders and early referral enables prompt management
and a favourable prognosis.
Disclosure of interests
There are no conflicts of interest.
ª 2020 Royal College of Obstetricians and Gynaecologists
Patil et al.
Contribution to authorship
ADP and AAE wrote and edited the article. THW, DY, DP,
DAY, CJV, MH and EPM reviewed and critically revised the
article. All authors approved the final version.
Supporting Information
Additional supporting information may be found in the
online version of this article at http://wileyonlinelibrary.com/
journal/tog
Infographic S1. Ocular manifestations of pregnancy.
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