Neuro-ophthalmology and Pregnancy (Neurology of Pregnancy February 2022)

Educational Objectives

The goal of this program is to improve management of neuro-ophthalmologic conditions commonly seen in pregnancy. After hearing and assimilating this program, the clinician will be better able to:

1. Distinguish between normal and pathophysiologic eye changes in pregnancy.
2. Appropriately evaluate patients presenting with visual symptoms during pregnancy.
3. Provide safe and effective treatment of eye disorders commonly seen in pregnancy.

Summary

Neuro-ophthalmology and Pregnancy (Neurology of Pregnancy February 2022)

Changes in the eye during pregnancy: Refraction may change during a normal pregnancy; this occurs in persons with preexisting myopia or hypermetropia, but even those who do not need eyeglasses before pregnancy may develop blurred vision at near or distance; hormonal changes can affect tear production, particularly in the late third trimester and postpartum period, causing dry eye, discomfort, and blurred vision.

Pathophysiologic changes: Central serous chorioretinopathy — collection of fluid under the retina resulting in detachment; more common in men but also occurs in pregnant women; causes a “spot” in vision; difficult to diagnose on eye examination (ophthalmic imaging may be needed); retinal infarcts — caused by occlusion of retinal arterioles and venules; can cause focal visual disturbances; important to consider in pregnant patients with unilateral eye symptoms.

Visual effects of preeclampsia and eclampsia: Symptoms may result from issues with the eyes, optic nerves, or brain; effects on the retina may cause changes in blood vessels; visual changes may be caused by retinal ischemia, serous retinal detachment, or edema or ischemia of the optic nerve head (prechiasmal conditions; may manifest differently in the right and left eyes); posterior reversible encephalopathy syndrome (PRES) — symptoms depend on the location of disease; effects on the occipital lobe cause visual field loss or cortical blindness; higher-order visual symptoms (eg, Balint syndrome, simultanagnosia) also may occur.

Approach to visual symptoms: Pregnant and nonpregnant patients are approached in the same way; the clinician should determine whether symptoms are unilateral or bilateral; if a symptom in one eye persists when the other eye is closed, the lesion is prechiasmal or in the brain (ie, afferent visual pathway); if the same symptom occurs in both eyes, the issue is likely to be in the brain; if symptoms differ between the eyes, the problem may be prechiasmal or chiasmal, but it is possible for prechiasmal lesions to cause the same symptom in both eyes; if symptoms in one eye improve when the fellow eye is covered, the issue is with coordination of the eyes (ie, eye misalignment).

Diplopia: If diplopia does not resolve when one eye is covered (ie, monocular diplopia), the problem is not neurologic but caused by optic changes that affect how light enters the eye; resolution or improvement of symptoms when either eye is covered (ie, binocular diplopia) suggests ocular misalignment; the cause may be an isolated problem with an eye muscle or a cranial nerve issue; in cranial nerve VI palsy, the eyes turn inward (esotropia), with worsening on looking toward the affected side; in cranial nerve III palsy, moving the eye upward, downward, and inward is difficult, and there is ptosis; cranial nerve IV palsy is difficult to diagnose on examination (one eye is typically higher than the other, causing vertical diplopia).

Papilledema: Refers to optic nerve swelling or optic disc edema secondary to elevated intracranial pressure (ICP); optic disc edema has a broader differential diagnosis, but papilledema should be excluded early when presentation is bilateral; conditions causing high ICP in pregnancy are the same as those in nonpregnant persons (eg, venous sinus thrombosis, brain tumor); in pregnancy, risk for venous sinus thrombosis is elevated because of the hypercoagulable state; idiopathic intracranial hypertension — a diagnosis of exclusion; high ICP without a secondary cause; may develop before or during pregnancy; weight gain is a contributing factor; ideally managed before pregnancy; requires careful monitoring during pregnancy.

Managing idiopathic intracranial hypertension: Acetazolamide, the first-line treatment agent, is a pregnancy Category C drug, but observational studies suggest that use in early pregnancy is safe; pregnant patients should be reminded of the importance of good vision in providing optimal care for their children; in patients with headache but no vision loss, treatment is optional; symptoms may be managed using acetaminophen or another analgesic medication, with appropriate monitoring of vision; during labor, Valsalva maneuvers and uterine contractions can increase ICP; the safety of spontaneous vaginal delivery should be discussed with the obstetric team; patients with no or mild papilledema may have no issues during labor; however, in those with optic neuropathy or severe papilledema, the risk of transiently high pressure is concerning and alternative plans for labor management may be needed.

Idiopathic cranial neuropathies: Common in pregnancy; localizing the problem and identifying potentially catastrophic conditions (eg, acute cranial nerve III palsy mimicking expanding posterior communicating artery aneurysm) is important; obstetric anesthesia (spinal or epidural) may spread and lead to Horner syndrome or cranial nerve palsies; dural puncture (planned or inadvertent) may cause CSF hypotension and false localizing cranial nerve VI palsy; cranial nerve VII (facial nerve) palsy — common in pregnant women, usually occurring in the third trimester; can be diagnosed without additional investigation; in nonpregnant patients, typically treated with steroids; although some experts consider steroids safe and reasonable in the third trimester, others question the risk-benefit ratio of use during pregnancy.

Other pearls: Eye care providers should be involved in the care of patients, as these clinicians have tools for examining and imaging the eye and can help with diagnosis.

The material presented in Continuum Audio has been made available by the AAN for educational purposes only and is not intended to represent the only method or procedure for the medical situations discussed but rather to present an approach, view, statement, or opinion of the speaker(s), which may be helpful to others who face similar situations. Opinions expressed by the speakers are not necessarily those of the AAN, its affiliates, or the publisher. The AAN, its affiliates, and the publisher disclaim any liability to any party for the accuracy, completeness, efficacy, or availability of the material contained in this program (including drug dosages) or for any damages arising out of the use or nonuse of any of the material contained in this program.

Readings

Moss HE. Neuro-ophthalmology and pregnancy. Continuum (Minneap Minn) 2022;28(1, Neurology of Pregnancy).

Disclosures

In adherence to ACCME Standards for Commercial Support, Audio Digest requires all faculty and members of the planning committee to disclose relevant financial relationships within the past 12 months that might create any personal conflicts of interest. Any identified conflicts were resolved to ensure that this educational activity promotes quality in health care and not a proprietary business or commercial interest. For this program, the following was disclosed: Dr Moss has served on the editorial board of the Journal of Neuro-Ophthalmology and as an associate editor for Frontiers in Neurology and MedLink Neurology, an assistant editor for Frontiers in Ophthalmology, a review editor for Current Eye Research, a guest editor for Current Opinion in Neurology and Current Neurology and Neuroscience Reports, and a special issue editor for Life. Dr Moss has served as a consultant for Twenty/Twenty Therapeutics and Verana Health and on an advisory board for Genentech, Inc; has received personal compensation for speaking engagements for Vindico Medical Education; and receives research/grant support from the National Institutes of Health (P30 EY 026 877, R21 EY 031 726) and Research to Prevent Blindness.

Unlabeled Use of Products/Investigational Use Disclosure: Dr Moss reports no disclosure.

To view disclosures of planning committee members with relevant financial relationships, visit: legacy.audio-digest.org/continuumaudio/committee. All other members of the planning committee report nothing to disclose.

Acknowledgements

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0 CE contact hours.

Lecture ID:

CA110108

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.