This extract first appeared in Glaucoma Now Issue 1 May 2018. It has been republished with the permission of Glaucoma Now.
Written by John Thygesen, M.D. Associate Professor, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark, Chair of European Glaucoma Society Training Support Committee
Women considering to become pregnant
Women with childbearing potential, who have glaucoma, should be encouraged to discuss their reproductive plans with a health care provider prior to becoming pregnant. This allows treatment choices to be planned appropriately, optimising benefits for the mother and minimising risks for the fetus by managing and potentially reducing medication exposure during critical early stages of foetal development. As many pregnancies are unplanned, exposure to medication might occur before women know they are pregnant.
Women who consider becoming pregnant and whose glaucoma requires medical treatment should be advised that their medication will reach the fetus and that early pregnancy is the period of greatest teratogenic risk. They should consider avoiding use of prostaglandin analogues, carbonic and anhydrase inhibitors and parasympathomimetic/ cholinergic agents (rated class C drugs by the US FDA).
An appropriate treatment plan will depend on the degree of the patient’s glaucomatous damage, the level of her IOP and personal preferences. It may be appropriate to offer primary laser trabeculoplasty or surgical intervention to women with glaucoma who wish to conceive.
Appropriate management of the pregnant woman at risk of, or with diagnosed glaucoma requires a balance between the treatment’s risk to the fetus and the risk to the mother if treatment is reduced or suspended.
Pregnancy often alters IOP, which tends to be lower in mid to late term, possibly from hormonal changes or decreased episcleral venous pressure. This may allow certain patients to be monitored on reduced medications or without treatment during pregnancy.
Some health care providers and patients opt for wide margins of safety, avoiding the use of medication for early or mild disease when the risk of significant glaucomatous progression during the course of the pregnancy is small. If continuation of treatment is mandated, the lowest effective dosage of medication should be used. Moreover, systemic absorption should be reduced by punctal occlusion, eyelid closure, and blotting excess drops away after instillation.
In some situations, glaucoma during pregnancy may be best managed through surgery, however, this management path is not without its risks as mentioned below.
For these reasons laser trabeculoplasty may be considered first as it offers significant advantages over surgical management of glaucoma during pregnancy. These include the use of only topical anaesthesia, upright positioning during the procedure, faster rehabilitation, and reduced need for post-operative medications both in dosage and duration.1
In the majority of cases, medications used for glaucoma can be used safely in women who are breastfeeding. With care, carbonic anhydrase inhibitors and beta-blockers may be used in nursing mothers as suggested by the American Academy of Pediatrics2. These are also the first line choices in infants with congenital glaucoma when medical therapy is being considered. Particular caution should be exercised however, if a breastfeeding mother is instilling alpha2-agonists.
The infant should be monitored closely for evidence of systemic toxicity; this is less likely with betablockers and carbonic anhydrase inhibitors than with alpha2-agonists. When managing glaucoma in women wishing to breastfeed, consider using the minimum number of medications and concentration sufficient to achieve target IOP. Eyelid closure and punctal occlusion should also be emphasized to reduce the potential for systemic absorption and therefore reduce transfer into breast milk (American Academy of Pediatrics 2001).2
1. Chung CY, Kwok AK, Chung KL. Use of ophthalmic medications during pregnancy. Hong Kong Med J. 2004 Jun;10(3):191-5.
2. Transfer of drugs and other chemicals into human milk. Pediatrics 2001;108(3):776- 789.
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