Treatment of glaucoma during pregnancy. Glaucoma during pregnancy: features of treatment. Measurement of intraocular pressure in glaucoma

In recent years, ophthalmologists have increasingly begun to face serious eye problems, including glaucoma in pregnant women, due to the fact that the introduction of new progressive reproductive technologies has significantly increased the childbearing age of women. As a result, women become pregnant at an older age, which significantly increases their risk of developing concomitant eye diseases. Moreover, thanks to the introduction of new diagnostic methods, glaucoma is increasingly being diagnosed at an earlier age, and pregnancy occurs already against the background of a diagnosed disease.

Given that a number of antiglaucoma and other pharmacological drugs used to treat this pathology can lead to adverse changes in the fetus and newborn, ophthalmologists and obstetricians face the real task of preserving the vision of the expectant mother and not harming the fetus, ensuring the birth of a healthy baby. Thus, glaucoma during pregnancy and lactation is a serious medical problem, the solution of which lies in the plane of interdisciplinary medicine.

According to numerous epidemiological and clinical studies, glaucoma most often occurs in 2-3% of the female population over the age of 40 and older. However, there is evidence that this pathology is also quite common in women aged 15 to 34 years, the prevalence of which can vary within 0.5%.

At present, it is not possible to provide more accurate data on the prevalence of glaucoma among pregnant women. However, it is known that glaucoma during pregnancy is quite rare. The literature presents individual observations on the features of the course of primary open-angle, congenital, juvenile and secondary glaucoma during pregnancy. It is known that a number of physiological changes occur in the body of a pregnant woman, primarily due to a change in the hormonal background, which, in turn, initiates the occurrence of certain changes in the system of the visual analyzer, both physiological and pathological. In this regard, during pregnancy, the level of intraocular pressure, as a rule, decreases, which is most often observed in the second half and in the early postpartum period. Such dynamics of changes in IOP is explained by the activation of uveoscleral outflow, a decrease in pressure both in the episcleral veins and in the vascular system of the upper extremities, which leads to an increase in the outflow of intraocular fluid. In turn, this has a beneficial effect on the course of the already existing chronic glaucoma process in pregnant women, as evidenced by the stabilization of visual functions in approximately 87.5% of cases. Moreover, according to a number of authors, this makes it possible to achieve compensation of the glaucoma process even with a decrease in the load of antiglaucoma drugs. Clinical evidence suggests that glaucoma is rarely diagnosed during pregnancy, and IOP in pregnant women with glaucoma is usually well controlled. Difficulties arise when glaucoma with intraocular pressure exceeding the individually tolerated level, with signs of trophic disorders in the outflow tract, in the retina and in the optic nerve, is first diagnosed in early pregnancy.

Given that during the instillation of antiglaucoma drops, part of the ingredients of pharmacological preparations can freely penetrate both into the mother’s blood and through the placental circulation into the fetus, and during breastfeeding into the body of the newborn, there are real difficulties in correcting IOP and selecting an antiglaucoma drug. Treatment tactics should protect the fetus from the negative effects of drugs and stabilize visual functions, preventing their deterioration.

Pregnancy and glaucoma is a rather dangerous combination. Pregnant women with glaucoma require careful monitoring by ophthalmologists and specialized specialists. The results of studies on the experience of using possible methods of treating glaucoma in pregnant women showed that more than 30% of ophthalmologists experience significant difficulties in determining the tactics of treating pregnant women with glaucoma.

To a certain extent, the treatment of glaucoma during pregnancy is complicated by the peculiarities of patients' perception of the real difficulties that arise. This is due to the fact that almost all antihypertensive drugs that are prescribed to control IOP, to one degree or another, have a teratogenic effect. This also applies to those drugs that are to a certain extent safe in the usual state. However, during pregnancy, the risk of teratogenic effects occurs in approximately 24%, i.e. in this percentage of cases, birth defects may develop.

Women aged 35 years and older are usually well informed that at this age the risk of developing congenital pathology in a baby increases significantly, especially when taking antiglaucoma drugs. This provokes them to have additional reasons for concern, in addition to their mature age, which in itself negatively affects the course of pregnancy. In some cases, patients become reluctant to take medications during pregnancy, violate the regimen and even completely refuse antihypertensive drops, which has an extremely negative effect on the functions of the eye and the course of glaucomatous optic neuroopticopathy. Although, in reality, even taking drugs with high teratogenic properties increases the risk of serious birth defects by only 1-3%. The low risk of birth defects, combined with patient concerns, often makes it tempting to forego the diagnosis of glaucoma during pregnancy. In fact, common sense says that quite often the glaucoma process during pregnancy stabilizes, and patients, as a rule, do not need treatment. Studies of healthy women and individuals with ocular hypertension show that IOP decreases as pregnancy progresses, which becomes especially pronounced as you move from the second to the third trimester. The hypothesized reasons for this decrease in IOP are an increase in the outflow of aqueous humor, a decrease in pressure in the episcleral veins, and the development of moderate metabolic acidosis. In this regard, it can be assumed that the risk of developing glaucoma during pregnancy still remains quite low.

However, studies demonstrating an association between pregnancy and lower IOP levels, however, do not apply to pregnant women who were diagnosed with glaucoma many years before pregnancy, including during childhood and adolescence. In addition, unfortunately, there are practically no large-scale studies to assess the dynamics of changes in IOP in pregnant women with glaucoma. As a rule, the literature presents mainly retrospective data. For example, the largest study is presented by Harvard Medical School on the examination of 28 eyes in 15 pregnant women with a previous diagnosis of glaucoma. According to these data, in 13 of 15 patients, antihypertensive drugs such as beta-blockers, alpha-agonists, cholinergics and carbonic anhydrase inhibitors were used for the treatment of glaucoma both before and during pregnancy. The results of the survey showed that in 57% of cases there were stable visual functions, in 18% of the cases the IOP level increased during pregnancy in the absence of negative dynamics from the visual functions, and 18% of the eyes were characterized by progressive loss of vision with a stable and normal IOP level. There was no need for surgical intervention in any of the cases. Based on these data, it can be judged that the course of glaucoma during pregnancy is characterized by significant variability, which, in turn, confirms the fact that monitoring of the glaucoma process and IOP during pregnancy should be carried out regularly.

Drug therapy for glaucoma during pregnancy

Today, there is no single standard in the treatment of glaucoma in pregnant women, which creates significant difficulties in the treatment of this pathology. With the use of ophthalmic medications during pregnancy, there is a potential risk to the mother and fetus. Unfortunately, there is limited information on this subject, given the paucity of randomized control trials. The results of some clinical observations and experimental studies indicate a number of side effects when taking antiglaucoma drugs. Studies have shown that non-ionized, low molecular weight (less than 700 daltons) lipid-soluble drugs easily cross the placental barrier. It is known that the bulk of antiglaucoma drops has a low molecular weight (90-390 daltons), which ensures that they can easily enter the fetal circulatory system. At the same time, active substances with a molecular weight of less than 200 daltons have the ability to accumulate in breast milk, which is also facilitated by its higher acidity in comparison with blood plasma. So, 30-120 minutes after the instillation of antiglaucoma drops, their concentration in breast milk can reach a maximum level, which is 1-2% of the applied dose. Despite the low concentration of eye drops, a systemic effect was recorded in some cases. To a certain extent, this is due to the fact that approximately 80% of the volume of eye drops through the nasolacrimal canal enters the nasal cavity and throat, is partially swallowed and absorbed, quickly entering the systemic circulation. To reduce the rate of absorption with local use of antiglaucoma drugs, nasolacrimal compression or the use of temporary occlusion of the lacrimal puncta is recommended.

With drug therapy of glaucoma, it is necessary to prescribe antiglaucoma drops in the lowest possible dosages. In this case, one should take into account the data of the special committee of the FDA (Food and Drug Administration), which has information about the possible effects of drugs on the human body and regulates their use, including during pregnancy. In accordance with this, 5 categories of drugs have been identified in relation to their use during pregnancy: category A - no risk to the fetus; category B - the risk to the fetus is not proven; category C - the risk to the fetus is not excluded; category D - possible risk to the fetus, but the positive effect of the application prevails; category X - the presence of a risk to the fetus has been proven and the use is not allowed. According to these data, all topical antiglaucoma drugs, except for brimonidine, for which there is no proven risk to the fetus, belong to group C, i.e. have questionable safety for the fetus due to the fact that the risk of their negative impact is not excluded.

To date, there are no clear protocols for the treatment of glaucoma during pregnancy, therefore, when determining the nature of treatment, it is necessary to take into account the potential for adverse reactions. In addition, it should be borne in mind that, for obvious reasons, clinical studies on the effect of pharmacological drugs are prohibited in pregnant and lactating women, therefore, for legal reasons, none of the following drugs can be used for use in this category of glaucoma patients .

Side effects of various antiglaucoma drugs

Miotics. The results of experimental studies on animals have shown that the use of pilocarpine can lead to various disorders of intrauterine development. However, the results of clinical observations do not allow us to talk about cases of development of anomalies in children when using this drug in the first trimester of pregnancy. However, it is believed that taking pilocarpine during lactation may contribute to weakness and / or fever in the newborn.

Alpha adrenometics. The safety of the use of an alpha-2 agonist (Brimonidine-Alphagan) during pregnancy or breastfeeding in humans has not been established at the level of evidence-based medicine. There is evidence that their use may contribute to delaying the second stage of labor, postpartum uterine atony and bleeding. Although only brimonidine and dipivefrine are classified as class B of all antiglaucoma drugs, since the risk of their teratogenic effects has not been proven, nevertheless, they should also be prescribed with caution in pregnant and lactating mothers. As a result of the penetration of the drug into breast milk, the development of vegetovascular and cardiovascular reactions in newborns in the early postpartum period is possible.

Beta blockers. The drugs of this group, most often Timoptol, Teoptic, Betagan, Betoptic, are considered the most dangerous in the early stages of intrauterine development, and therefore it is advisable to limit their intake as much as possible in the first trimester of pregnancy. This is due to the small volume of blood and the immature metabolic system of the fetus, as a result of which the concentration of timolol in the fetal plasma can reach a fairly high level. However, even a 6-fold increase in the concentration of timolol remains only at the level of 1/80 of the cardio-effective dose. In addition, their negative impact on uterine contractility is possible. In later periods (2-3 trimesters) and during lactation, the effect of these drugs can cause a feeling of depression, bradycardia and hypoglycemia in a child. Special care must be taken in the presence of hepatic or renal dysfunction in the newborn. In recent years, however, the emergence of preservative-free forms in separate containers, such as Metipranolol Minims and Nyogel, may be a solution to this issue to some extent.

carbonic anhydrase inhibitors. These drugs are considered safer for the child, but the features of their use during pregnancy and during breastfeeding have not yet been studied well enough. There is evidence that drugs in this group can easily pass into breast milk and adversely affect lactation. Among the drugs of this group for systemic use, tablets (acetazolomide-Diamox) and capsules (dichlorophenamide-Daranide) with slower absorption are known. It can be assumed that the systemic effect of eye drops (Dorzolamide-Trusopt) should be much less pronounced than when taking this group of drugs orally. It is advisable to completely refuse the appointment of Brinzolamide (Azopt) eye drops during pregnancy and during lactation.

prostaglandin analogues. The results of experimental studies did not reveal the consequences of taking drugs from this group. Reliable data on the presence of teratogenic properties, as well as their effect on the newborn when breastfeeding, have not been identified. However, drugs such as Xalatan (Latanoprost), Xalacom (a combination of Latanoprost and Timolol), Lumigan (Bimatoprost) and Travatan (Travaprost) are recommended to be completely avoided during pregnancy.

Tactics of laser and surgical treatment of glaucoma during pregnancy

The previously noted features of the physiological state explain the fact that, as a rule, during pregnancy, glaucoma is rarely diagnosed for the first time, and the clinical course of glaucoma in a pregnant woman is characterized by a favorable course with good IOP control. However, in certain patients there is a need for laser or microsurgical treatment. We are talking about those cases when glaucoma is ever diagnosed during pregnancy, or pregnancy occurs against the background of uncontrolled glaucoma. In cases where it is not possible to achieve IOP compensation with a minimal regimen of antiglaucoma drugs, alternative methods of treatment may be recommended. In these cases, it is necessary to assess the possible risks that may be associated with the influence of the psychogenic factor, as well as the physiological state of the pregnant patient and the side effects of anesthetic drugs. In this regard, preference remains on the side of laser therapy, in particular, laser trabeculoplasty (ALT), selective laser trabeculoplasty (SLT), cyclophotocoagulation. According to the literature, ALT is somewhat less effective than SLT. Moreover, the SLT procedure can be repeated several times if necessary. The lack of IOP compensation after the laser procedure is an indication for surgery. The choice of tactics for surgical treatment of uncompensated glaucoma during pregnancy has no fundamental differences. However, one should not forget about the real risks for both the mother and the fetus, which is also explained by the physiological state of the patient. This is primarily about the negative impact of drugs used during and after surgery, including diuretics. Moreover, with an increase in blood plasma volume and cardiac output during pregnancy, blood pressure in pregnant women in the second half of pregnancy can significantly decrease, and a horizontal position on the operating table can significantly increase hypotension and lead to fetal hypoxia. To prevent these phenomena, it is necessary to correct the position of the woman on the operating table (preferably on the left side, maintaining the correct position of the head) to create the required level of oxygenation. The use of narcotic substances, relaxants and inhalational anesthetics should be minimal, given their possible impact on the fetus. For example, there are data on the teratogenic properties of sodium thiopental and nitrous oxide, on cardiovascular reactions in the fetus when bipuvacaine is used. We must not forget about the decrease in the tone of the gastroesophageal sphincter, as a result of which there is a real danger of vomiting and aspiration of the contents of the stomach during the operation. On the basis of this, on the one hand, performing surgery in the 1st trimester can reduce the risk of developing a teratogenic effect of antiglaucoma drops, on the other hand, there is a real danger of a teratogenic effect of pharmacological preparations for surgical support of the operation and the postoperative period. In this regard, when deciding on the timing of surgical treatment, all possible risk factors should be taken into account, and such operations during pregnancy must be performed under conditions of mandatory monitoring of the fetal condition.

Conclusion

Thus, the discussion of the treatment plan for glaucoma in women of childbearing age should be carried out even before pregnancy, which will avoid possible negative consequences of the action of drugs on the process of ontogenesis, which, as is known, takes place during the 1st trimester of pregnancy. In the first trimester, it is advisable to refrain from antiglaucoma drugs, given the high risk of their teratogenic effects. It is permissible to use eye drops from group B (brimonidine) in minimal concentrations. The use of drugs from the groups of beta-blockers, prostaglandins and carbonic anhydrase inhibitors should be avoided. In addition, given that most anesthetics, sedatives and metabolic drugs that are used during surgery are far from safe for the development of the unborn child, it is better to refrain from surgical intervention in order to reduce the risk of teratogenicity or spontaneous abortion during these periods. In the second trimester of pregnancy, with normal fetal growth and heart rate, in addition to brimonidine, beta-blockers can also be used. If necessary, it is permissible to use drugs from the groups of prostaglandin analogues and local carbonic anhydrase inhibitors, the appointment of which must be combined with regular monitoring of the fetal condition and careful monitoring of the appearance of unwanted symptoms. In the third trimester, the noted groups of drugs, except for prostaglandins, can be used at higher doses. At the beginning of this trimester, it is still desirable to refrain from prescribing prostaglandins due to the risk of preterm birth. At the end of this period, brimonidine should be discontinued, as its action may lead to undesirable effects on the central nervous system of the newborn. The drugs of choice in the third trimester of pregnancy may be a group of carbonic anhydrase inhibitors.

Surgery for glaucoma in the second and third trimesters should be performed only when absolutely indicated, given the potential risk of side effects of medications: maternal hypotension and fetal asphyxia. During these periods, laser interventions (argon laser trabeculoplasty and/or selective laser trabeculoplasty) are the preferred glaucoma treatment methods or operations of choice, since they can be performed at any time. However, it should be borne in mind that their hypotensive effect in the long term may be insufficient. During lactation, carbonic anhydrase inhibitors and beta-blockers in minimal dosages can be prescribed. These groups of drugs have been approved for use by the American Academy of Pediatrics, while the use of brimonidine during this period is contraindicated. Based on the above, it can be concluded that the use of antiglaucoma drugs during pregnancy and lactation should be carried out taking into account their side and teratogenic effects. Moreover, the development of a lifestyle and therapy for glaucoma in women with glaucoma of childbearing age should be carried out before pregnancy. Pregnancy, especially in such cases, must be planned. In general, it can be assumed that the use of antiglaucoma drugs has a very low risk of teratogenic effects on the fetus during pregnancy. However, the appointment of antiglaucoma drugs must be carried out with precautions, and to reduce paraocular absorption of drugs and minimize their systemic effects, instillations of antiglaucoma drops should be performed with nasolacrimal compression or with temporary occlusion of the lacrimal openings.

conclusions

The appointment of antiglaucoma drugs with increased IOP is necessary only with objective data indicating the progression of the disease. The regimen of antiglaucoma drugs during pregnancy and lactation should be minimal, and antiglaucoma surgery (preferably laser) should preferably be performed taking into account the duration of pregnancy. To minimize the systemic effect of antiglaucoma drops, instillations should be carried out either with nasolacrimal compression or with temporary occlusion of the lacrimal openings.

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In the medical literature, all the features of glaucoma are sufficiently described: what it is, the causes of its occurrence and possible complications. Pathology represents an increased danger due to the long stage of its development, which is not accompanied by clinical manifestations. As a result, the patient does not have the opportunity to promptly seek medical help.

Glaucoma develops against the background of increased intraocular pressure

The disease develops against the background of increased intraocular pressure. As the changes increase, the patient has a decrease in visual fields, followed by damage to the structure of the optic nerve. Optometrists strongly recommend not to delay the trip to a medical institution. In the event of a prolonged lack of medical care, the patient develops blindness.

Depending on the stage of development of the disease, glaucoma of the eye is acute or chronic. Its first form suggests that pathological changes in the region of the optic nerve arose for the first time. If the clinical manifestations are repeated with regular intensity, then the doctor makes an assumption that the patient has a chronic form. These symptoms include:

• increased intraocular pressure (IOP);
• the appearance of trophic disorders in the region of the optic nerve;
• violation of the outflow of intraocular fluid;
• decreased visual acuity;
• physical damage to the optic nerve head.

Despite the current level of technical equipment of medical institutions, doctors carefully monitor patients with glaucoma. Based on the information collected, a conclusion is made about the presence of one of the three main types of pathology. You can quickly cope with periodic attacks of high IOP. This diagnosis is made to the patient only after passing the tests and passing the examination.

Optometrists emphasize that for each person there are unique allowable IOP limits. Numerous studies have shown that with age, the threshold of normal shifts up or down. Before making a conclusion about the presence of an optic nerve pathology in a patient, the doctor will determine the limits of the normal IOP.

The occurrence of the II degree of the disease is provoked by concomitant chronic diseases. As a result of the "unification" of efforts, the patient is diagnosed with damage to the optic fibers. As it further develops, neuropathy leads to atrophy of the optic nerve. Probability drops catastrophically restore vision with III degree of glaucoma.

Reasons for the development of the disease

Regardless of the age of the patient and the presence of concomitant diseases, the development of glaucoma is always associated with many factors. The first place among these is heredity. Many pathogenesis of glaucoma begins against the background of hereditary changes in the structure of the optic nerve. This category of citizens should be constantly under the supervision of an ophthalmologist.

Optometrist constantly monitors patients with hereditary diseases

A number of other comorbidities can increase the chance of developing glaucoma, for example, disruption of the endocrine and cardiovascular systems, as well as a previous head injury. Regardless of the ailments that have weakened the optic nerve, the further development of glaucoma follows the following scenario:

• cessation of the outflow of excess moisture from the eye cavity;
• gradual increase in IOP;
• failure in the circulatory system of the eye;
• development in the eyeball of oxygen starvation;
• increases the likelihood of tissue necrosis in the optic nerve;
• compression of nerve fibers in the place where they come into contact with the eyeball;
• gradual destruction of the structure of nerve fibers, provoked by a failure in the supply of their nutrients;
• there is atrophy of the eye canal with subsequent blindness.

Classification of types of pathology of the optic nerve

As soon as the doctor had suspicion of glaucoma, the patient is prescribed a mandatory examination in such a case. Depending on the data obtained, a conclusion is made about the degree of pathological changes that have occurred. In most clinical cases, glaucoma, the forms of which are divided into 4 types, has characteristic signs. Based on them, it is easy to make a diagnosis.

Most often, the open-angle form of the disease is diagnosed. The patient has an increased accumulation of fluid in the fundus, which is provoked by an increase in IOP. Doctors say it's changing fundus in glaucoma slightly. As a therapeutic agent, medications are used that help reduce IOP.

As an additional therapeutic agent that allows you to restore field of view in glaucoma using a laser.

Laser helps restore visual fields

In addition, there are several more categories of pathology:

1. The closed-angle form is the result of a pathological change in the physical structure of the eyeball. The patient complains of severe "aching" pain. The disease provokes a narrowing of the space located between the cornea and the iris. As the stagnation of intraocular fluid increases, a gradual increase in IOP occurs. In addition to pain, the result of the appearance of the angle-closure form is nausea, "flies" and vomiting.
2. The congenital form is diagnosed extremely rarely. Immediate glaucoma healing possible only as a result of surgical intervention.
3. The secondary form in most cases occurs against the background of an injury or an incorrectly performed operation. Quite often this appears glaucoma in diabetes.

Development of possible complications

As mentioned earlier, only in the case of a prompt visit to a medical facility is there a chance to save vision. If this recommendation is ignored, then consequences of glaucoma will not make you wait long. Due to the peculiarities of the structure of the eyeball, its normal functioning is ensured by a constant outflow and inflow of fluid. In a literal sense, it acts as a natural regulator of the vital activity of the visual organ.

To answer the question, how dangerous is glaucoma, it is necessary to pay attention once again to the features of its development. It all starts with an increase in the degree of load on the elements of the eyeball. Increased fatigue, smoothly turning into prolonged headaches, is only the “first bell” indicating the seriousness of the problem. Optometrists do not get tired of repeating that for a very long time the disease is in a latent state.

Even in the presence of an active phase of glaucoma, it can be extremely difficult for a patient to suspect such an ailment. There is no need to despair. Regular preventive visits to the optometrist allow you to "sound the alarm" at an early stage. As a result restore vision it will be easy. It is important to remember that this fact is not a reason for complacency.

On the one side, glaucoma is curable in the case of a promptly appointed and professionally conducted therapeutic course. On the other hand, the "lion's share" of all pathological changes in the structure of the eyeball is irreversible. The sooner a qualified physician intervenes, the greater the chance of preserving the structural elements of the eye.

Some patients have more dangerous complications of glaucoma- attacks of sudden loss of vision. If some of them are reversible, then in the presence of concomitant chronic diseases, restoration of vision is impossible. Patients may also suffer from an inability to correctly distinguish between colors in the world around them.

Every day that has passed without medical intervention leads to further destruction of the optic nerve. As a result, the intensity of the passage of nerve impulses responsible for the transmission of color information decreases. Regardless of which types of glaucoma are diagnosed in patients, complete or partial loss of the ability to distinguish colors is one of the most common types of complications.

Basic therapeutic methods

The actions of the doctor largely depend on the stage at which the disappointing diagnosis was made. Therapy is carried out conservatively or surgically. It all depends on the age of the patient and the presence of medical contraindications. Often there are additional factors. Patients in a delicate position are allocated into a separate category.

The doctor conducts treatment depending on the stage of development of the disease

Expectant mothers with glaucoma should not be afraid. Their fetus will not stop living and developing, so there is no need to rush to the pharmacy for medicines. Throughout the entire period of pregnancy, a woman is under the strict supervision of a doctor. The ophthalmologist must select drugs with great care. In most cases glaucoma and pregnancy- a combination requiring the use of gentle medications.

No less caution must be exercised when it comes to elderly patients. Due to age-related changes, the surgeon's healing scalpel or tablet should be used only after the risks have been eliminated. If this is not possible, then the appointment of the operation is considered inappropriate. Otherwise, there is a high risk of developing serious complications.

"I have glaucoma", - those who admit such an idea should definitely consult a doctor to confirm the diagnosis.

Glaucoma is a disease characterized by a pathological change in the structure of the optic nerve. Pathology occurs at any age, but it poses a great danger to the elderly. At risk are citizens whose age is in the range from 35 to 45 years, and also exceeds the figure of 75 years.

Nov 22, 2016 Doc

Most often, eye drops are used to treat glaucoma. After instillation into the eyes, part of the ingredients of the drops penetrates into the bloodstream. As a result, they can enter the body of the fetus through the placenta, and during breastfeeding - through milk, into the body of an already born child. Therefore, pregnancy and glaucoma is a rather dangerous combination, which should be under the vigilant supervision of a doctor.

Because glaucoma is relatively rare in women of childbearing age, such problems are fortunately rare. However, when they do occur, the doctor and the expectant mother herself are faced with the need to solve a difficult problem.

The situation is complicated by the fact that at present there is practically no data on how drugs for the treatment of glaucoma affect the prenatal development of a person, as well as the health of infants.

Using special techniques for applying eye drops (for example, closing the eyes for a couple of minutes after instilling the medicine, or pressing the fingers on the inner corners of the eyes to partially block the tear ducts), it is possible to reduce the amount of active substances entering the bloodstream by about two-thirds. While this helps to greatly alleviate side effects, such measures cannot be relied upon when it comes to the health of an unborn child or infant. Reducing the doses of the drugs used also does not help to completely solve the problem.

Normally, intraocular pressure decreases in pregnant women, and due to this, the need for glaucoma medications may also decrease. However, this does not always provide a significant reduction in the risk of further damage to the optic nerve during pregnancy. Sometimes, to reduce intraocular pressure to a safe level, doctors resort to laser trabeculoplasty or other types of surgery - such treatment relieves the patient of the need to use eye drops for some time. Thus, glaucoma will not progress during pregnancy, although in the future the patient will most likely need medical treatment again. Women with glaucoma who plan to have children in the future should talk to their doctor about it in advance so that they can receive the necessary treatment in time. Below we will talk about exactly how the most common glaucoma medications can affect the development of pregnancy.

Beta blockers

Drugs in this category are considered the most dangerous in the early stages of fetal development, so they should not be taken in the first trimester of pregnancy. However, even later they do not become completely safe. If a mother takes beta-blocker eye drops during the second and third trimesters of pregnancy, as well as during lactation, this can lead to depression, a decrease in heart rate and a decrease in blood sugar The child has. These drugs can also interfere with the natural contractions of the uterus, which can be dangerous during childbirth.

miotics

Although pilocarpine has been associated with various abnormalities in infants during fetal development in animal studies, human studies have not shown any abnormalities in infants whose mothers took the drug during the first four months of pregnancy. However, when exposed to newborns, it can cause weakness and a significant increase in body temperature. Other drugs from the miotic group did not cause developmental defects in animals, and in children they became the cause of muscle weakness.

Carbonic anhydrase inhibitors

Taking carbonic anhydrase inhibitor tablets can cause birth defects and should be avoided during pregnancy. Eye drops with carbonic anhydrase inhibitors are considered safer for a child, but the features of their use during pregnancy and during breastfeeding have not yet been studied well enough.

For a long time, glaucoma was considered the lot of the elderly, but nowadays, with the ever-increasing load on the eyes, the insidious disease has become much younger. Women of childbearing age also suffer from it, so pregnant women with a diagnosis of glaucoma have become more common.

Not so long ago, the following letter arrived in the editorial e-mail of the site: “Good afternoon! Tell me, please, how can I be. I am 32 years old, highly myopic, and 2 years ago I was diagnosed with glaucoma. I'm dripping travatan, I haven't had an operation. They didn't offer. I plan to have a baby, but I know that many antiglaucoma medicines, in particular travatan, can harm the development of a child in the womb. No doctor gave me detailed instruction. One said: "I don't know what to drip." And the other: “Well, don’t drip anything,” and this is the doctor who insisted for 2 years that without drops I can’t get anywhere ... How is it? After all, without drops, eye pressure rises instantly, and this can threaten blindness. Does a child need a blind mother? What should I do? (Alena, Yekaterinburg).

We thank Alena for the topical question and with the help of experts we will find out how expectant mothers, if they suffer from glaucoma, maintain normal eye pressure during pregnancy and give birth to a healthy baby?

Many antiglaucoma drugs, getting into the body of the fetus,
may disrupt its embryonic development, accompany
the appearance of deformities, anomalies and various defects.

What is glaucoma?

This is an eye disease characterized by an increase in intraocular pressure. It is dangerous because the intraocular fluid begins to put pressure on the optic nerve, depressing it. If glaucoma is left untreated, narrowing of the visual fields, blurred vision, and even atrophy of the optic nerve leading to blindness are possible.

Treatment methods for glaucoma:

• medical method (instillation of drops);
• physiotherapy;
• surgical intervention.

Causes of glaucoma

The main cause of glaucoma is a violation of the outflow of intraocular fluid. The disease can appear against the background of a high degree of myopia, diabetes mellitus, atherosclerosis, with impaired blood supply to the neck and brain, etc.

Is there a risk of pregnancy with glaucoma?

Glaucoma itself does not harm conception and gestation and does not affect pregnancy in any way. On the contrary, according to the results of studies conducted in the United States and Europe in recent years, it was found that a small percentage of women suffering from this visual pathology normalize eye pressure during pregnancy.

It's all about the drugs that women take. Many of them negatively affect the development of the fetus, and after the birth of a child, they can enter his body with mother's milk, which is also very dangerous. What about those who, having a similar disease, dream of a baby?

We are planning a pregnancy
Before pregnancy, it is important to tell your ophthalmologist about your plans to have a baby. At this point, you can continue to take those drugs that were previously prescribed. While there is time, the doctor will prescribe a new treatment regimen: replace drugs that are potentially dangerous for the fetus with others, change the dosage, etc. If necessary, before pregnancy, you can perform a surgical or laser operation to restore the normal outflow of intraocular fluid.

Avoid drugs that are not recommended for pregnant women
In the first trimester of pregnancy, and it is then that the fetus is formed, glaucoma treatment begins according to a new scheme. Beta-blockers, prostaglandins (such as travatan, which our reader asks about in her letter) and carbonic anhydrase inhibitors should be avoided, as they can provoke a teratogenic effect (irradiation of the fetus) or miscarriage. Brimonidine (Alphagan*R) is considered the safest option for the first trimester.

If the doctor does not see a clear threat to the visual apparatus, then he usually advises to stop taking antiglaucoma drugs at least during the first trimester.

In the second trimester, brimonidine and beta-blockers (timolol, ocumed, ocupress) can be used. In this case, the doctor necessarily monitors the heart rate of the fetus in the womb and observes its growth.

In the third trimester, brimonidine and prostaglandin should be used with caution. At the beginning of the trimester, it is better to stop taking brimonidine, as it can provoke a miscarriage. At the end of the trimester, prostaglandins should be abandoned, as they can cause depression of the central nervous system in newborns.

We evaluate the possibilities of surgical treatment
Surgery to treat glaucoma during the second and third trimesters can be done, but the effect of anesthetics and sedatives on the fetus must be considered. Laser surgery can be performed throughout pregnancy.

Glaucoma affects about 70 million people worldwide, including 1 million
patients with this eye disease living in Russia.

During lactation, that is, during breastfeeding, the use of antiglaucoma drugs should also be agreed with the doctor.

The presence of glaucoma in a woman does not affect the ability to conceive a child and endure it. But the drugs used to treat glaucoma can have a negative effect on the fetus, so women with an established diagnosis of glaucoma need to plan pregnancy.

Before pregnancy, you need to consult with an ophthalmologist and conduct a complete examination. The complex of diagnostic measures includes:

• determination of visual acuity;
• definition of fields of view;
• determination of intraocular pressure;
• biomicroscopy of the anterior segment of the eye;
• ophthalmoscopy of the fundus with a detailed study of the state of the optic nerve head;
• gonioscopy.

If there are indications, it is possible to supplement the main examination methods with more specialized ones, which are focused on detecting changes in the eye that have arisen due to glaucoma.

After the examination and analysis of the data obtained during the instrumental studies, the doctor can adjust the treatment. Medicines that may be used during pregnancy may be prescribed, or the doses or frequency of taking eye drops that the woman is already using may be changed. In some cases, surgical or laser surgery is recommended so that the patient has the opportunity to completely abandon the use of anti-glaucoma eye drops during pregnancy.

If the pregnancy was not planned or glaucoma was first detected only during pregnancy, then it is necessary to immediately register with an ophthalmologist so that in the early stages of gestation it is possible to prescribe the correct treatment and reduce the negative effect of drugs on the fetus.

Is glaucoma hereditary for a child?

Glaucoma, like many diseases, can be both congenital and acquired (secondary). If the mother or father, as well as close relatives, have a history of glaucoma, then this fact should be alarming, since there is a risk of developing glaucoma in the child. But glaucoma is not inherited, but only a predisposition to it.

A feature of congenital glaucoma is that it develops due to the presence of an anomaly in the development of the intraocular fluid outflow system, for example, a violation of the structure of the angle of the anterior chamber of the eye. It is these anatomical features that can be inherited.

Violation of the outflow of fluid leads to an increase in intraocular pressure and the formation of glaucoma changes. Changes can begin to appear both in early childhood and in older children, it depends on the severity and type of anomalies in the anatomical structure of the fluid outflow system in the eye.

How does pregnancy affect the course of glaucoma?

During pregnancy, a woman's body undergoes a number of changes that affect the development of the glaucoma process.

During pregnancy, due to the hormonal background, there is an improvement in the outflow of intraocular fluid, which leads to a decrease in IOP, this is especially pronounced in the second and third trimester. This fact favorably affects the safety of visual functions. Sometimes compensation of IOP allows you to reduce the dose or even completely abandon the use of eye drops.

Given the possibility of fluctuating values, it is necessary to regularly conduct tonometry and determine the visual fields.

Treatment of glaucoma during pregnancy

The treatment of glaucoma during pregnancy causes difficulties associated with the choice of drugs, since there are no standards for treatment. Clinical studies on the effect of drugs in pregnant women have not been conducted. Prescription of drugs is based on possible side effects from taking.

Antiglaucoma drugs are in the category of drugs with questionable safety for the fetus, except for brimonidine (this drug has not been proven to have a risk to the fetus). The possibility of using eye drops depends on the trimester of pregnancy, namely:

• in the first trimester of pregnancy, it is advisable to abandon the use of drugs. In the event that this is not possible, for example, without the use of eye drops, an increase in eye pressure and a deterioration in visual functions are observed, then it is possible to use an alpha-receptor agonist - Brimonidine in a minimum concentration;
• in the second trimester, in addition to brimonidine, beta-blockers and prostaglandins can also be used. Taking drugs is carried out under the control of the child's condition, special attention should be paid to the heart rate of the fetus;
• in the third trimester, carbonic anhydrase inhibitors are the drugs of choice. Brimonidine, beta-blockers and prostaglandins should be used with caution as they may induce preterm labor.

To slow down the absorption of drugs and reduce their systemic action, the method of nasolacrimal compression can be used - when instilling drops, the lower lacrimal opening is squeezed for a while.

Important! In no case should you independently cancel or, conversely, prescribe eye drops for yourself, as well as change the frequency of administration. Treatment is prescribed only by a doctor and is carried out under his supervision.

Childbirth with glaucoma: natural or surgical?

The question of the method of delivery is decided in each case individually, and the decision is made by obstetrician-gynecologists together with an ophthalmologist.

For glaucoma, it is the preferred choice for childbirth. The exclusion of the straining period allows you to avoid complications from the eyes.

During childbirth through the natural birth canal, the following complications may develop:

• a sharp increase in intraocular pressure during attempts with the development of a pronounced pain syndrome;
• development of hemophthalmos;
• deterioration of visual functions, decompensation of the glaucomatous process.

Yulia Chernova, ophthalmologist, specially for the site

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