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ORIGINAL ARTICLE
Year : 2019  |  Volume : 32  |  Issue : 2  |  Page : 672-677

Evaluation of macular changes during pregnancy by optical coherence tomography


1 Department of Ophthalmology, Faculty of Medicine, Menoufia University, Menoufia, Egypt
2 Department of Ophthalmology, Mansoura Ophthalmology Hospital, Mansoura, Egypt

Date of Submission17-Dec-2017
Date of Acceptance29-Jan-2018
Date of Web Publication25-Jun-2019

Correspondence Address:
Ahmed Abd Elhakiem Darrag
Department of Ophthalmology, Mansoura Ophthalmology Hospital, Mansoura
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mmj.mmj_886_17

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  Abstract 

Objective
The aim of the study was to evaluate macular changes during pregnancy by optical coherence tomography (OCT).
Background
The study included pregnant female individuals during the three trimesters.
Patients and methods
This prospective cohort study was carried out from October 2015 to August 2017 on a total number of 52 eyes (26 right eyes and 26 left eyes) of pregnant women of noncomplicated pregnancy recruited from the outpatient ophthalmology clinic at Menoufia University Hospital and Mansoura Ophthalmology Hospital. The certificate approval number is 886. The study was subdivided into three groups: group 1 includes pregnant women during the third month of the first trimester, group 2 includes the same pregnant women during the second month of the second trimester, and group 3 includes the same pregnant women during the second month of the third trimester. All patients were subjected to full ophthalmological examination including OCT, fundus examination, intraocular pressure measurement, visual acuity, and best corrected visual acuity measurement.
Results
Among the 52 eyes of those normal pregnant women, three eyes showed central serous retinopathy; two of them started in the second trimester and one in the third trimester.
Conclusion
This study showed that the central macular thickness increased in the second trimester than in the first and increased in the third trimester than in the second. There were three cases of central serous retinopathy among the 52 (5.7%) eyes.

Keywords: central serous retinopathy, macula, optical coherence tomography, pregnancy, trimesters


How to cite this article:
El Din Farahat HG, Elsawy MF, Elhakiem Darrag AA. Evaluation of macular changes during pregnancy by optical coherence tomography. Menoufia Med J 2019;32:672-7

How to cite this URL:
El Din Farahat HG, Elsawy MF, Elhakiem Darrag AA. Evaluation of macular changes during pregnancy by optical coherence tomography. Menoufia Med J [serial online] 2019 [cited 2019 Sep 16];32:672-7. Available from: http://www.mmj.eg.net/text.asp?2019/32/2/672/260937




  Introduction Top


Pregnancy is often associated with ocular changes that may be more commonly transient, but occasionally permanent. The ocular effects of pregnancy may be physiological or pathological or may be modifications of pre-existing conditions[1],[2],[3],[4],[5]. Physiological changes include increased pigmentation around the cheeks, ptosis, and alterations in corneal thickness and refractive status, and decreased intraocular pressure (IOP). Fluid retention can lead to swelling of the cornea. Corneal nerve function will also be affected as a result of the edema. Reduced sensitivity may reduce tear production and increase the possibility of dry eye, infection, and localized trauma. These alterations usually resolve postpartum[6],[7],[8]. Pathologic conditions reported to develop during pregnancy include hypertensive and vascular disorders, central serous chorioretinopathy (CSCR), uveal melanoma, and others. The most significant modified pre-existing condition is diabetes mellitus. Moreover, visual field changes have been reported during pregnancy. Defects include enlarged blind spots, bitemporal loss, and generalized constriction of field. Hormone changes may lead to an increase in size of the pituitary gland and thereby compression of the optic nerve at the chiasm. Previously asymptomatic pituitary tumors may also increase during pregnancy, to visual acuity and field loss[9],[10].

Pregnancy hormones may lead to an increase in fluid volume in many tissues of the body. From this point of view, an increase in both total macular volume and foveal thickness (FT) can be expected, and it can be investigated how these alterations affect the visual functions (visual acuity and visual field)[11].

Optical coherence tomography (OCT) is a new, noninvasive, noncontact, transpupillary imaging technology that can image retinal structures in vivo with a resolution of 10–17μm. Cross-sectional images of the retina are produced using the optical backscattering of light in a fashion analogous to B-scan ultrasonography. It is increasingly used in the diagnosis and monitoring of retinal diseases including age-related macular degeneration, diabetic retinopathy, and glaucoma. The anatomic layers within the retina can be differentiated and retinal thickness can be measured[12],[13].

Thus, the aim of this study was to evaluate macular changes during pregnancy by OCT.


  Patients and Methods Top


This study was a 'prospective cohort study' carried out on 52 eyes; we started with 60 eyes of 30 pregnant women, but eight cases were excluded because of complicated pregnancy or sudden termination of pregnancy. The available cases were subdivided into three groups:

  1. Group 1: pregnant women during the third month of the first trimester (we wait till the third month for pregnancy confirmation).
  2. Group 2: the same pregnant women during the second month of the second trimester (we chose the second month as the middle of the second trimester).
  3. Group 3: the same pregnant women during the second month of the third trimester (we did not wait for the third month to avoid pregnancy termination).


Before initiating this study, all procedures were reviewed and approved by the Ethics Committee of the Menoufia University Hospital. Each patient was informed that participation was voluntary, and that the patient could withdraw from the study at any time and without giving reasons.

Inclusion criteria

The inclusion criteria included pregnant women with noncomplicated pregnancy.

Exclusion criteria

Exclusion criteria included complicated pregnancy, history of previous ocular trauma, history of previous intraocular surgery, glaucoma, high myopia, diabetic cases, and disease affecting macular thickness, and we excluded cases with poor OCT image reliability.

The following measures were undertaken for every case: visual acuity using snellen chart, refraction using automated refractometer, best corrected visual acuity, slit-lamp examination to evaluate the anterior segment, IOP measurement using Applanation tonometer (Goldmann Applanation Tonometer; Keeler, Windsor, UK), dilated fundus examination using +90 Volk lens, and indirect ophthalmoscope and OCT (Spectralis SD-OCT; Heidelberg Engineering GmbH, Heidelberg, Germany) to evaluate macula.

Scanning technique

First, the pupil was dilated at least 4–6 mm with tropicamide 1% and cyclopentolate HCl 1% 1 h before tomography. Thereafter, the patient was positioned on a slit-lamp head rest and then the slit-lamp and condensing lens unit were put along the optical axis of the eye. The entire unit was brought forward until the imaging lens was about 1 cm from the eye. The image of transverse scanning mirror was placed at the patient's pupil plane and then the position of the condensing lens was adjusted along the optical axis until the image of the fundus was brought into focus. The desired scanning position was localized while the examiner was observing both the real time display of OCT in progress and video image of the OCT probe beam location at the fundus.

To allow precise positioning of the retina, the fixation spot was generated under computer control by OCT probe beam that interleaved with scanning pattern on the retina of the eye being imaged; alternatively, a standard external fixation light was used.

Statistical analysis

Results were collected, tabulated, and statistically analyzed (SPSS Inc. Released 2015. IBM SPSS statistics for windows, version 23.0; IBM Corp, Armonk, New York, USA) by an IBM compatible personal computer with SPSS statistical package version.

The Student's t-test is a test of significance used for comparison of quantitative variables between two groups of normally distributed data, while the Mann–Whitney's test was used for comparison of quantitative variables between two groups of not normally distributed data.

Repeated measures analysis of variance test was used for comparison of quantitative variables between more than two consecutive measures in the same group of normally distributed data, and the Friedman test was used for comparison of quantitative variables between more than two consecutive measures in the same group of not normally distributed data with least significant difference test as post-hoc test.


  Results Top


Demographic data show the age ranges from 21 to 41 years with an average age of 26.92 ± 4.06 years. Half the eyes (26 eyes) were right, and the other half (26 eyes) were left [Table 1].
Table 1: Patients' characteristics

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Visual acuity (VA) was worst at third trimester (0.25 ± 0.11 by LogMar) than second trimester (0.19 ± 0.10 by LogMar) and first trimester (0.15 ± 0.11 by LogMar). It was also worse at the second than the first trimester. The IOP was lower at the third (13.27 ± 1.27) trimester than the second (13.92 ± 1.11) and first (14.84 ± 1.33) trimesters. It was also lower at the second than the first trimester. Central macular thickness (CMT) was higher at the third (242.32 ± 72.84 μm) trimester than the second (221.44 ± 51.66 μm) and first (197.88 ± 23.54 μm) trimesters. It was also higher at the second than the first trimester [Table 2].
Table 2: Comparison between the first, second, and third trimester with regard to VA, intraocular pressure, and central macular thickness in the studied group

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There was no significant difference with regard to vitreoretinal interface between the first, second, and third trimesters, but there were three cases of central serous retinopathy (CSR); two of them started in the second trimester and one in the third trimester, and they resulted in photoreceptor damage [Figure 1],[Figure 2],[Figure 3].
Figure 1: Optical coherence tomography of a 27-year- old healthy pregnant woman in the first trimester.

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Figure 2: Optical coherence tomography of the same pregnant woman in the second trimester showing central serous retinopathy.

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Figure 3: Optical coherence tomography of the same pregnant woman in the third trimester showing central serous retinopathy.

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The mean CMT changed from 197.88 ± 23.54 μm in the first trimester to 213.00 ± 23.20 μm in the second trimester, and, finally, 255.61 ± 25.45 μm in the third trimester in the absence of CSR. However, in the presence of CSR, the mean CMT was higher and ranged from 432.50 ± 130.81 μm in the second trimester to 515.33 ± 33.54 μm in the third trimester [Table 3] and [Figure 4].
Table 3: Comparison between cases with central serous retinopathy and cases without as regards central macular thickness at first, second, and third trimesters

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Figure 4: Cases with central serous retinopathy and cases without regarding central macular thickness at first, second, and third trimesters.

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The difference of CMT between the first and the third trimester is higher than the difference between the second and the third trimester [Figure 5].
Figure 5: The difference of central macular thickness between the first and third trimester is higher than the difference between the second and third trimester.

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  Discussion Top


The assessment of FT and volume are important for the diagnosis, treatment, and follow-up of retinal diseases such as diabetic retinopathy, age-related macular degeneration, and glaucoma.

In this study, OCT was utilized to detect changes to the fovea during the pregnancy trimesters.

Several studies have shown alterations, in the choroidal thickness during pregnancy, especially in the third trimester[14],[15],[16],[17]. The affected regions include the central subfield, inferior inner macular choroid, temporal, nasal, and subfoveal areas[17],[18]. In contrast, others reported that pregnancy had no effect on the choroidal thickness and that it was comparable to healthy nonpregnant women[19],[20].

The current results showed that pregnancy could significantly alter the FT and visual field (VF) as compared with healthy nonpregnant values. This is in accordance with Demir et al.[21], findings in which women in their third trimester had higher mean values for the foveal and parafoveal thickness. One may expect that the third trimester is associated with more changes compared with earlier gestational periods; this study shows that earlier changes can also be detected in the first and second trimester using OCT.

Cankaya et al.[22], found that total macular volume and FT were increased in the first, second, and third trimesters in healthy women. As no pathological findings were found, this could be explained by the expansion of plasma volume in pregnancy, which is reported to increase by 45%[9],[23]. One of the main limitations of the current study was the small sample size. In addition, it is worth monitoring one group from the first trimester till postpartum and monitor the time needed for the FT and FV values to return to the baseline.

In this study, demographic data show the age ranges from 21 to 41 years with an average age of 26.92 ± 4.06 years. Half the eyes (26 eyes) were right and the other half (26 eyes) were left. Fahmy et al.[24] has conducted his study on pregnant women (age range: 19–37 years) in the first, second, and third trimester.

Visual impairment and other ocular changes are rare in pregnancy. They arise in at most 15% of pregnant women and are usually harmless, but are nonetheless a cause for concern among the women who have them and their nonophthalmologist treating physicians. Women with pre-existing ocular conditions often wonder, even before they become pregnant, how pregnancy might affect their condition and its treatment, and how the treatment of the ocular condition might affect the unborn child.

In this study we found that VA was worst at the third trimester (0.25 ± 0.11 by LogMar) than the second trimester (0.19 ± 0.10 by LogMar) and first trimester (0.15 ± 0.11 by LogMar). It also was worse at the second than the first trimester. IOP was lower at the third (13.27 ± 1.27) trimester than the second (13.92 ± 1.11) and first (14.84 ± 1.33) trimesters. It was also lower at the second than the first trimester. CMT was higher at the third trimester (242.32 ± 72.84 μm) than the second (221.44 ± 51.66 μm) and first (197.88 ± 23.54 μm) trimesters. It is also higher at the second than the first trimester.

In this study, there was no significant difference with regard to vitreoretinal interface between the first, second, and third trimesters, but there were three cases of CSR; two of them started in the second trimester and one in the third trimester, and they resulted in photoreceptor damage.

In this study, there was no difference with regard to the presence of posterior vitreous detachment (PVD) or vitreomacular traction (VMT) between the three trimesters. CSCR is a disorder that is characterized by a localized serous retinal detachment of the neurosensory retina in the macula. It most commonly affects adults between the ages of 20 and 45. CSCR affects men more often than women, at a ratio of 10: 1. Pregnancy is considered a risk factor for CSCR development in women[23],[25],[26]. A recent study found that pregnant woment were 7.1 times more likely to develop CSCR than an age-matched group with no history of pregnancy[27].

Hormonal and hemodynamic changes, ischemia, and permeability changes in vasculature have been proposed to explain the development of CSCR, but none have been proven to be a definitive cause[26]. CSCR can occur at any time during pregnancy. Subjective complaints include blurred vision, metamorphopsia, color changes, and darkening of the central visual field. Recurrence in the same eye in successive pregnancies has been documented[28]. CSCR associated with pregnancy, compared with cases in men and nonpregnant women, has been found to cause increased amounts of subretinal fibrous exudates[27].

Two case–control studies have estimated the odds ratio of various risk factors for CSCR. Pregnancy was associated with an odds ratio of 7.1 (95% CI: 1.0–50.7)[29]. In this study, there were three cases of CSR (5.7%); two of them (3.8%) started in the second trimester and one case (1.9%) in the third trimester. In addition to the previous two cases, a total of three (5.7%) cases. Sequelae that may follow CSR episodes include areas of retinal pigment epithelium depigmentation, geographic atrophy, subretinal fibrinous deposits, and choroidal neovascularization. Other sequelae that can occur include attenuation of neurosensory retina, mainly of the photoreceptor layer[30].

In this study, the three CSR cases were associated with inner segment/outer segment junction line disruption; two of them (3.8%) started in the second trimester and one in the third trimester, in addition to the previous two cases, a total of three (5.7%) cases. In this study, the mean CMT changed from 197.88 ± 23.54 μm in the first trimester to 213.00 ± 23.20 μm in the second trimester, and finally 255.61 ± 25.45 μm in the third trimester in the absence of CSR. However, in the presence of CSR, the mean CMT was higher and ranged from 432.50 ± 130.81 μm in the second trimester to 515.33 ± 33.54 μm in the third trimester. In this study, the difference of CMT between the first and third trimester is higher than the difference between the second and third trimester.


  Conclusion Top


This study showed that the CMT was statistically increased in the second and third trimester of pregnancy. OCT measurements can be a valuable parameter to assess the macula during pregnancy.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
 
 
    Tables

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