Keywords
pre-eclampsia - retinal detachment - pregnancy complications - decreased visual acuity
Palavras-chave
pré-eclâmpsia - descolamento da retina - complicação da gravidez - diminuição da acuidade
visual
Introduction
Serous retinal detachment is an unusual cause of visual loss in < 1% of pre-eclampsia
(PE) cases.[1]
[2] It tends to be bilateral, diagnosed postpartum, and more prevalent in women who
are primiparous and/or undergo caesarean delivery.[1] The condition typically resolves completely and rarely causes total visual loss
in the affected women.[1]
[3]
[4] Fluorescence angiographic findings support the hypothesis that retinal detachment
in PE is secondary to choroidal ischemia from intense arteriolar vasospasm.[1]
[3]
[5]
Case Description
A 37-year-old pregnant woman submitted to in vitro fertilization with no relevant
personal medical history and no previous pregnancies. She was admitted at 36 weeks
of pregnancy with a diagnosis of PE after presenting high blood pressure (BP) (150/87 mmHg)
associated with occasional proteinuria of 300 mg/dL. Blood analysis showed Hb 11.1 g/dL,
LDH 355 U/L and AST/TGO 96U/L. During admission, oral nifedipine 10mg was administered
to control BP. Despite the improvement of the woman's BP on the second day of hospitalization,
there was a slight worsening of blood test results. At that time, induction of labor
with misoprostol was started. Due to recurrent variable decelerations and absent baseline
Fetal Heart Rate (FHR) variability on cardiotocography (Category III of the American
College of Obstetricians and Gynecologists [ACOG] classification), the patient was
submitted to an emergent caesarean section (CS). A female was delivered weighing 2,470 g
and with an Apgar Score of 10/10.
On the first postoperative day, the patient presented blurred vision and decreased
visual acuity and was observed by an ophthalmologist who diagnosed a bilateral serous
retinal macular detachment. On the third postoperative day, the patient had a spontaneous
recovery in her visual acuity and experienced improvements in her other clinical symptoms,
as well as her physical and analytical examinations. The patient was therefore discharged
from the hospital medicated with nifedipine and enoxaparin that were started on the
first postoperative day as indicated in all patients submitted to an urgent/emergent
CS, and was referred to ophthalmology for follow-up.
Discussion
Pre-eclampsia is an obstetric disease with a complex and multifactorial cause that
affects ∼ 5% of pregnant women.[4]
[6] It usually occurs in the 3rd trimester of pregnancy, although it can occur at any time from 20 weeks of gestation
to 6 weeks postpartum and is characterized by the presence of hypertension and proteinuria
(> 0.3 g in 24-hour urine), thrombocytopenia (platelets < 100,000 3 × 109), renal insufficiency, impaired liver function or pulmonary edema.[2]
[6]
[7] Retinal detachment is a rare complication of PE, affecting 1 to 2% of pregnant women
with severity criteria and 10% of eclampsias, and may manifest before or after delivery.[6] The most common ocular finding is severe arteriolar spasm resulting from segmental
or generalized constriction of retinal arterioles. Retinal hemorrhage, edema, and
“cotton wool spots” may result from arteriolar damage, areas of hypoperfusion or occlusive
disease.[3] Serous retinal detachment is an extremely rare complication of hypertensive disease
in pregnancy.[1]
[2]
[3]
[6]
[8] There are few reports in the literature describing it as a cause of vision loss
in PE and it involves the separation of the sensorineural retinal from the retinal
pigment epithelium as an ophthalmic emergency. Its exact pathophysiology is unknown.[1]
[3] Doppler evaluation of ophthalmic arterial flow may offer new perspectives regarding
the understanding of the pathophysiology, diagnosis and quantification of PE severity.
In severe forms, increased impedance of orbital vessels was observed. Studies using
fluorescence angiography and green indocyanine angiography indicate that much of the
retinal damage presented is caused by changes in the choroid vasculature, including
occlusion of choroid and coriocapillary arterioles.[3] After resolution of retinal detachment, there is a change in the shape of irregular
focal areas of hyper and hypopigmentation, which correspond to the ischemic stroke
– “Elschnig spots”.[1]
[3] In general, visual acuity gradually improves and visual field defects disappear
within 3 months after delivery, with complete recovery of vision.[1]
[5]
[6]
[8] In this particular situation, the timely medical intervention together with a good
BP control and adequate patient stabilization allowed a relatively quick reversal
of the condition. This case shows the good clinical outcome of conservative therapy
applied to retinal detachment in PE.
Final Considerations
Pregnancies complicated by PE are associated with a worse prognosis for mother and
child, hence it is important to be aware of the many complications that may arise.
Most patients with retinal detachment in pregnancy-induced hypertension have full
spontaneous resolution within a few weeks without any long-term complications. Medical
treatment with antihypertensive drugs and steroids may be helpful.
