The Glaucoma Foundation has received numerous inquiries from younger women with glaucoma, asking whether they should be concerned about the disease when planning a family. We spoke with Sharon Freedman, MD, a physician specializing both in glaucoma and pediatric ophthalmology, and share some of her thoughts with you. Dr. Freedman is Associate Professor of Ophthalmology and Associate Professor of Pediatrics at Duke University Eye Center, in Durham, North Carolina.

Q: Are there special concerns for a pregnant woman who is taking glaucoma medications?

A: Yes, that’s why it’s really very important for a woman beginning to think about having a family to speak with her ophthalmologist and her OB/GYN about her glaucoma before she conceives. The biggest risk to the fetus is during the first trimester of pregnancy. A woman may not yet know she is pregnant during the first weeks, so I strongly advise meeting with your doctors to discuss a plan before you get pregnant.

Q: What are the specific concerns?

A: Some medications have shown adverse fetal affects in animals. While there have been no large-scale controlled trials, we have accumulated experience, so we rely on information gathered from case studies, treating each case individually with the goal of minimizing risks to the fetus. The minimum amount of medical treatment possible for glaucoma should be prescribed. Doctors will consider potential risks versus the benefits of controlling the mother’s glaucoma with medication to decide whether a particular drug should be used.

Q: Can you give some examples?

A: The goal is to absolutely minimize drug exposure to the fetus during the first trimester. Some patients are able to come off all medications for the first 12 weeks. This might be true, for example, if a patient is a glaucoma suspect or has early glaucoma with limited optic nerve damage and modestly elevated intraocular pressure (IOP). The main point is weighing the potential risk to the mother’s vision versus risk to the fetus. Frequent monitoring of the eyes is the key.
If stopping all medications is not possible, for example if a patient already has vision loss in one eye and elevated IOP in the other, she may not be able to tolerate higher pressure even for a short period. Then her physician would probably prescribe the fewest possible medications, following each eye drop with punctal occlusion* to minimize systemic absorption of the drug. (*When administering the eye drop, press your index finger firmly in the nasal corner of the eye, holding your finger there for 1-2 minutes after the drop has been instilled. This maneuver blocks the tear drainage into the nose, and helps minimize the amount of medication that gets into the body’s bloodstream.) Punctal occlusion is a technique recommended for all glaucoma patients. A diagram for placing eye drops in your eye is available on TGF’s website, at: http://www.glaucomafoundation.org/docs/EyedropGuide.pdf.

Q: I have read that surgery is sometimes recommended if medication has been curtailed. Is this true?

A: Surgery, such as laser trabeculopasty, may be the next best option for patients who cannot achieve an acceptable IOP level or have progressive visual field loss with no or limited use of eye drop medications. If necessary, laser trabeculoplasty can be performed at any time during pregnancy. Incisional surgery, such as trabeculectomy, is probably safest in the second trimester when general anesthesia can be used. A local anesthetic is preferred, whenever possible, and carries even less risk to the unborn fetus.

Q: Are some glaucoma medications safer than others during pregnancy?

A: Although all drugs carry pregnancy ratings of A (least harmful), B, C, D, or X, it’s important to remember that none of these drugs have been tested on pregnant women. Ratings are based on animal studies, usually using higher than normal doses used for people with glaucoma. Most glaucoma medications fall in the “C” category, indicating you can not rule out risk. One drug, Brimonidine, has been placed in class “B” (controlled studies in animals show no risk to the fetus) and may be slightly safer. But, Beta Blockers, which have a “C” rating, probably have the longest “track record,” since they have been used in systemic form occasionally in pregnant women by our medical colleagues (only when absolutely needed, of course). The selection of the right drugs for the right patient is extremely important. Medications must be thoughtfully selected and dosed to minimize risks to the fetus.

Q: Are there special problems associated with labor and delivery?

A: We’ve seen no data to suggest difficulties related to glaucoma.

Q: What about nursing?

A: Just as medications may enter the circulation of an unborn fetus when the pregnant woman uses glaucoma drops, they may also be secreted into her breast milk. Decisions on glaucoma treatments during the nursing period must be carefully considered, again weighing potential risks to the newborn baby versus the benefits to the glaucoma patient. At times the decision not to nurse may be safest for both mother and baby if the glaucoma needs medical treatment.

Q: Any other special advice?

A: A patient should remember that the body undergoes many hormonal and other changes during pregnancy including a woman’s IOP. That’s normal and still another reason to include your ophthalmologist as a member of your health care team during your pregnancy and while nursing your baby.

Q: Does my glaucoma put my child at risk for developing the disease?

A: Family history is a significant risk factor for the disease. Once a child is old enough to sit still for an eye examination, the child should get tested, and should be retested at periodic intervals thereafter. As the child ages, the frequency of eye exams may need to increase. Be sure to let your child’s pediatrician know that you have glaucoma.

                                                                                                         January, 2003