Since glaucoma primarily affects older adults, the percentage of pregnant people being treated for glaucoma is naturally small. As a consequence, not all doctors are well-versed regarding eye drops and other treatments that may be unsafe during pregnancy.

Here, Parisah Moghaddampour, M.D., senior-level resident at Loma Linda University and specialist in comprehensive ophthalmology, describes how best to manage glaucoma during pregnancy and breastfeeding.*

Glaucoma and pregnancy

Studies show that:

• Internal eye (intraocular) pressure, or IOP, decreases during pregnancy, particularly in the third trimester, while
• Glaucoma progression increases during pregnancy, with consequent visual field loss. 

Moghaddampour says this can happen from IOP fluctuations in pregnant patients taking few medications. Clinicians are advised to monitor pregnant glaucoma patients at least once per trimester.

Treating glaucoma during pregnancy

Moghaddampour strongly recommends telling your ophthalmologist if you plan on becoming pregnant, as the choice of appropriate eye drops to lower IOP will depend on the trimester of pregnancy. Speak with your doctor about future treatment options, preferably before conception. This discussion should include the risks and benefits of glaucoma treatment during pregnancy.

It’s also important for your doctor to collaborate with your neonatologist and/or obstetrician during your pregnancy and breastfeeding.

Glaucoma treatment options during pregnancy

Eye drop medications

According to Moghaddampour, certain glaucoma medications should and shouldn’t be used during weeks 0-12, 13-37, and 37-40 of pregnancy, as well as during breastfeeding (lactation).

Brimonidine (alpha 2 agonist) can be used through week 37 of pregnancy, but should be stopped at week 37 due to infant’s risk of apnea (temporary breathing cessation). Breastfeeding mothers should not use brimonidine, to avoid transference to their infant via breast milk.

Beta-blockers, like timolol, are advised as an initial or second-line treatment during weeks 0-12 and second-line therapy during weeks 13-37. They can be prescribed during weeks 37-40, but fetal heart rate must be monitored. They can be used when breastfeeding under certain conditions, but the infant’s heart rate and growth should be monitored.

Prostaglandin analogs, like latanoprost, can be used as a first-line therapy after birth, third-line treatments for weeks 0-37 (third-line due to risk of increased uterine contractions and induced labor), and second-line therapy at 37 weeks. A study of 11 pregnant women on latanoprost showed nine (9) with healthy babies before and after delivery.

Topical carbonic anhydrase inhibitors (CAI), like dorzolamide, are advised as a third-line therapy for weeks 0-12 and second-line therapy from week 13-36. At 37 weeks, however, monitoring for neonatal acidosis should begin. After birth, topical CAI can be a first-line therapy. 

Systemic CAIs, like acetazolamide, should not be used during weeks 0-12. After 13 weeks, they can be considered for controlling IOP, but should first be discussed with an obstetrician.

Rho kinase (ROCK) inhibitors, such as netarsudil, haven’t been investigated and aren’t advised for pregnant glaucoma patients.

Laser treatments

There are a handful of laser procedures for glaucoma that are safe and authorized for use during pregnancy.

• • Selective laser trabeculoplasty (SLT)

• Argon laser trabeculoplasty (ALT), though less effective in young patients

• Endo- and cyclophotocoagulation (ECP and CPC)

• Laser peripheral iridotomy (LPI)

Surgery

For the pregnant glaucoma patient, glaucoma surgery presents unique risks involving:

• Absorption of anesthesia (local and general)
• Gastroesophageal reflux disease (GERD), which can lead to aspiration
• Surgical failure, due to typically younger age and not using certain pre-operative drugs 

Because patients may be on fewer medications during pregnancy, Moghaddampour notes that selective laser trabeculoplasty (SLT) may be a good option for primary open-angle glaucoma.

The second trimester, she says, offers the best safety to mother and child if surgery is planned. 

She advises pregnant glaucoma patients to see their provider every trimester to monitor eye pressure and avoid further damage. Clear communication between patient and eye doctor, and eye doctor and obstetrician, is essential for optimal glaucoma management during pregnancy.

*Moghaddampour, P. (2022, December 14). A Guide to Glaucoma During Pregnancy. Eyes on Eyecare. https://eyesoneyecare.com/resources/guide-to-glaucoma-during-pregnancy