A look at the data on how to manage these patients

A 34-year-old, high-risk pigmentary-dispersion glaucoma suspect, returned for repeat glaucoma testing after being lost to follow-up for a few years. Her pachymetry readings were 574 OD μm and 579 OS μm, while her untreated Goldmann applanation tonometry IOPs continued to average 20 mmHg OD and 22 mmHg OS. She reported stable vision, overall good health and, at the time of the exam, she was 10 weeks pregnant. Based on her test results and per her pre-ference, initial management tilted toward topical therapy with a prostaglandin analog OS only. The patient asked, “Can I take this medication while I am pregnant?”

Here are some insights into this common, long-standing question regarding topical therapy among glaucoma patients who are pregnant.¹

LABORING FOR A SAFE PREGNANCY

Until just a few years ago, and in general, less than 20% of all drugs were classified as Category A or B (pregnancy safe), while most glaucoma medications were classified as category C, “uncertain safety, with no human studies and animal studies showing adverse effect.”^2,3 This classification system was too simplified, was frequently misinterpreted by providers and patients as a grading system and inadvertently minimized the need for prudent prescribing by providers.

More recently, the FDA moved to phase out all pregnancy cate-gory drug letters and replace them with a more structured approach, referred to as the PLLR – Pregnancy and Lactation Labeling Rule.⁴ This transition requires the drug companies to provide relevant human and animal risk statements, which can then be used between providers and their patients to better determine the benefits and/or risks of their respective various medical therapies.⁴

DELIVERING THE TREATMENT

Regardless of the topical treatment selected, and importantly, fetal safety can be further maximized (and complications minimized) by using the lowest concentration dose possible and at the lowest frequency possible.^3,5-6 Additionally, using preservative-free formulations limits fetus exposure to preservatives, while punctal occlusion following drop instillation further minimizes systemic absorption and maximizes ocular bioavailability for the patient.^2,3,6

My personal preference in patients who are (or who may be) pregnant and have open-angle glaucoma is selective laser trabeculoplasty (SLT). SLT has been proven effective as a first-line therapy and is safe for the fetus without any associated teratogenic effects or additional risks to the mother.^3,6,7

DON’T GESTATE ON MANAGEMENT

The greatest risk of damage to the fetus occurs during the first trimester of pregnancy — a time when the patient may not yet know they are pregnant. As such, a proactive approach as eye care providers is to question women in child-bearing years who are glaucoma suspects whether they may be or are planning on becoming pregnant, so that appropriate treatment options can be considered.^2,3

After further discussion and information, our patient as presented above chose to undergo SLT OS for safer and more stable glaucoma control. Although “the overall level of evidence for the risk of giving anti-glaucoma drugs to pregnant women is low,” I recommend O.D.s work closely with the patient’s PCP and OB/GYN for further guidance both during and after the pregnancy, as indicated.³ Professional and consistent communication with other providers helps ensure a healthy baby for the family and stable glaucoma for the mother. OM

REFERENCES

1. Vaideanu D, Fraser S. Glaucoma management in pregnancy: a questionnaire survey. Eye (Lond). 2007 Mar;21(3):341-343. doi: 10.1038/sj.eye.6702193.
2. Razeghinejad MR. Glaucoma medications in pregnancy. Oman J Ophthalmol. 2018;11(3):195-199.
3. European Glaucoma Society Terminology and Guidelines for Glaucoma, 4th Edition - Chapter 3: Treatment principles and options Supported by the EGS Foundation: Part 1: Foreword; Introduction; Glossary; Chapter 3 Treatment principles and options. Br J Ophthalmol. 2017;101(6):130-195. doi: 10.4103/ojo.OJO_212_2017
4. The Pregnancy and Lactation Labeling Rule (PLLR). Pregnancy and Lactation Labeling Rule (PLLR) (fda.gov ) and Pregnancy and Lactation Labeling (Drugs) Final Rule | FDA (Accessed 06/03/21)
5. Razeghinejad MR, Nowroozzadeh MH. Anti-glaucoma medication exposure in pregnancy: an observational study and literature review. Clin Exp Optom. 2010;93(6):458–465.
6. Razeghinejad MR, Tania Tai TY, Fudemberg SJ, Katz LJ. Pregnancy and glaucoma. Surv Ophthalmol. 2011;56(4):324-335. doi: 10.1111/j.1444-0938.2010.00526.x
7. Gazzard G, Konstantakopoulou E, Garway-Heath D, et al. Selective laser trabeculoplasty versus eye drops for first-line treatment of ocular hypertension and glaucoma (LiGHT): a multicentre randomised controlled trial. Lancet. 2019;393 (10180):1505–1516. doi: 10.1016/S0140-6736(18)32213-X

DR. LIFFERTH practices at Grossnickle Eye Center as a consultative optometrist with an emphasis in glaucoma management, and he is a member of the Optometric Glaucoma Society. For additional glaucoma cases, you can also follow Dr. Lifferth on his Instagram account: glaucomaqd. Disclosures: None. Email him at austinlifferth@yahoo.com.