|Year : 2015 | Volume
| Issue : 3 | Page : 139-142
Ocular fundus changes in pre-eclampsia and eclampsia in a rural set-up
Akshay Jawaharlal Bhandari, Surekha V Bangal, Pratik Y Gogri
Department of Ophthalmology, Pravara Institute of Medical Sciences and Rural Medical College, Loni, Ahmednagar, Maharashtra, India
|Date of Submission||16-Aug-2014|
|Date of Acceptance||10-Dec-2014|
|Date of Web Publication||20-Aug-2015|
Akshay Jawaharlal Bhandari
Department of Ophthalmology, Pravara Institute of Medical Sciences and Rural Medical College, Loni, Ahmednagar - 413 736, Maharashtra
Source of Support: None, Conflict of Interest: None
Context: Pregnancy-induced hypertension (PIH) is one of the common complications met with pregnancy and contributes significantly to maternal and fetal mortality and morbidity. Aims: To grade the ocular fundus changes in patients of pre-eclampsia and eclampsia. Settings and Design: Hospital-based prospective observational study. Materials and Methods: Hospital-based prospective observational study conducted over a period of 2 years. One hundred patients of pregnancy having pre-eclampsia and eclampsia were included. Statistical analysis used: Chi-square test. Results: Out of 100 cases, 32 (32%) had mild pre-eclampsia while 50 (50%) had severe pre-eclampsia. Eighteen (18%) patients had eclampsia. Out of 100 cases examined in this study, 54 presented with ocular symptoms and 46 were asymptomatic. Arteriolar attenuation was the most common retinal change observed and it was seen in 44 (44%) cases. Exudative retinal detachment was seen in 7 (7%) cases and macular edema was present in 12 (12%) cases of PIH. Conclusions: Cases of severe pre-eclampsia and of eclampsia showed higher grades of retinal changes. Visual disturbances and symptoms like headache were commonly associated with retinal changes. It is essential to examine each and every patient of pre-eclampsia and eclampsia for ocular manifestations, which should be helpful for obstetrician in the management of patient.
Keywords: Eclampsia, grades of retinopathy of PIH, ocular fundus changes, pre-eclampsia, pregnancy-induced hypertension
|How to cite this article:|
Bhandari AJ, Bangal SV, Gogri PY. Ocular fundus changes in pre-eclampsia and eclampsia in a rural set-up. J Clin Ophthalmol Res 2015;3:139-42
|How to cite this URL:|
Bhandari AJ, Bangal SV, Gogri PY. Ocular fundus changes in pre-eclampsia and eclampsia in a rural set-up. J Clin Ophthalmol Res [serial online] 2015 [cited 2020 Jul 9];3:139-42. Available from: http://www.jcor.in/text.asp?2015/3/3/139/163264
Pregnancy-induced hypertension (PIH) is one of the common complications met with pregnancy and contributes significantly to maternal and fetal morbidity and mortality. 
PIH is the hypertension that develops as a direct result of gravid state. According to national high blood pressure education program  (NHBPEP-2000) and American college of obstetricians and gynecologists  (ACOG-2002), PIH includes gestational hypertension, pre-eclampsia, and eclampsia. Pre-eclampsia is best described as multi-system disorder of unknown etiology characterized by development of hypertension to the extent of 140/90 mm of Hg or more with proteinuria after the 20 th week of pregnancy in a previously normotensive and non-proteinuric patient. Pre-eclampsia is divided into two groups according to its severity as mild and severe. Blood pressure more than 160/110 mm of Hg and proteinuria more than 2 gm/24 hours or > + 2 are included in severe pre-eclampsia.  If convulsions are associated with it, then it is termed as eclampsia.  Overall incidence of PIH in hospital practice varies widely from 5-15%.  The incidence in primigravida is 10% and in multigravida is 5%.  Ocular involvement in PIH is common and the occurrence rate varies from 30-100% in different studies.  Of all the maternal deaths, 10-15% is attributed to pre-eclampsia, of which 99% occur in the developing world. Aim of this study was to grade the retinal vascular changes in patients of pre-eclampsia and eclampsia at admission. The present study was undertaken to evaluate the ocular fundus changes in pre-eclampsia and presenting to tertiary healthcare center.
| Materials and Methods|| |
The study was a hospital based, prospective, observational study conducted over a period of 2 years at a tertiary rural hospital in western Maharashtra of India. Ethical clearance was taken from Ethics committee of Institute and written informed consent was taken from all the patients.
One hundred patients diagnosed with pre-eclampsia or eclampsia admitted in maternity ward and intensive care unit were included in the study. Patients with history of pre-existing hypertension and convulsions, patients with pre-eclampsia or eclampsia superimposed on chronic hypertension, patients having other systemic disorders, e. g., diabetes mellitus, thyroid disorders, hematological disorders, HIV were excluded from the study.
All patients fulfilling above inclusion and exclusion criteria were studied for ocular fundus changes at admission and for follow-up changes at 1 week of termination of pregnancy. Cases were divided into mild and severe pre-eclampsia and eclampsia according to the severity. A detailed history and ocular examination of each patient were recorded. Direct as well as indirect ophthalmoscope was used for examination of fundus after full dilatation of pupil with 1% tropicamide (mydriatic) eye drops. Fundus photographs were taken whenever possible.
Retinal changes in cases of toxemia of pregnancy were divided into 4 stages.
Grade I: Spastic narrowing of arterioles of the retina.
Grade II: Irregular constriction of the lumen.
Grade III: Narrowing and constriction are more fixed with cotton wool patches and hemorrhages.
Grade IV: Diffuse retinitis with papilledema.
| Results|| |
Out of 100 cases enrolled in the study, 32 cases (32%) had mild pre-eclampsia and 50 cases (50%) had severe pre-eclampsia. Eighteen cases (18%) in the present study had eclampsia. Ocular fundus changes were seen in 44 cases of PIH. It is seen that ocular fundus changes were more observed in cases with eclampsia (61%), severe pre-eclampsia (50%), followed by mild pre-eclampsia (25%). The present study shows highest percentage of ocular fundus changes in the age-group of 18 to 22 years (50%).
Amongst the 48 cases of PIH in the age group 18-22 years, 24 cases (50%) showed fundus changes. This was followed by 12 cases (36.36%) from 33 cases of PIH in the age-group 23-27 years. Next commonly affected age-group was 28-32 years with 14 cases and 7 cases (50%) of them showed fundus changes. Only 1 case out of 4 from age-group between 33-37 years showed changes in fundus. This shows that younger the age, more are the possibilities of fundus changes in the eye.
In the present study of 100 cases, focal arteriolar attenuation was seen in 36 cases and it was the most commonly observed retinal sign. It was seen in more number of cases of eclampsia (44%) and severe pre-eclampsia (42%), followed by mild pre-eclampsia (22%). Macular edema was seen in 12 cases and more commonly seen in cases of eclampsia (17%) and severe pre-eclampsia (14%), followed by mild pre-eclampsia (6%). Generalized arteriolar attenuation, cotton wool spots, retinal hemorrhages, hard exudates papilloedema, and retinal edema were seen in severe pre-eclampsia and eclampsia group only. Seven cases had retinal detachment belonging to severe pre-eclampsia (10%) and eclampsia (11%) group only [Table 1]. By applying Chi-square test, there is a significant association between ocular fundus changes and severity of pre-eclampsia and eclampsia (P < 0.05).
|Table 1: Distribution of various retinal signs according to severity of pre-eclampsia and eclampsia|
Click here to view
In the present study of 100 cases of PIH, 56 cases (56%) did not show evidence of any ocular fundus changes. Grade I retinal vascular changes were seen in 29 cases (29%), followed by 5 cases (5%) with Grade II retinal vascular changes. In the present study, 3 cases (3%) showed Grade III retinal vascular changes. Grade IV retinal vascular changes were seen in 2 cases (2%). Out of 5 cases having other changes, 4 cases (4%) had macular edema and 1 case (1%) had retinal edema. These were isolated findings not associated with any grades of retinopathy.
Out of 32 cases with mild pre-eclampsia, 6 cases (19%) had Grade I retinal vascular changes. Twenty-four cases (75%) had normal fundus. Two cases (6%) had macular edema which was not associated with any grades of retinal changes. Out of 50 cases with severe pre-eclampsia, 16 cases (32%) had Grade I retinal vascular changes. Normal fundus was seen in 25 cases (50%). Grade II and III retinal vascular changes were seen in 4 (8%) and 2 (4%) cases, respectively. Macular edema was seen in 2 cases (4%). Out of 18 cases with eclampsia, 7 cases (39%) had normal fundus on examination. Grade I retinal vascular changes were seen in 7 cases (39%), whereas remaining 3 cases showed Grade II, III, and IV retinal vascular changes, respectively. Retinal edema was seen in 1 case (6%) which was not associated with any grades of retinal changes.
| Discussion|| |
The retinal vascular changes have been said to correlate with the severity of hypertension. Many studies have considered the progression of retinal vascular changes as a sign of increasing severity of PIH  and have correlated them with fetal mortality. These changes help as a guideline for termination of pregnancy as they may reflect similar ischemic vascular changes in the placenta.  Therefore, this study was undertaken to evaluate the fundus changes in patients of pre-eclampsia and eclampsia.
Cases having ocular fundus changes were 44%. Mean age of the cases in our study was 23.85 ± 6.58 years. In a prospective cohort study conducted by Karki et al., it was found that mean age group of patients with retinal changes was 23.86 ± 5.51 years and without retinal changes was 24.36 ± 5.65 years.  In prospective study conducted by Shukla et al., they examined 20 cases of pre-eclampsia and eclampsia and noted incidence of retinal changes in 70% of the cases in different age groups.  In their study, 60% cases aged < 25 years. Mean age-group of patients in the present study matches with the studies by Karki et al., and Shukla et al., Tadin et al., in their retrospective study of 40 women with pre-eclampsia, 45% (18 cases) showed retinal changes. The average age of 40 patients was 29.1 ± 7.4 years.  In a study by Jaeffe and Schatz, mean age of patients with pre-eclampsia was 28 years.  Mean age of patients in studies by Tadin et al., Jaeffe, and Schatz was higher than that of our study.
According to Duke Elder the most common retinal change is attenuation of retinal arterioles, occurring in approximately 60% of patients with pre-eclampsia.  In our study, forty-four cases (44%) showed arteriolar attenuation. Arteriolar attenuation was seen in 7 cases (21.88%) of mild pre-eclampsia, 26 cases (52%) of severe pre-eclampsia, and 11 cases (61.11%) of eclampsia group.
From above, it is seen that arteriolar attenuation is the major retinal change seen in PIH. The percentage of occurrence of arteriolar attenuation in these studies was closely correlated with that of our study.
In the present study, we observed that retinal edema is more prominent adjacent to the constricted vessels. In our study retinal edema was seen in 6 (6%) cases. Reddy et al., in their study found 46 cases (23%) with retinal edema, of which 8 cases (6.6%) of mild pre-eclampsia and 38 cases (47.5%) were of severe pre-eclampsia.  Naval et al., in his study found 10% of cases with retinal edema.  Francis in his study of patients with PIH found 2% of cases with retinal edema. 
Findings of Naval et al., are similar to our study findings. Percentage of occurrence of retinal edema by Reddy et al., and Francis et al., does not match with our study. We did not find any case of retinal edema in mild pre-eclampsia group. Reddy et al., found 6 cases (3%) with retinal hemorrhages and 6 cases (3%) with cotton wool spots belonging to severe pre-eclampsia.  Naval et al., found 1.5% of cases with cotton wool spots and retinal hemorrhage.  Francis et al., found 5% of cases with cotton wool spots and retinal haemorrhage.  None of these three studies showed observations as we found in our study. We found higher number of cases with retinal hemorrhages and cotton wool spots. Karki et al., mentioned optic nerve head changes in 8 cases. Shukla et al., found 10% case of papilloedema. Decline in the percentage was found in our study regarding papilloedema could be due to early and prompt obstetrical and medical management of PIH. Fry W have stated in their study that the serous retinal detachment occurs in approximately 1% of patients with pre-eclampsia and 10% of those with eclampsia.  Our observations regarding retinal detachment in eclampsia group matches with Fry W. Jaffe G in his study of ocular manifestations of pre-eclampsia did not find any case of retinal detachment.  Reddy SC et al., (2012) in their study did not find any case of retinal detachment. 
In our study normal fundus findings were seen in 56% of cases of PIH. Grade I, II, III, and IV retinal vascular changes were seen in 29%, 5%, 3%, and 2% of cases, respectively. Five cases (5%) had other changes like macular edema and retinal edema which were not associated with any other grades of retinopathy [Table 2].
In the study by Tadin et al., the percentage of occurrence of Grade I retinal vascular changes in PIH cases was similar to that of our study. Reddy et al., (2012) in their study found higher percentage of occurrence of Grade I retinal vascular changes (52.6%) as compare to our study. In the study by Reddy et al., (2012), the percentage of occurrence of Grade II retinal vascular changes in PIH cases was similar to that of our study. Tadin et al., in their study found higher percentage of occurrence of Grade II retinal vascular changes (15%) as compare to our study. In the study by Tadin et al., the percentage of occurrence of Grade III retinal vascular changes in PIH cases was higher than that of our study. Higher percentage of women in severe pre-eclampsia and eclampsia group had retinal changes as compared to mild pre-eclampsia group [Table 3].
|Table 3: Retinal vascular changes according to severity of pregnancy-induced hypertension (PIH) in various studies|
Click here to view
In the studies by Reddy et al., (1983) and Naval et al., the percentage of occurrence of retinal vascular changes in mild pre-eclampsia was similar to that of our study. The percentage of occurrence of retinal vascular changes in severe pre-eclampsia in studies by Reddy et al., (1983) and Naval et al., was higher than that of our study. Naval et al., in their study found 90% of eclampsia cases with retinal vascular changes. This is higher than that found in our study (61%).
Vision is important criteria to be seen in these patients including on follow-up after delivery. Most cases of late onset severe eclampsia present with exudative retinal detachment which usually resolves with termination of pregnancy. Vision and the retinal findings documented need to be followed up after the termination of pregnancy and any residual optic nerve affection should be correlated. In some of the cases, optic nerve changes are seen. In our study on follow-up examination of cases after termination of pregnancy, all the changes were resolved with no residual retinal or optic nerve changes.
| Conclusion|| |
Hundred cases of pre-eclampsia and eclampsia were studied in which 44% of the cases showed retinal changes. This is comparable with various studies. Attenuation of arterioles was the first detectable and most common retinal change. Majority of retinal changes were of Grade I retinopathy. Cases of severe pre-eclampsia and of eclampsia showed higher grades of retinal changes. This signifies that retinal changes progress with severity of PIH. Ocular examination reveals important objective information concerning the disorder. Also, we can consider presence of the retinal changes to be an indirect marker of severity of PIH and of the prognostic value.
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[Table 1], [Table 2], [Table 3]
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