Review
Copyright ©The Author(s) 2021. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Diabetes. Sep 15, 2021; 12(9): 1386-1400
Published online Sep 15, 2021. doi: 10.4239/wjd.v12.i9.1386
Review of the management of sight-threatening diabetic retinopathy during pregnancy
Priscilla Peixi Choo, Norshamsiah Md Din, Nooraniah Azmi, Mae-Lynn Catherine Bastion
Priscilla Peixi Choo, Norshamsiah Md Din, Nooraniah Azmi, Mae-Lynn Catherine Bastion, Department of Ophthalmology, Universiti Kebangsaan Malaysia Medical Centre, Kuala Lumpur 56000, Wilayah Persekutuan, Malaysia
Nooraniah Azmi, Department of Ophthalmology, Universiti Putra Malaysia, Serdang 43400, Selangor, Malaysia
Author contributions: Choo PP conducted the literature review, wrote the first draft, and performed plagiarism and grammar checks; Bastion MLC revised the drafts, formatted the article, and directed the writing; Azmi N and Md Din N critically evaluated the writing and made further amendments to it.
Supported by National University of Malaysia, Bangi, Selangor, Malaysia for English Editing, No. GP-K009894 (2015).
Conflict-of-interest statement: Mae-Lynn Catherine Bastion has received fees for serving as a speaker and/or an advisory board member for Novartis, Alcon, and Santen. She received fees for serving as a speaker for Bayer and Allergan. She has received research funding from Alcon, Novartis, Santen, and Universiti Kebangsaan Malaysia. She is an employee of National University of Malaysia. She holds a patent draft (PT/7449/UKM/20) pending for topical insulin eyedrops. Norshamsiah Md Din has received fees for serving as a speaker and/or an advisory board member for Novartis. She receives fees for serving as a speaker for Santen, DKSH, and Novartis. She has received research funding from Allergan. She is an employee of Universiti Kebangsaan Malaysia. She holds a patent draft (file no: UKM. IKB. 800–4/1/1960) for the synthetic eye model for cataract surgery simulation. Choo Peixi and Nooraniah Azmi have no conflicts of interest to disclose.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) licence, which permits others to distribute, remix, adapt, build upon this work non-commercially, and licence their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/Licences/by-nc/4.0/.
Corresponding author: Mae-Lynn Catherine Bastion, FRCS, MBBS, Doctor, Professor, Surgeon, Department of Ophthalmology, Universiti Kebangsaan Malaysia Medical Centre, Faculty of Medicine Universiti Kebangsaan Malaysia Jalan Yaacob Latif, Kuala Lumpur 56000, Wilayah Persekutuan, Malaysia. mae-lynn@ppukm.ukm.edu.my
Received: January 25, 2021
Peer-review started: January 25, 2021
First decision: June 16, 2021
Revised: June 25, 2021
Accepted: August 12, 2021
Article in press: August 12, 2021
Published online: September 15, 2021
Abstract

Diabetes mellitus (DM) is a noncommunicable disease reaching epidemic proportions around the world. It affects younger individuals, including women of childbearing age. Diabetes can cause diabetic retinopathy (DR), which is potentially sight threatening when severe nonproliferative DR (NPDR), proliferative DR (PDR), or sight-threatening diabetic macular oedema (STDME) develops. Pregnancy is an independent risk factor for the progression of DR. Baseline DR at the onset of pregnancy is an important indicator of progression, with up to 10% of women with baseline NPDR progressing to PDR. Progression to sight-threatening DR (STDR) during pregnancy causes distress to the patient and often necessitates ocular treatment, which may have a systemic effect. Management includes prepregnancy counselling and, when possible, conventional treatment prior to pregnancy. During pregnancy, closer follow-up is required for those with a long duration of DM, poor baseline control of blood sugar and blood pressure, and worse DR, as these are risk factors for progression to STDR. Conventional treatment with anti-vascular endothelial growth factor agents for STDME can potentially lead to foetal loss. Treatment with laser photocoagulation may be preferred, and surgery under general anaesthesia should be avoided. This review provides a management plan for STDR from the perspective of practising ophthalmologists. A review of strategies for maintaining the eyesight of diabetic women with STDR with emphasis on prepregnancy counselling and planning, monitoring and safe treatment during pregnancy, and management of complications is presented.

Keywords: Sight-threatening diabetic retinopathy, Severe nonproliferative diabetic retinopathy, Proliferative diabetic retinopathy, Diabetic macula oedema, Pregnancy, Panretinal photocoagulation

Core Tip: Progression of diabetic retinopathy (DR) to the sight-threatening DR (STDR) is rare during pregnancy but can cause significant ocular morbidity and distress to the mother. Good prepregnancy and intrapartum control of systemic risk factors, especially blood sugar and blood pressure, and adequate prepregnancy treatment of STDR will reduce complications during pregnancy. When STDR develops, conventional therapy for nonpregnant individuals may not be applied. This includes avoidance of anti-vascular endothelial growth factor agents conventionally for diabetic macular oedema and proliferative DR (PDR), especially during early trimesters. Panretinal photocoagulation is a safe option for PDR. Surgical treatments should be performed under local anaesthesia or preferentially deferred until postpartum.