What are safe eyedrops for glaucoma (Glaucomatous disease) during pregnancy?

Safe Eyedrops for Glaucoma During Pregnancy

Brimonidine is the safest first-line eyedrop for glaucoma during pregnancy, as it has an FDA Pregnancy Category B rating, while beta-blockers are generally considered second-line options despite their Category C rating due to long-term clinical experience. 1

Medication Safety Rankings During Pregnancy

First-Line Option:

• Brimonidine (Category B): The only glaucoma medication with FDA Pregnancy Category B rating, indicating animal studies failed to show fetal risk 1
  • Should be used in first, second, and early third trimester 2
  • Important caveat: Should be discontinued late in third trimester as it can cause central nervous system depression in newborns 2

Second-Line Options:

• Beta-blockers (Category C): Despite Category C rating, these are often used during pregnancy due to extensive clinical experience 1
  • Minimize systemic absorption by using punctal occlusion, eyelid closure, and blotting excess drops 3

Medications to Use with Caution:

• Topical Carbonic Anhydrase Inhibitors (Category C): May be considered late in third trimester when brimonidine needs to be discontinued 2
• Prostaglandin Analogs (Category C): Generally avoided during pregnancy due to theoretical risk of premature labor 1
  • Limited data exists, though a small case series of 11 pregnant women using latanoprost showed no adverse effects on pregnancy or birth defects 1

Medications to Avoid:

• Oral Carbonic Anhydrase Inhibitors: Have shown teratogenicity in high doses in animal studies 1

Non-Pharmacological Alternatives

When medication risks are concerning, consider these alternatives:

• Laser Trabeculoplasty: Can be safely performed in all trimesters of pregnancy 2, 3

  • No identified teratogenic effects or increased side effects for pregnant women 3
  • May be considered before medical management in some cases to prevent fetal exposure 4

• Glaucoma Surgery: Can be performed with caution in second and third trimester if strongly indicated 2

  • Avoid antimetabolites during surgery 3
  • Newer minimally invasive glaucoma surgery (MIGS) procedures may provide options for pregnant patients 4

Practical Management Algorithm

1. Pre-pregnancy planning: Ideally, discuss glaucoma management before conception
2. First trimester through early third trimester: Use brimonidine as first-line therapy
3. Late third trimester: Switch from brimonidine to topical carbonic anhydrase inhibitors
4. If inadequate IOP control: Consider beta-blockers as second-line therapy
5. If medical therapy fails: Consider laser trabeculoplasty in any trimester
6. For severe cases: Consider glaucoma surgery in second or third trimester without antimetabolites

Risk Minimization Strategies

When using any glaucoma medication during pregnancy:

• Use lowest effective dosage 3
• Reduce systemic absorption by:
  • Punctal occlusion
  • Eyelid closure for 1-2 minutes after drop instillation
  • Blotting excess drops away 3

Common Pitfalls to Avoid

• Discontinuing all medications: Untreated glaucoma can lead to irreversible vision loss; optimal treatment must not be withheld 2
• Ignoring IOP fluctuations: Both elevations and reductions of IOP have been reported during pregnancy 3
• Failing to adjust medications in third trimester: Brimonidine should be discontinued late in third trimester to prevent CNS depression in newborns 2
• Using antimetabolites during surgery: These should be avoided during pregnancy 3

Remember that management of glaucoma during pregnancy requires balancing the risk of vision loss to the mother against potential harm to the fetus. A careful approach using the safest medications first, considering non-pharmacological options, and implementing risk minimization strategies will help achieve the best outcomes for both mother and child.