How does myopia (nearsightedness) affect the management of a cesarean section?

Management of Cesarean Section in Patients with Myopia

Myopia alone is not an indication for cesarean section, and vaginal delivery is generally safe for most myopic patients. Only specific, rare ophthalmologic conditions warrant consideration of cesarean section as an alternative to vaginal delivery 1.

Ophthalmologic Conditions and Delivery Method

Myopia and Retinal Conditions

• High myopia by itself is not an indication for cesarean section, as there is no evidence that spontaneous vaginal delivery increases the risk of retinal detachment in myopic patients 2, 3.
• Studies examining retinal changes in patients with high myopia before and after delivery have found no progression of retinal changes or development of retinal tears 4.
• The only specific myopia-related indication for cesarean section is the presence of choroidal neovascularization, which could cause subretinal bleeding with acute visual loss during vaginal delivery 2, 1.

Other Ophthalmologic Conditions

• Active proliferative diabetic retinopathy may be an indication for elective cesarean section due to the risk of retinal hemorrhage during the Valsalva maneuver in the second stage of labor 2, 1.
• Advanced glaucoma with significant visual field changes may warrant cesarean section, as intraocular pressure fluctuations during vaginal delivery could damage retinal ganglion cells and cause further progression of visual field loss 2, 1.
• Advanced keratoconus is another rare condition that might benefit from cesarean section in specific cases 1.

Trends in Clinical Practice

• Despite evidence-based recommendations, there has historically been a discrepancy between clinical practice and evidence-based medicine regarding myopia and delivery method 3.
• Analysis of delivery modes for myopic patients across different time periods (1990,2000, and 2010) showed that myopia still remained an indication for cesarean section despite guidelines to the contrary 5.
• The number of ophthalmological consultations for myopic patients increased over time, but the rates of referrals for cesarean section decreased, suggesting gradual alignment with evidence-based practices 5.

Anesthesia Considerations for Cesarean Section

If cesarean section is indicated for ophthalmologic or other reasons:

• Regional anesthesia (spinal or epidural) is the preferred method for cesarean delivery 6.
• For postoperative pain management, add intrathecal morphine 50–100 μg or diamorphine 300 μg to spinal anesthesia 7, 6.
• Administer paracetamol and NSAIDs after delivery and continue regularly postoperatively 7, 6.
• A single dose of intravenous dexamethasone after delivery can help with pain management 7, 6.
• If intrathecal morphine is not used, consider local anesthetic infiltration, continuous wound local anesthetic infusion, and/or fascial plane blocks 7, 6.

Surgical Technique Recommendations

• Use the Joel-Cohen incision technique when possible to reduce postoperative pain 7, 6.
• Non-closure of the peritoneum is recommended 7, 6.
• Use of abdominal binders can improve postoperative pain management 7, 6.

Common Pitfalls and Caveats

• Many ophthalmologists and obstetricians still incorrectly believe that high myopia alone is an indication for cesarean section, despite lack of supporting evidence 2, 3.
• Unnecessary cesarean sections expose patients to surgical risks without providing ophthalmologic benefits 1.
• The World Health Organization recommends that cesarean sections should be reserved for cases with clear indications, considering the potential short- and long-term implications 1.
• There is a notable lack of high-quality evidence in this area, with no randomized controlled trials specifically addressing myopia and delivery method 1.

Decision Algorithm

1. Assess the specific type and severity of myopia:

   • Simple high myopia without complications → Vaginal delivery is appropriate 2, 3
   • Myopia with choroidal neovascularization → Consider cesarean section 2, 1

2. Evaluate for associated ophthalmologic conditions:

   • Active proliferative diabetic retinopathy → Consider cesarean section 2, 1
   • Advanced glaucoma with significant visual field changes → Consider cesarean section 2, 1
   • History of retinal detachment surgery without current complications → Vaginal delivery is appropriate 2, 3

3. Obtain ophthalmologic consultation in the third trimester for patients with high-grade myopia or other eye conditions to assess current status 5.

4. If cesarean section is indicated for ophthalmologic reasons, follow best practices for anesthesia and surgical technique as outlined above 7, 6.