Glaucoma management during pregnancy
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It's very challenging to manage glaucoma in pregnancy for the patient and doctor. During pregnancy, the intraocular pressure (IOP) decreases. However, some women with pre existing glaucoma have elevated IOP requiring enhanced medical treatment. Glaucoma refractory to medical treatment combined with disease progression may necessitate laser trabeculoplasty or surgical intervention. Surgery during pregnancy has potential risks for both the mother and fetus. The challenges include problems with anesthesia, positioning for surgery, difficulties in the surgical procedure, potential risk with antimetabolites, and concerns with the management of postoperative complications.

Medical Management
Drug drainage through the nasolacrimal duct, lack of ocular metabolism, and bypassing hepatic enzymatic metabolism causes systemic absorption of drugs exposes the fetus to the side effects of AGM.Simple techniques such as punctal occlusion and eyelid closure can reduce systemic absorption.Medical management requires a fine balance between the risk of vision loss to mother and side effects ofAGMs on fetus. Hence, pregnant women should be prescribed minimum medications as indicated.

Laser Therapy
Argon laser trabeculoplasty (ALT) and selective laser trabeculoplasty (SLT) are useful alternatives to reduce the number or need for AGMs and possibly defer surgery. However, the inability to perform laser trabeculoplasty in dysgenetic angles, lower efficacy in young patients, delayed onset of IOP reduction, and compromised long‑term IOP control are some limitations.] There is scant literature on the use of micropulse or diode cyclophotocoagulation to control IOP during pregnancy. Given the short time frame of pregnancy, trabeculoplasty should be considered whenever feasible.

Glaucoma Surgery
During pregnancy, surgery is best avoided, however, IOP can increase and pre existing glaucoma can worsen despite medical and laser treatment. The failure of conservative management combined with disease progression makes surgical intervention inevitable.Glaucoma surgery during pregnancy has serious risks. Challenges related to preoperative planning, anesthetic concerns, intraoperative modifications, and postoperative management are discussed in this article.

Conclusively, Elevated IOP management during pregnancy varies based on the trimester of pregnancy, the severity of the disease, and risk versus benefit of treatment. Though IOP is known to decrease during pregnancy, some patients develop uncontrolled IOP not amenable to medical treatment.A subset of such patients shows high disc and field progression, where glaucoma surgery is warranted.Anesthesia and surgical intervention pose risk to both mother and fetus.It might be safer to perform glaucoma surgery in the second trimester to reduce the anesthesia‑related risk of defective organogenesis and risk of termination of pregnancy in the first trimester. Surgery in the third trimester should be avoided because of difficulties with positioning, anesthesia, premature labor,fetal distress, and difficult tissue handling and healing. The chances of surgical failure in pregnant women may be high due to young age and contraindicated antimetabolite usage. Trabeculectomy with Ologen implant may be a safer alternative to modulate wound healing in pregnant women.
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