HIGH MYOPIA IN PREGNANCY: AN ALGORITHM FOR RISK STRATIFICATION OF RETINAL COMPLICATIONS AND SELECTION OF DELIVERY MANAGEMENT
Keywords:
High myopia, pregnancy, retinal complications, rhegmatogenous retinal detachment, peripheral retinal degeneration, retinal breaks, myopic maculopathy, choroidal neovascularization, vaginal delivery, cesarean section, ophthalmological assessment, risk stratification, maternal health, multidisciplinary management.Abstract
High myopia in pregnancy represents a clinically relevant condition because of its association with axial elongation of the eyeball, peripheral retinal degeneration, myopic maculopathy, and an increased lifetime risk of retinal detachment. The management of pregnant women with high myopia remains an important interdisciplinary issue involving ophthalmology and obstetrics. Historically, high refractive error has frequently been considered a reason to recommend cesarean delivery because of concerns that the physical effort associated with the second stage of labor might precipitate retinal complications. However, the available clinical evidence does not support the routine selection of operative delivery solely on the basis of refractive error. An individualized approach that considers retinal anatomy, the presence of active pathology, previous ophthalmological interventions, and independent obstetric indications is therefore essential. The aim of this article is to analyze published evidence concerning retinal complications in pregnant women with high myopia and to propose an algorithm for ophthalmological risk stratification and selection of delivery management. A narrative review of relevant ophthalmological and obstetric literature was undertaken, focusing on pregnancy-associated ocular changes, peripheral retinal degeneration, retinal breaks, rhegmatogenous retinal detachment, myopic macular pathology, and reported outcomes following vaginal delivery. The proposed algorithm integrates clinical history, assessment of visual symptoms, dilated fundus examination, selective retinal imaging, identification of active pathology, and multidisciplinary decision-making. The literature indicates that refractive error alone is insufficient to determine the risk of retinal complications during childbirth. Observational studies involving women with high myopia and selected pre-existing retinal abnormalities have not demonstrated consistent postpartum deterioration attributable to spontaneous vaginal delivery. Nevertheless, the available evidence is limited by small study populations, heterogeneous examination protocols, and a lack of large prospective investigations. The proposed approach distinguishes women with uncomplicated high myopia from those with peripheral retinal abnormalities requiring individualized assessment and those with active sight-threatening pathology requiring urgent specialist management. It is concluded that delivery planning should be based primarily on the anatomical and functional condition of the retina rather than the degree of myopia alone. Vaginal delivery remains an appropriate option for most women without active ophthalmological pathology or independent obstetric contraindications. Cesarean delivery should be considered when a specific clinical indication is established through individualized assessment. Prospective multicenter studies are needed to validate the proposed algorithm and determine its effectiveness in improving maternal visual outcomes.
References
1. Flitcroft D.I., He M., Jonas J.B., Jong M., Naidoo K., Ohno-Matsui K., et al. IMI—Defining and classifying myopia: A proposed set of standards for clinical and epidemiologic studies. Investigative Ophthalmology & Visual Science. 2019;60(3):M20–M30. Publisher: Association for Research in Vision and Ophthalmology.
2. Williams K.M., Hammond C.J. High myopia and its risks. Community Eye Health. 2019;32(105):5. Publisher: International Centre for Eye Health.
3. Garg P., Aggarwal P., Garg S., et al. Ocular changes in pregnancy. Nepalese Journal of Ophthalmology. 2012;4(1):150–161. Publisher: Nepal Ophthalmic Society.
4. Rzeszotarska A., Szczapa-Jagustyn J., Kociecki J. Ophthalmological problems in pregnancy: A review. Ginekologia Polska. 2020;91(8):473–477. Publisher: Via Medica.
5. Neri A., Grausbord R., Kremer I., Ovadia J., Treister G. The management of labor in high myopic patients. European Journal of Obstetrics & Gynecology and Reproductive Biology. 1985;19(5):277–279. Publisher: Elsevier. DOI: 10.1016/0028-2243(85)90041-3.
6. Landau D., Seelenfreund M.H., Tadmor O., Silverstone B.Z., Diamant Y. The effect of normal childbirth on eyes with abnormalities predisposing to rhegmatogenous retinal detachment. Graefe’s Archive for Clinical and Experimental Ophthalmology. 1995;233(9):598–600. Publisher: Springer. DOI: 10.1007/BF00404712.
7. Sapuła-Grabowska M., Ciszewska J., Brydak-Godowska J., Sawa A., Laszewicz P., Bartha E., Pietrzak B. Delivery in myopic women: A comparison of mode of delivery in years 1990, 2000, and 2010. Medical Science Monitor. 2019;25:7715–7719. Publisher: International Scientific Information, Inc. DOI: 10.12659/MSM.916479.
8. Sumual V., Chandra A.P., Sutanto R.L. High-grade myopia and vaginal delivery: A narrative review. Science Midwifery. 2024;12(4):1552–1557. Publisher: IOCS Publisher. DOI: 10.35335/midwifery.v12i4.1700.
9. Zakirkhojaev R.A., Shavkatkhujaev K.N. Refractive changes in pregnancy. In: Materials of the Republican Multidisciplinary Scientific Remote Online Conference “Scientific and Practical Research in Uzbekistan”. Tashkent: Tadqiqot Publishing House; 2020. Conference collection, issue 18, section “Biomedical Research and Practice,” pp. 12–13. Publisher: Tadqiqot LLC.
10. Du Y., Meng J., He W., Qi J., Lu Y., Zhu X. Complications of high myopia: An update from clinical manifestations to underlying mechanisms. Advances in Ophthalmology Practice and Research. 2024;4(3):156–163. Publisher: Elsevier. DOI: 10.1016/j.aopr.2024.06.003.