Mode of Delivery in the Setting of Repeated Vitreous Hemorrhages in Proliferative Diabetic Retinopathy: A Case Report and Review of the Literature

The state of pregnancy affects all organ systems including the eyes. Progression of diabetic retinopathy (DR) is a known association. In proliferative DR, there is an increased risk of vitreous hemorrhage (VH) during spontaneous vaginal delivery (SVD) due to the Valsalva maneuver. A 30-year-old female with poorly controlled type I diabetes and hypothyroidism on treatment was following up with the antenatal services at our hospital. This was her second pregnancy having had a previous miscarriage. Three months into her pregnancy, our Ophthalmology service was consulted to assess her and give our advice regarding the safest mode of delivery for her. Questioning revealed that she was following regularly elsewhere for proliferate DR with previous interventions and history of multiple and repeated VHs. When she was seen in our Ophthalmology clinic, she was anxious about the mode of delivery that was best suited for her with regard to her ocular condition. On examination, her visual acuity (VA) without correction was 20/40 in both eyes, improving to 20/20 in the right eye and 20/30 in the left eye after refraction. Her intra-ocular pressure was normal. A dilated fundus examination (DFE) showed changes of high-risk proliferative DR in both eyes and a VH in the right eye. Subsequent follow-up did not reveal any new complaints or concerns. She required one session of pan-retinal photocoagulation (PRP) in her first-trimester visit. DFE showed improvement in VH when compared to her initial examination. After discussing her condition with her obstetrician, it was decided to offer the patient a cesarean section (C/S) delivery, as her risk of developing VH during SVD was greater than normal. At 38 weeks of gestation, she delivered a healthy boy following an uneventful elective C/S. There were no visual complaints throughout her admission for the procedure or thereafter. During the reproductive age, DR is a leading cause of decreased vision. Pregnancy is an independent risk factor for progression of DR, with the stage of DR prior to conception being another. If not managed well, proliferative DR can result in VH, with the risk also existing in relation to SVD due to recurrent Valsalva maneuvers during labor. Our patient who initially presented with proliferative DR in both eyes and a VH in the right eye received one session of PRP to both eyes in the first trimester and was closely followed up throughout her pregnancy thereafter. When her due date neared, it was decided that the safest and most suitable mode of delivery was an elective C/S due to her increased risk of VH related to Valsalva maneuvers during SVD, especially since this was to be her first delivery.