How to best treat pregnant and breastfeeding patients

Excerpted from the May edition of AOA Focus, page 46.

It's the responsibility of the doctor of optometry to warn pregnant and breastfeeding patients about the risks of using any ocular medications, including dilation drops. Even though the patient may choose to forego dilation or treatment, sometimes not using a drop or medication can put the patient at risk for ocular problems.

Jill Autry, O.D., is helping to put an end to the confusion by sharing her knowledge about safe treatments for pregnant and breastfeeding patients. Dr. Autry, who also has a pharmacy degree, often lectures on which topical and oral treatments are safe for this patient subgroup.

"Obstetricians have patients who need all types of pharmaceutical care during pregnancy," she says. "They have seen it all. So when we call them and ask about putting a drop in the eye one time to dilate a six-months-pregnant patient, they're looking at us like, 'What?' They are going to get more exposure to toxins when they eat something at a restaurant that's been prepackaged than they are ever going to get in that drop in the eye."

FDA changes

Recently the Food and Drug Administration (FDA) changed its coding system for medicines to be used during pregnancy and breastfeeding, which, until last year, was set up in a category system of A, B, C, D and X. Now the FDA provides three detailed subsections that describe the risks of treating pregnant and breastfeeding women.

"It puts more onus on the physician to weed through the information and see what they think based on the information given," Dr. Autry says. "I think there's good and bad in that."

Doctors of optometry are wise to understand what drugs MDs commonly prescribe for their pregnant patients, which likely means they are safe for optometric use as well. For example, "There aren't a lot of glaucoma drugs labeled category B," Dr. Autry says. "The most common one is brimonidine and once you've used that one, what are you going to use for your second choice? Although beta blockers are historically category C, I know MDs use beta blockers all the time when women have trouble keeping their blood pressure down. To me, that would be my next logical choice."

Different options

Dr. Autry notes that some drugs aren't used in pregnancy out of a potentially overabundance of caution. For instance, because prostaglandins are used on the cervix to initiate labor, U.S. doctors of optometry don't use them to treat glaucoma in pregnant patients, though doctors in other countries do.

However, use of brimonidine around delivery and in newborns has been shown to cause apnea, says Dr. Autry. "I would remove brimonidine at month 8 or 9 and wouldn't use it in breastfeeding patients. At that point, I would use a prostaglandin or nothing until after the baby is born and then start the prostaglandin."

In a course at the 2016 Optometry's Meeting^®, Dr. Autry will run through ocular issues—such as viral conjunctivitis, corneal abrasions, preseptal cellulitis, iritis, herpes virus in the eye, glaucoma and bacterial keratitis—and discuss how to treat them in pregnant and breastfeeding patients.

"My goal is to educate other optometrists, give them some options, make them feel more comfortable, and, therefore, make patients feel more comfortable with options for treating ocular disease during their pregnancy," Dr. Autry says.