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Managing Glaucoma in Pregnancy 2026: Evidence and Consensus · Glaucoma, Vision & Longevity: Supplements & Science

• 0:00
  SPEAKER_00: Managing glaucoma in pregnancy.
• 0:02
  SPEAKER_00: 2026.
• 0:03
  SPEAKER_00: Evidence and Consensus, Evidence Cutoff, July 24, 2026.
• 0:09
  SPEAKER_00: Pregnancy does not automatically make glaucoma treatment unsafe, and stopping glaucoma medication without medical supervision can permanently threaten vision.
• 0:18
  SPEAKER_00: The goal is to protect the pregnant patient's optic nerve while reducing avoidable exposure of the fetus or breastfed infant to glaucoma medicines.
• 0:27
  SPEAKER_00: The best available evidence remains limited.
• 0:29
  SPEAKER_00: There are no large randomized trials of glaucoma treatment during pregnancy.
• 0:34
  SPEAKER_00: Current recommendations rely on medication labels, animal reproductive studies, pharmacokinetic research, retrospective case series, case reports, and expert consensus.
• 0:45
  SPEAKER_00: The most current major guidance includes the 2026 American Academy of Ophthalmology Primary Open Angle Glaucoma Preferred Practice Pattern, the American Glaucoma Society and Canadian Glaucoma Society Practical Guide, and updated clinical reviews.
• 1:01
  SPEAKER_00: Important, this article is educational and cannot replace individualized care from a glaucoma specialist, obstetric clinician, and when appropriate, a pediatric or neonatal clinician.
• 1:12
  SPEAKER_00: Key recommendations at a glance.
• 1:14
  SPEAKER_00: Plan before conception whenever possible.
• 1:17
  SPEAKER_00: Establish a target pressure, document the optic nerve and visual field, review medications, and consider laser treatment or surgery before pregnancy if glaucoma is advanced or difficult to control.
• 1:29
  SPEAKER_00: Do not assume that pregnancy will lower pressure enough.
• 1:32
  SPEAKER_00: Interocular pressure often falls, but some patients with established glaucoma experience pressure elevation or visual field progression.
• 1:40
  SPEAKER_00: Use the fewest medicines at the lowest effective exposure.
• 1:44
  SPEAKER_00: Punctal occlusion and gentle eyelid closure should be used after every drop.
• 1:49
  SPEAKER_00: Ramonidine is commonly preferred when a glaucoma drop is needed during pregnancy, but it should be stopped before delivery and avoided during breastfeeding because of possible infant central nervous system depression and apnea.
• 2:03
  SPEAKER_00: Timolol may be used selectively, particularly when the maternal benefit is important, but fetal growth and heart rate should be considered, and newborns may require observation after late pregnancy exposure.
• 2:17
  SPEAKER_00: Topical carbonic anhydrase inhibitors such as dorzolamide or brinzolamide are possible alternatives when needed, although human pregnancy and milk data are limited.
• 2:27
  SPEAKER_00: Oral acetazolamide is generally reserved for serious or refractory pressure elevation.
• 2:33
  SPEAKER_00: It is often considered acceptable during breastfeeding, but exposure near delivery has occasionally been associated with temporary neonatal metabolic acidosis.
• 2:42
  SPEAKER_00: Prostaglandin analogues are not first-line during pregnancy because of a theoretical risk of uterine contraction or premature labor and limited human data.
• 2:52
  SPEAKER_00: Selective laser trabeculoplasty may reduce or eliminate medication exposure.
• 2:57
  SPEAKER_00: Guidance differs slightly on first trimester elective treatment, so timing should depend on disease severity and urgency.
• 3:05
  SPEAKER_00: Incisional surgery is unusual but justified when vision is at meaningful risk.
• 3:10
  SPEAKER_00: If it cannot be deferred, the second trimester is generally preferred, with local anesthesia and avoidance of antimetabolites whenever possible.
• 3:19
  SPEAKER_00: How pregnancy changes interocular pressure?
• 3:21
  SPEAKER_00: Normal physiologic changes.
• 3:23
  SPEAKER_00: Interocular pressure usually decreases during pregnancy.
• 3:27
  SPEAKER_00: Proposed explanations include increased aqueous humor outflow related to hormonal changes, reduced episcleral venous pressure, effects of progesterone and relaxin, pregnancy-related changes in blood chemistry and vascular physiology.
• 3:42
  SPEAKER_00: One study found that average intraocular pressure in the first trimester was approximately 2 mm of mercury higher than in the third trimester.
• 3:52
  SPEAKER_00: Another study reported an approximately 19.6% reduction in women without ocular hypertension and a 24.4% reduction in women with ocular hypertension, although these studies were relatively small and older.
• 4:06
  SPEAKER_00: Pregnancy can also change corneal thickness in biomechanics, which may influence applination pressure readings.
• 4:13
  SPEAKER_00: For this reason, clinicians should interpret pressure trends together with the optic nerve, retinal nerve fiber layer imaging, and visual field, not pressure alone.
• 4:22
  SPEAKER_00: In one review, both intraocular pressure and central corneal thickness had returned toward first trimester values by approximately three months after delivery.
• 4:32
  SPEAKER_00: Why glaucoma can still worsen?
• 4:35
  SPEAKER_00: The average fall in pressure does not protect every patient.
• 4:39
  SPEAKER_00: In a retrospective series of 28 eyes from 15 women with glaucoma, 57.1% had stable pressure without visual field progression.
• 4:48
  SPEAKER_00: 17.9% developed visual field progression even though pressure was stable or increased.
• 4:54
  SPEAKER_00: 17.9% developed pressure elevation without documented visual field progression.
• 4:59
  SPEAKER_00: Two eyes had inconclusive data.
• 5:02
  SPEAKER_00: Many patients required glaucoma medication during pregnancy.
• 5:05
  SPEAKER_00: The practical lesson is important.
• 5:07
  SPEAKER_00: A lower pregnancy pressure does not prove that glaucoma is stable, and a normal looking pressure does not exclude progression.
• 5:15
  SPEAKER_00: Monitoring during pregnancy and after delivery, minimum monitoring.
• 5:20
  SPEAKER_00: At a minimum, a pregnant patient with established glaucoma should generally be assessed at least once during each trimester.
• 5:27
  SPEAKER_00: This is a consensus-based recommendation rather than one supported by a large pregnancy trial.
• 5:32
  SPEAKER_00: A useful examination may include visual acuity, intraocular pressure using the same method when possible, optic nerve examination and photographs, visual field testing when the patient can perform it reliably, optical coherence tomography of the retinal nerve fiber layer and ganglion cell layer, gonioscopy when angle status is uncertain or angle closure is possible, medication review, adherence, and drop technique, heart rate and respiratory history if a beta blocker is being used.
• 6:04
  SPEAKER_00: Practical monitoring intervals.
• 6:06
  SPEAKER_00: The following schedule is a practical risk-based framework, not a universally validated guideline.
• 6:12
  SPEAKER_00: For the full table, please open this article on VisualfieldTest.com.
• 6:17
  SPEAKER_00: A visual field and structural baseline should ideally be obtained before conception.
• 6:22
  SPEAKER_00: Repeating both tests once per trimester may be reasonable for moderate or advanced disease if the patient can tolerate testing, but excessive testing can create fatigue and unreliable results.
• 6:34
  SPEAKER_00: Postpartum pressure rebound.
• 6:36
  SPEAKER_00: Pressure may rise again after delivery as pregnancy-related physiologic changes resolve.
• 6:41
  SPEAKER_00: This may be especially important when medication was reduced or stopped during pregnancy.
• 6:47
  SPEAKER_00: A postpartum plan should therefore be made before delivery rather than waiting for symptoms because glaucoma progression is often silent.
• 6:56
  SPEAKER_00: Medication safety during pregnancy and breastfeeding.
• 6:59
  SPEAKER_00: A note about pregnancy categories.
• 7:01
  SPEAKER_00: Many older articles describe glaucoma medicines as category B or category C.
• 7:07
  SPEAKER_00: The United States Food and Drug Administration replaced the former letter categories with descriptive pregnancy and lactation labeling in 2015.
• 7:15
  SPEAKER_00: The older categories may still appear in reviews, but they should not be interpreted as modern, precise safety rankings.
• 7:23
  SPEAKER_00: The current labeling emphasizes the quality of human data, animal findings, and the balance between maternal benefit and fetal or infant risk.
• 7:31
  SPEAKER_00: Medication comparison.
• 7:33
  SPEAKER_00: For the full table, please open this article on VisualFieldTest.com.
• 7:38
  SPEAKER_00: Bromonidine.
• 7:39
  SPEAKER_00: Bramonidine is frequently described as the preferred first medication during pregnancy because animal studies did not demonstrate fetal malformations at exposures substantially above typical ophthalmic exposure.
• 7:52
  SPEAKER_00: However, current United States product labeling states that human pregnancy data are inadequate and that the medicine should be used only when the maternal benefit justifies potential fetal risk.
• 8:04
  SPEAKER_00: The more important issue is the newborn.
• 8:07
  SPEAKER_00: Bramonidine crosses the blood-brain barrier and has been associated with central nervous system depression, excessive sleepiness, hypotension, bradycardia, and apnea in infants exposed directly to the medication.
• 8:19
  SPEAKER_00: Animal studies also demonstrate transfer into milk.
• 8:23
  SPEAKER_00: For this reason, the American Glaucoma Society Handout and Product Labeling recommends stopping bromonidine before delivery and avoiding it during breastfeeding.
• 8:33
  SPEAKER_00: The precise stopping date is not established by high-quality evidence.
• 8:38
  SPEAKER_00: A practical plan is to discontinue it well before expected delivery with the exact timing based on disease severity, the alternative treatment, and obstetric and neonatal advice.
• 8:49
  SPEAKER_00: There are a few reports of breastfeeding without apparent harm, but these involve very small numbers and sometimes multiple medications.
• 8:57
  SPEAKER_00: LACTMED therefore acknowledges the limited reassuring reports while also noting that manufacturers and many clinicians recommend avoiding bromonidine because the potential consequences in a newborn could be serious.
• 9:10
  SPEAKER_00: Timolol and other beta blockers.
• 9:13
  SPEAKER_00: Topical timolol is systemically absorbed and can cross the placenta.
• 9:18
  SPEAKER_00: Potential fetal or neonatal concerns include a slow heart rate and low blood pressure.
• 9:23
  SPEAKER_00: Current clinical guidance supports selective use with the lowest effective exposure and consideration of fetal heart rate and growth monitoring, especially with prolonged or late pregnancy treatment.
• 9:35
  SPEAKER_00: The American Glaucoma Society has suggested that clinicians may consider reducing exposure, for example, using a lower concentration when clinically adequate, but patients should not change concentration or dosing on their own.
• 9:49
  SPEAKER_00: Timolol is detectable in human milk.
• 9:52
  SPEAKER_00: LACTMED reports that one drop of 0.5% timolol in one eye twice daily was estimated to provide approximately 0.63% of an oral cardiac dose to a fully breastfed infant.
• 10:03
  SPEAKER_00: Treatment of both eyes was estimated at approximately 1.25%.
• 10:08
  SPEAKER_00: A separate report estimated a much lower weight-adjusted infant exposure.
• 10:13
  SPEAKER_00: No adverse effect was reported in one nine-week-old infant, but data remain limited.
• 10:18
  SPEAKER_00: During breastfeeding, timolol may be reasonable when needed, particularly if the infant is full-term and healthy.
• 10:26
  SPEAKER_00: A gel-forming preparation or the lowest effective dose is used.
• 10:30
  SPEAKER_00: The dose is given immediately after breastfeeding or pumping.
• 10:33
  SPEAKER_00: The infant is observed for poor feeding, unusual sleepiness, breathing difficulty, or a slow heart rate.
• 10:40
  SPEAKER_00: Extra caution is appropriate for premature infants, newborns with harder breathing problems, or infants with impaired kidney function.
• 10:47
  SPEAKER_00: Topical carbonic and hydrase inhibitors, dorzolamide and brinzolamide, have limited human pregnancy data.
• 10:55
  SPEAKER_00: Animal studies showed developmental effects at higher systemic exposures, including fetal vertebral malformations with oral dorzoramide in rabbits and reduced fetal or offspring growth at high exposures.
• 11:07
  SPEAKER_00: Current labels do not establish their safety in human pregnancy or breastfeeding.
• 11:12
  SPEAKER_00: In practice, topical carbonic and hydrase inhibitors may be used when the maternal benefit is important and other options are inadequate.
• 11:22
  SPEAKER_00: Some clinical guidance considers topical carbonic and hydrase inhibitors a preferred class during breastfeeding.
• 11:28
  SPEAKER_00: LACTMED describes limited dorzolamide experience as unlikely to adversely affect the nursing infant, although direct milk level data are not available.
• 11:38
  SPEAKER_00: If a topical carbonic anhydrase inhibitor is used during pregnancy, some clinicians consider monitoring fetal growth when treatment is prolonged or combined with other potentially growth-affecting medicines.
• 11:50
  SPEAKER_00: Combining a topical and oral carbonic anhydrase inhibitor may increase systemic acid base effects and is generally avoided unless specifically justified.
• 12:00
  SPEAKER_00: Oral acidosolamide.
• 12:02
  SPEAKER_00: Oral acidosolamide is more systemically available than an eye drop and is therefore usually reserved for markedly elevated pressure, rapid progression, acute or severe secondary glaucoma.
• 12:13
  SPEAKER_00: A temporary bridge to laser or surgery.
• 12:16
  SPEAKER_00: Animal studies found limb abnormalities at high systemic doses, and older case reports raised concern about congenital abnormalities.
• 12:24
  SPEAKER_00: Conversely, small human series, particularly in patients treated for idiopathic intracranial hypertension, have not consistently shown fetal harm.
• 12:33
  SPEAKER_00: This is why oral acetazolamide remains a benefit-risk decision rather than an automatically prohibited medicine.
• 12:41
  SPEAKER_00: The most important neonatal signal is temporary metabolic acidosis after exposure during pregnancy.
• 12:47
  SPEAKER_00: LACTMED describes cases in which newborn metabolic disturbances resolved after birth, even while breastfeeding continued.
• 12:55
  SPEAKER_00: Breastfeeding data are more reassuring, milk concentrations are low.
• 12:59
  SPEAKER_00: In one report, the estimated infant milk dose was less than 0.7% of the maternal weight adjusted dose.
• 13:06
  SPEAKER_00: In another report, an infant's plasma concentrations averaged approximately 1.5% of maternal plasma concentrations.
• 13:14
  SPEAKER_00: No apparent adverse effect was seen in one infant receiving maternal sustained release acetazolamide at 1,000 mg daily.
• 13:22
  SPEAKER_00: Several professional guidelines consider acetazolamide compatible with breastfeeding, but monitoring is prudent for a premature infant or a newborn with kidney disease, poor feeding, dehydration, or unexplained lethargy.
• 13:35
  SPEAKER_00: Prostaglandin analogues, latanoprost, bimatoprost, travoprost, and tafluprost are highly effective glaucoma medicines, but they are generally not first-line during pregnancy.
• 13:46
  SPEAKER_00: The concern is partly theoretical.
• 13:49
  SPEAKER_00: Prostaglandin activity can stimulate uterine contraction.
• 13:52
  SPEAKER_00: Whether the very small systemic exposure from an eye drop is sufficient to cause premature labor is uncertain.
• 13:59
  SPEAKER_00: A small report of 10 women exposed to latanoprost during the first trimester described nine normal deliveries without neonatal malformation and one spontaneous abortion in a 46-year-old patient.
• 14:12
  SPEAKER_00: The report cannot establish whether latanoprost caused the abortion.
• 14:16
  SPEAKER_00: The current latanoprost label states that there are no adequate human pregnancy studies.
• 14:22
  SPEAKER_00: Intravenous animal exposure caused fetal loss and malformations at clinically relevant or higher exposures, and the medicine's presence in human milk is unknown.
• 14:33
  SPEAKER_00: A prostaglandin analog may still be considered if the alternative is meaningful maternal vision loss, but patients should be counseled about premature labor symptoms and should generally avoid these medicines near delivery when another effective option exists.
• 14:49
  SPEAKER_00: Newer glaucoma medicines.
• 14:51
  SPEAKER_00: Pregnancy and breastfeeding data for natarsudal and latanoprostine bunod remain very limited, because both are newer agents, and because latanoprostein boon contains a prostaglandin analog, most guidance recommends avoiding them when established alternatives are available, particularly near delivery.
• 15:09
  SPEAKER_00: Reducing systemic absorption from eye drops.
• 15:12
  SPEAKER_00: An eye drop is not purely local.
• 15:14
  SPEAKER_00: Medication can drain through the tear duct into the nose, where it may enter the bloodstream without the same first pass metabolism that occurs after swallowing a medicine.
• 15:23
  SPEAKER_00: After instilling a drop, close the eye gently, press the inner corner of the eye over the tear duct.
• 15:29
  SPEAKER_00: Continue pressure for at least one minute.
• 15:32
  SPEAKER_00: Five minutes is reasonable when practical.
• 15:35
  SPEAKER_00: Blot away excess fluid.
• 15:37
  SPEAKER_00: Wait at least five minutes before applying another glaucoma drop.
• 15:42
  SPEAKER_00: This technique is particularly important with bromonidine, timolol, and multiple drop regimens.
• 15:49
  SPEAKER_00: Pharmacokinetic studies confirm that systemic exposure occurs.
• 15:53
  SPEAKER_00: With a bromonidine-temolol combination used in both eyes twice daily, peak plasma concentrations in healthy volunteers were approximately 30 picograms per milliliter for bromonidine and 400 picograms per milliliter for timolol.
• 16:07
  SPEAKER_00: The reported systemic half-lives were approximately 3 hours for bromonidine and 7 hours for timolol.
• 16:14
  SPEAKER_00: Laser treatment during pregnancy.
• 16:16
  SPEAKER_00: Selective laser trabeculoplasty.
• 16:18
  SPEAKER_00: Selective laser trabeculoplasty can reduce pressure without daily fetal exposure to topical medication.
• 16:24
  SPEAKER_00: It is most appropriate when the drainage angle is open.
• 16:28
  SPEAKER_00: The glaucoma is primary open angle or another laser responsive form.
• 16:32
  SPEAKER_00: Pressure is not urgently high.
• 16:34
  SPEAKER_00: The patient wishes to reduce medication burden.
• 16:37
  SPEAKER_00: The expected laser benefit is sufficient for the period of pregnancy.
• 16:41
  SPEAKER_00: The 2026 American Academy of Ophthalmology guideline recognizes laser trabeculoplasty as an alternative or adjunct to medication in selected patients during pregnancy and breastfeeding.
• 16:54
  SPEAKER_00: A small study summarized in a clinical review included approximately 40 pregnant or breastfeeding women and reported successful pressure reduction with a reduction in the number of glaucoma medicines used afterward.
• 17:07
  SPEAKER_00: The evidence is encouraging but not strong enough to establish a universal treatment rule.
• 17:12
  SPEAKER_00: Selective laser trabeculoplasty also has a delayed effect, so it is not a substitute for urgent treatment when pressure is dangerously high.
• 17:22
  SPEAKER_00: When should laser be performed?
• 17:24
  SPEAKER_00: Guidance is slightly different.
• 17:26
  SPEAKER_00: The updated American Academy of Ophthalmology Educational Guidance states that argon laser trabeculoplasty or selective laser trabeculoplasty can be performed during any trimester when clinically necessary.
• 17:40
  SPEAKER_00: Some pregnancy guidance is more conservative and recommends deferring elective laser procedures during the first trimester when possible.
• 17:48
  SPEAKER_00: The 2024 evidence-based optometric guideline describes laser and other surgical options as alternatives to medication, but recommends particular caution in the first trimester.
• 17:59
  SPEAKER_00: A reasonable consensus approach is, before conception, strongly consider laser if it may avoid medication.
• 18:06
  SPEAKER_00: First trimester, defer elective laser if pressure and optic nerve status are stable, perform it if the maternal benefit is important.
• 18:15
  SPEAKER_00: Second trimester, often the most practical time for planned laser if treatment is needed.
• 18:20
  SPEAKER_00: Third trimester, laser remains possible, especially when it can avoid delivery time medication exposure, but consider the time needed for the effect to develop.
• 18:30
  SPEAKER_00: Pressure should be checked after treatment because a temporary pressure spike can occur.
• 18:36
  SPEAKER_00: The pressure lowering effect is usually assessed several weeks later rather than immediately.
• 18:42
  SPEAKER_00: Other laser procedures.
• 18:44
  SPEAKER_00: Laser peripheral, erodidotomy, and laser iridoplasty are generally considered reasonable options during pregnancy when required for angle closure disease.
• 18:53
  SPEAKER_00: They can be preferable to prolonged systemic medication or urgent incisional surgery.
• 18:59
  SPEAKER_00: The exact procedure depends on the anatomy and the cause of angle narrowing.
• 19:04
  SPEAKER_00: Glaucoma surgery during pregnancy.
• 19:06
  SPEAKER_00: When surgery is justified, surgery should be considered when there is documented optic nerve or visual field progression, pressure substantially above the individualized target, failure or intolerance of medication, failure of laser treatment, advanced glaucoma with little remaining visual reserve.
• 19:26
  SPEAKER_00: A situation in which continued medical exposure is more concerning than a carefully planned operation.
• 19:32
  SPEAKER_00: The decision is not based on a single pressure reading.
• 19:35
  SPEAKER_00: It should account for the severity and rate of glaucoma progression, the patient's visual reserve, the gestational age, the expected delivery date, and the risks of postponing surgery.
• 19:46
  SPEAKER_00: Timing.
• 19:47
  SPEAKER_00: First trimester, avoid elective incisional surgery when possible because organ formation is occurring and the risks of anesthesia, sedation, and pregnancy loss are of greatest concern.
• 19:57
  SPEAKER_00: Second trimester, generally preferred if surgery cannot be deferred.
• 20:02
  SPEAKER_00: Third trimester, avoid when possible because of positioning difficulty, maternal hypotension, preterm labor, fetal distress, and the increasing complexity of anesthesia.
• 20:12
  SPEAKER_00: If surgery is urgent, it should not be withheld solely because the patient is pregnant.
• 20:18
  SPEAKER_00: Surgical technique and anesthesia.
• 20:20
  SPEAKER_00: Important precautions include prefer topical, subconjunctival, or carefully selected regional anesthesia when appropriate.
• 20:28
  SPEAKER_00: Avoid general anesthesia when a safe local technique is feasible.
• 20:32
  SPEAKER_00: Use leftward uterine displacement or another position that reduces compression of the major abdominal blood vessels.
• 20:38
  SPEAKER_00: Avoid prolonged flat supine positioning in later pregnancy.
• 20:42
  SPEAKER_00: Maintain maternal oxygenation, hydration, and blood pressure.
• 20:46
  SPEAKER_00: Coordinate with obstetric anesthesia.
• 20:49
  SPEAKER_00: Consider fetal monitoring according to gestational age, procedure length, and obstetric advice.
• 20:55
  SPEAKER_00: Lidocaine has generally been favored over agents with greater fetal or cardiac concerns, but anesthetic planning must be individualized.
• 21:03
  SPEAKER_00: Antimetabolites.
• 21:04
  SPEAKER_00: Mitomycin C and 5-fluorocil are commonly used to reduce scarring after trabeculectomy, but their reproductive safety is not established and their mechanisms raise concern for fetal toxicity.
• 21:16
  SPEAKER_00: They are generally avoided during pregnancy.
• 21:19
  SPEAKER_00: Avoiding antimetabolites may increase the chance of surgical scarring and failure, especially in younger patients.
• 21:26
  SPEAKER_00: Some reports have used collagen matrix implants, such as olegen, as a non-antimetabolite wound modulation strategy, but this remains based on small studies and case reports rather than comparative pregnancy trials.
• 21:40
  SPEAKER_00: What the case series show, the available surgical evidence is small but informative.
• 21:46
  SPEAKER_00: A case series of three pregnant patients and six eyes describe trabeculectomy without antimetabolites, bilateral Ahmed valve implantation after failed medical treatment, and selective laser trabeculoplasty and barevelt valve implantation.
• 22:00
  SPEAKER_00: The operations controlled pressure, but the small sample cannot establish fetal safety or long-term surgical superiority.
• 22:08
  SPEAKER_00: A two-case report described modifications to trabeculectomy during pregnancy, including concerns about tissue handling, postoperative medication, and the increased risk of bleb failure without antimetabolites.
• 22:21
  SPEAKER_00: A report described bilateral sequential Zen gel stent surgery during the third trimester after failed laser and maximum medical therapy in a patient with advanced glaucoma.
• 22:32
  SPEAKER_00: The result was favorable, but it remains a single case and does not make xen routine treatment during pregnancy.
• 22:39
  SPEAKER_00: A first trimester trabeculectomy has also been reported, but this should be viewed as an exceptional response to serious disease rather than evidence that first trimester surgery is generally safe.
• 22:51
  SPEAKER_00: Trimester specific management algorithms.
• 22:54
  SPEAKER_00: These algorithms are practical frameworks for discussion with a glaucoma specialist.
• 22:59
  SPEAKER_00: They are not substitutes for individualized target pressure decisions.
• 23:03
  SPEAKER_00: Before conception, confirm disease status, establish the glaucoma type and stage, document pressure, optic nerve appearance, visual field, and optical coherence tomography.
• 23:15
  SPEAKER_00: Identify the eye with the least visual reserve.
• 23:18
  SPEAKER_00: Review the current regimen, remove unnecessary medicines.
• 23:22
  SPEAKER_00: Consider preservative-free formulations if ocular surface disease is substantial.
• 23:26
  SPEAKER_00: Discuss planned breastfeeding early.
• 23:28
  SPEAKER_00: Reduce future medication exposure.
• 23:31
  SPEAKER_00: Consider selective laser trabeculoplasty for open angle disease.
• 23:35
  SPEAKER_00: Consider definitive surgery before pregnancy if the disease is advanced or poorly controlled.
• 23:41
  SPEAKER_00: Do not delay pregnancy planning solely because of glaucoma without discussing alternatives.
• 23:46
  SPEAKER_00: Create an emergency plan, decide what to do if pressure rises.
• 23:49
  SPEAKER_00: Identify the glaucoma specialist, obstetric clinician, and pediatric or neonatal contact.
• 23:56
  SPEAKER_00: First trimester.
• 23:57
  SPEAKER_00: Do not abruptly stop all medication without assessment.
• 24:00
  SPEAKER_00: If disease is mild and stable, consider observation with close follow-up.
• 24:05
  SPEAKER_00: Recheck sooner than the next routine trimester visit if pressure rises or symptoms occur.
• 24:10
  SPEAKER_00: If treatment is required, bromonidine is often the preferred initial drop.
• 24:15
  SPEAKER_00: Use punctal occlusion.
• 24:17
  SPEAKER_00: Avoid prostaglandin analogs and oral acetazolamide when reasonable alternatives exist.
• 24:22
  SPEAKER_00: Use timolol or topical carbonic anhydrase inhibitors only after a benefit risk discussion.
• 24:28
  SPEAKER_00: If pressure is above target, consider selective laser trabeculoplasty if the angle is suitable.
• 24:34
  SPEAKER_00: If there is rapid progression or vision-threatening pressure, treatment should not be postponed merely because the patient is in the first trimester.
• 24:42
  SPEAKER_00: Defer elective incisional surgery whenever possible.
• 24:45
  SPEAKER_00: Second trimester.
• 24:47
  SPEAKER_00: Continue the minimum effective regimen.
• 24:49
  SPEAKER_00: If bromonidine is insufficient, consider timolol with obstetric awareness of fetal heart rate and growth.
• 24:56
  SPEAKER_00: Consider topical dorzolamide or brinzolamide if appropriate.
• 25:00
  SPEAKER_00: Consider selective laser trabeculoplasty if not already performed.
• 25:05
  SPEAKER_00: If glaucoma is progressing despite medication and laser, this is generally the preferred trimester for necessary surgery.
• 25:12
  SPEAKER_00: Use local or regional anesthesia when feasible.
• 25:15
  SPEAKER_00: Avoid mitomycin C and 5-fluorouroracil unless an exceptional multidisciplinary decision supports their use.
• 25:22
  SPEAKER_00: Reassess pressure and optic nerve status after each treatment change.
• 25:26
  SPEAKER_00: Third trimester.
• 25:27
  SPEAKER_00: Avoid starting or continuing bromonidine close to delivery when another effective option exists.
• 25:33
  SPEAKER_00: Use Timolol cautiously and coordinate plans for newborn observation if exposure continues near delivery.
• 25:39
  SPEAKER_00: Prefer topical carbonic anhydrase inhibitors over oral acidosolamide when they provide adequate control.
• 25:46
  SPEAKER_00: Reserve oral acidosolamide for substantial maternal need and notify the neonatal team if exposure occurs near delivery.
• 25:54
  SPEAKER_00: Avoid prostaglandin analogues if possible because of the theoretical labor-related risk.
• 26:00
  SPEAKER_00: Avoid elective incisional surgery.
• 26:02
  SPEAKER_00: Proceed only when postponement poses a greater threat to vision.
• 26:06
  SPEAKER_00: Finalize the delivery and breastfeeding medication plan before labor begins.
• 26:12
  SPEAKER_00: Postpartum and breastfeeding.
• 26:13
  SPEAKER_00: Arrange an early pressure check, especially if medicines were stopped or reduced.
• 26:18
  SPEAKER_00: Expect pressure to move back toward the pre-pregnancy level over the first several months.
• 26:23
  SPEAKER_00: If breastfeeding, avoid bromonidine.
• 26:26
  SPEAKER_00: Consider a topical carbonic anhydrase inhibitor or carefully selected timolol.
• 26:32
  SPEAKER_00: Use the lowest effective dose and punctal occlusion.
• 26:35
  SPEAKER_00: Apply drops immediately after breastfeeding or pumping.
• 26:38
  SPEAKER_00: Consider oral acetazolamide when necessary, with additional caution for premature or medically fragile infants.
• 26:45
  SPEAKER_00: Ask the pediatric clinician to observe the infant for poor feeding, unusual sleepiness, breathing difficulty or pauses, slow heart rate, poor weight gain.
• 26:55
  SPEAKER_00: If the patient is not breastfeeding, the most effective pre-pregnancy regimen can often be restarted once medically appropriate.
• 27:03
  SPEAKER_00: Labor and delivery.
• 27:04
  SPEAKER_00: Glaucoma alone is not an indication for elective cesarean delivery.
• 27:08
  SPEAKER_00: Normal vaginal delivery has not been shown to cause a harmful pressure rise in otherwise healthy women, and there is no evidence that glaucoma routinely requires cesarean birth.
• 27:18
  SPEAKER_00: A different discussion is needed if the patient has recent trabeculectomy, recent tube shunt surgery, a fragile filtering bleb, severe pain or pressure elevation, another obstetric indication for cesarean delivery.
• 27:33
  SPEAKER_00: The obstetric clinician and glaucoma surgeon should decide whether the timing of delivery creates a risk to the surgical result.
• 27:40
  SPEAKER_00: Shared decision making.
• 27:42
  SPEAKER_00: A good pregnancy glaucoma plan should explicitly compare three risks.
• 27:46
  SPEAKER_00: Risk of untreated glaucoma, permanent optic nerve nerve damage, and visual field loss may occur without symptoms.
• 27:53
  SPEAKER_00: Risk of treatment.
• 27:54
  SPEAKER_00: Medicines may cause fetal, neonatal, cardiovascular, respiratory, or acid-base effects, although the absolute risk from a topical drop is often uncertain and may be low.
• 28:04
  SPEAKER_00: Risk of intervention.
• 28:06
  SPEAKER_00: Laser treatment avoids or reduces drug exposure but may be incomplete or delayed.
• 28:10
  SPEAKER_00: Surgery can protect vision but involves anesthesia, positioning, postoperative medicines, wound healing, and possible surgical failure.
• 28:19
  SPEAKER_00: The discussion should include glaucoma severity and rate of progression, the patient's target pressure, whether one eye or both eyes are threatened, the patient's tolerance for medication uncertainty, gestational age, breastfeeding plans, availability of laser or surgical expertise, the patient's priorities and acceptable trade-offs.
• 28:39
  SPEAKER_00: The correct decision is not always no medicine or no surgery.
• 28:43
  SPEAKER_00: It is the option that best protects long-term maternal vision while keeping fetal and infant exposure as low as reasonably achievable.
• 28:52
  SPEAKER_00: Conclusion.
• 28:53
  SPEAKER_00: As of July 24, 2026, the prevailing approach to glaucoma in pregnancy is individualized and multidisciplinary.
• 29:01
  SPEAKER_00: Observe stable, low-risk disease when appropriate.
• 29:04
  SPEAKER_00: Plan before conception whenever possible.
• 29:07
  SPEAKER_00: Use punctal occlusion and the lowest effective medication exposure.
• 29:10
  SPEAKER_00: Prefer bromonidine during pregnancy only when a drop is needed, but stop it before delivery and avoid it during breastfeeding.
• 29:18
  SPEAKER_00: Use timolol and topical carbonic and hydrase inhibitors selectively with appropriate fetal or infant monitoring.
• 29:25
  SPEAKER_00: Reserve oral acidazolamide for meaningful maternal need.
• 29:29
  SPEAKER_00: Avoid prostaglandin analogues when practical during pregnancy, especially near delivery.
• 29:34
  SPEAKER_00: Consider selective laser trabeculoplasty early when it can reduce medication exposure.
• 29:40
  SPEAKER_00: Use incisional surgery during pregnancy only for significant or progressive disease, with the second trimester generally preferred and antimetabolites avoided.
• 29:49
  SPEAKER_00: Monitor closely after delivery because pressure may rebound.
• 29:54
  SPEAKER_00: The evidence base remains too small to promise zero risk.
• 29:57
  SPEAKER_00: However, careful planning can usually protect both the patient's vision and the health of the fetus or breastfed infant.
• 30:05
  SPEAKER_00: Selected sources American Academy of Ophthalmology, Primary Open Angle Glaucoma Preferred Practice Pattern, 2026, American Academy of Ophthalmology.
• 30:16
  SPEAKER_00: Glaucoma Management in Pregnancy and Postpartum.
• 30:19
  SPEAKER_00: American Glaucoma Society, Glaucoma in Pregnancy for Physicians.
• 30:23
  SPEAKER_00: A Practical Guide to the Pregnant and Breastfeeding Patient with Glaucoma.
• 30:28
  SPEAKER_00: The course of glaucoma during pregnancy, a retrospective case series, glaucoma surgery in pregnancy, a case series and literature review.
• 30:36
  SPEAKER_00: Trabeculectomy in Pregnancy, Case Studies and Literature Review.
• 30:40
  SPEAKER_00: LACMED BROMONIDEN, LACMED TIMOLOL, LACMED Acetazolamide.
• 30:46
  SPEAKER_00: All links to sources are available in the text version of this article.
• 30:49
  SPEAKER_00: You can find the full article at VisualFieldTest.com.
• 30:53
  SPEAKER_00: Thanks for listening.
• 30:54
  SPEAKER_00: To check your visual field, click the link at the bottom of this article or visit visualfieldtest.com.