Open access peer-reviewed chapter

Ophthalmic Disorders in Posterior Reversible Encephalopathy Syndrome Associated with Preeclampsia

Written By

Katarina Cvitkovic, Anita Pusic Sesar, Antonio Sesar and Ivan Cavar

Submitted: September 10th, 2021Reviewed: October 18th, 2021Published: November 14th, 2021

DOI: 10.5772/intechopen.101270

Chapter metrics overview

92 Chapter Downloads

View Full Metrics

Abstract

Posterior reversible encephalopathy syndrome (PRES) is a clinicoradiological entity presented with different symptoms such as visual disturbances, headaches, seizures, severe hypertension and altered mental status. It has been recognized in a different pathological conditions, although preeclampsia/eclampsia is the most common cause of PRES. The pathogenesis of PRES is still not fully understood, but it seems that failure of cerebrovascular autoregulation causing vasogenic edema, cerebral vasoconstriction, and disruption of the blood brain barrier plays an important role. Cortical blindness, hypertensive retinopathy, serous retinal detachment (SRD), central retinal artery and vein occlusions, retinal or vitreous hemorrhages, anterior ischemic optic neuropathy (AION) and Purtscher’s retinopathy are ophthalmic disorders that may occur in PRES associated with preeclampsia. Among these, cortical blindness is the best documented complication of preeclampsia. Magnet resonance imaging (MRI) is a gold standard to establish the diagnosis of PRES because clinical findings are not sufficiently specific. Typically, there are bilateral cortical occipital lesions with hyperdensity on T2-weighted MRI. Blindness due to occipital lesions is reversible and the vision loss is usually regained within 4 h to 8 days.

Keywords

  • preeclampsia
  • eclampsia
  • posterior reversible encephalopathy syndrome
  • ophthalmological disorders
  • cortical blindness

1. Introduction

Posterior reversible encephalopathy syndrome (PRES) is a clinicoradiological entity presented with different symptoms, such as headaches, seizures, visual disturbances, severe hypertension, and altered mental status [1]. Previously, it has been known by various names such as reversible posterior leukoencephalopathy syndrome, reversible posterior cerebral edema syndrome, and reversible occipital parietal encephalopathy [2, 3]. PRES was first described in 1996 by Hinchey et al. in patients with acute neurological symptoms and since then it has been recognized in different pathological conditions such as preeclampsia, eclampsia, hypertensive encephalopathy, autoimmune diseases, renal failure, infection, and the use of cytotoxic or immunosuppressive drugs [1, 3, 4, 5, 6, 7, 8, 9]. Among these, preeclampsia and eclampsia are the most common causes of PRES. Preeclampsia is pregnancy-specific disorder clinically characterized by a new onset of hypertension and proteinuria that appear after the 20th week of gestation and up to 6 weeks postpartum in a previously normotensive woman [5, 6]. Preeclampsia and its variants affect approximately 5% of pregnancies and is the leading cause of both maternal and fetal morbidity and mortality worldwide [10]. It is characterized by impaired organ perfusion that occurs as a result of vasospasm and activation of the coagulation system [11]. Eclampsia is an acute cerebral complication of preeclampsia, presented with the occurrence of tonic-clonic convulsions in pregnant or recently postpartum women [12]. Severe intracranial vasospasm, local ischemia, intracranial hypertension, and endothelial dysfunction associated with vasogenic and cytotoxic edema are possible causes of seizures in PRES [11]. Rare cases of PRES in pregnant women with normal blood pressure and without preeclampsia have also been described in the literature [13]. Early recognition of PRES is essential in order to timely apply the medication, which typically includes drugs that lower blood pressure, act as anti-edematous and interrupt tonic-clonic convulsions [7].

Advertisement

2. Pathogenesis of PRES

The exact pathophysiological mechanisms of PRES are not precisely known. Failure of cerebrovascular autoregulation, cerebral vasoconstriction, and disruption of the blood brain barrier due to endothelial disfunction are possible mechanisms involved in the pathogenesis of PRES [2]. Failure of cerebrovascular autoregulation causing vasogenic edema is the most accepted one. It seems that hyperperfusion plays a crucial role in disorders where hypertension is a key feature, such as in preeclampsia [14]. During fluctuations of systemic blood pressure, cerebrovascular autoregulation maintains cerebral blood flow, leading to vasodilation during systemic hypotension and vasoconstriction during systemic hypertension. The rapid development of hypertension can exceed the capacity of cerebral blood flow autoregulation leading to hyperperfusion [14]. It is supposed that posterior brain regions are more vulnerable to hyperperfusion, which is explained by better autoregulation of the anterior circulation due to better sympathetic innervations as compared to the posterior circulation [15]. Another theory suggests spasm of cerebral arteries in response to acute hypertension, thus resulting in decreased cerebral blood flow, intraarterial thrombosis, and cerebral ischemia leading to cytotoxic edema, especially in the border zones between arterial territories [16, 17, 18]. Breakdown of the blood brain barrier and endothelial dysfunction occurs in PRES with fluid and macromolecule extravasation into the interstitium. Further, increased concentrations of circulating cytokines activate endothelial cells and allow adhesion of circulating leukocytes. On the other hand, the tight junctions are disrupted and vascular endothelial growth factor expression is increased, leading to increased vascular permeability and vasogenic edema [19].

Advertisement

3. Neuroimaging features of PRES

The diagnosis of PRES cannot be established exclusively on clinical findings [1]. Brain lesions are usually located in the white matter, although rarely, overlying cortex may also be affected [20]. The parieto-occipital regions of the brain are main foci of changes, that are usually bilateral and symmetric. However, the lesions can also extend to other brain structures such as the frontal and temporal lobes, cerebellar hemispheres, basal ganglia, brain stem, and deep white matter [21]. A multislice computed tomography (MSCT) scan is often normal or shows cortical-subcortical hypodensities, predominantly in posterior brain regions. However, MSCT scans in PRES show lesions in only of about 50% cases [22]. Because of that, magnet resonance imaging (MRI) is a gold standard for the diagnosis of PRES and the follow-up of these patients. Neuroimaging studies showed hypointense or isointense signal changes on T1-weighted images. The typical neuroimaging feature is a high signal intensity on T2-weighted images predominantly in the posterior regions, which is caused by subcortical white matter vasogenic edema [1]. Abnormalities are more observable on fluid-attenuated inversion recovery imaging (FLAIR), which increases the ability to detect subtle lesions in PRES [15]. Supplemental diffusion-weighted imaging (DWI) and apparent diffusion coefficient (ADC) map images are helpful in distinguishing vasogenic oedema from cytotoxic edema [15, 16, 17, 18, 19]. Cytotoxic edema appears hyperintense on DWI with a low signal intensity image on the corresponding ADC sequence. A predominantly low signal on DWI and a high signal on ADC image indicates vasogenic edema. Vasogenic edema and cytotoxic edema can also coexist in eclampsia [23].

Advertisement

4. Ocular disorders in PRES associated with preeclampsia

Visual disorders in pregnancy can be highly variable and range from mild symptoms such as transient blurred vision, photopsia, and different types of visual field defects to transient or permanent total blindness [24]. Vision loss during pregnancy has been documented in 1–3% of cases and a possible causes are cortical blindness, central retinal artery and vein occlusions, retinal detachment, ischemic optic neuropathy, retinal or vitreous hemorrhages, and Purtscher’s retinopathy [24, 25, 26]. Approximately 25% patients with severe preeclampsia and 50% patients with eclampsia present different visual symptoms including blurred vision, homonymous hemianopsia, visual neglect, visual anosognosia, and cortical blindness [27, 28]. They seem to be a consequence of the cerebral edema located in the occipital cortex or in the temporal and parietal association cortices. In most patients, the visual impairment is reversible, but in rare cases, permanent blindness has been described [29].

4.1 Cortical blindness

Cortical blindness is among the best-documented complications of preeclampsia/eclampsia and affects almost 15% of eclamptic women [30, 31]. Cortical blindness is caused by a dysfunction in the visual pathway that conducts visual information from the lateral geniculate nucleus of the thalamus to the cerebral visual cortex [20]. Vasogenic edema is the main cause of cortical blindness. It appears that the primary visual cortex in the occipital lobes is more susceptible to the breakdown of cerebrovascular autoregulation and subsequent hyperperfusion than other brain regions [31]. Cortical blindness has been described to occur several hours before or after eclamptic seizures, rarely several days or weeks postpartum [32, 33, 34]. The bilateral vision loss often begins with blurry vision and progresses within a couple of hours to bare light perception [35]. Sometimes, the woman is unaware of her blindness and feels that she can see, which is known as visual anosognosia or Anton syndrome, indicating involvement of the visual association cortex [34, 36]. However, cortical blindness is associated with an intact pathway from the eye to the lateral geniculate body and therefore ophthalmological examination including the pupillary reflexes, ocular motility, and fundoscopic findings is normal in these patients [29]. Blindness due to occipital lesions is reversible and the vision loss is usually regained within 4 h to 8 days [27].

Advertisement

5. Other ocular disorders in pregnancy complicated with preeclampsia

5.1 Hypertensive retinopathy

According to some studies, the prevalence rate of hypertensive retinopathy in women with hypertensive disorders in pregnancy is 32.5% [37]. Generally, the retinal vascular changes correlate with the severity of systemic hypertension. At the pathophysiological level, increased blood pressure leads to focal or diffuse vasoconstriction. In addition, increased vascular permeability leads to the extravasation of fluid to the extravascular spaces. Clinically, the most common abnormality seen during fundoscopy is narrowing of retinal arterioles [38]. Other retinal changes that may be present are decreased retinal artery to vein ratio, cotton wool spots, hemorrhages and Elschnig spots [39]. Vasospastic manifestations are reversible, and the retinal vessels rapidly return to normal after delivery [38].

5.2 Serous retinal detachment

Serous retinal detachment (SRD) is a rare complication of hypertensive disease in pregnancy, affecting 1–2% of preeclamptic and 10% of eclamptic women [40]. It is characterized by separation of the neurosensory retina from the pigmented retinal epithelium and it is usually observed in the absence of significant retinal vascular abnormalities or retinal breaks [41]. It may be present either before or after delivery [42]. Clinically, patients report loss of visual acuity and visual field defects [42, 43]. The detachments are often bullous and bilateral [27]. The exact pathophysiology of SRD in cases of preeclampsia is not well known, but it seems to be related with choroidal ischemia, which is secondary to an intensive arteriolar vasospasm [27]. The choroidal vascular insufficiency can lead to lesions in retinal pigment epithelium, fluid transudation, and focal retinal detachment. The majority of women who manifest SRD during pregnancy have a gradually improvement of visual acuity in few weeks after delivery, ending with complete recovery of vision [31]. Management of SRD in preeclampsia is conservative and involves treating the underlying condition [27].

5.3 Purtscher’s retinopathy

Purtscher’s retinopathy is a rare cause of visual loss during pregnancy and has been mostly described in association with complicated labor [24]. However, isolated cases during normal spontaneous labor have also been described in the literature [44]. Clinically, it presents with decreased visual acuity and a different types of visual field defects such as central or paracentral scotoma. The retinal changes include ischemia at the posterior pole with white patches of edema known as Purtscher’s flecken, which represent areas of capillary bed infarction. In the initial phase, the optic disc is normal, but in the later phases, disc pallor and optic atrophy occur [27]. According to some researchers, these fundoscopic changes may be caused by embolic occlusion of the precapillary arterioles of the retina by fat, air, platelets, and leukocyte aggregates [45, 46]. The diagnosis is established on the basis of clinical findings and confirmed by intravenous fluorescein angiography [47]. The majority of patients recover some of their visual function without treatment. Use of systemic steroids may improve visual outcome in some patients, but momentary specific medication is not available [47].

5.4 Anterior ischemic optic neuropathy

Anterior ischemic optic neuropathy (AION) is a rare ophthalmological disorder in preeclampsia that has been described to occur before and after delivery. Clinically, it is presented with sudden vision loss and unilateral or bilateral disc edema [48, 49]. The exact pathophysiology of AION in preeclampsia remains unclear, but it is suggested that uncontrolled hypertension leads to vasoconstriction or ischemia in the posterior ciliary artery circulation [49].

5.5 Central retinal vein occlusion

Central retinal vein occlusion (CRVO) is also described in preeclamptic women and was presented with bilateral vision loss up to 21 days postpartum. Ophthalmologic examination reveals multiple retinal hemorrhages in all 4 quadrants, venous dilatation, and macular edema. Improvement of visual acuity is significant but not complete [31]. The exact pathophysiological mechanism of CRVO in preeclampsia is not fully understood; however, it is proposed that central retinal artery thickening is thought to cause compression of the central retinal vein, thereby leading to venous occlusion [50, 51].

5.6 Central retinal artery occlusion

Central retinal artery occlusion (CRAO) is rare in young people, and it is usually associated with a predisposing pathological disorders such as cardiac valvular disease, systemic vascular disease, and hypercoagulable disorders. According to some studies, CRAO is rarely described in women with eclampsia [52, 53]. Clinically, it is presented with sudden, painless, and persistent vision loss. Fundoscopy shows typical changes such as pallor of posterior pole with cherry-red spot. It seems that the activation of coagulation system could be a cause of multiple emboli and vascular occlusion in these patients [53].

5.7 Retinal and vitreous hemorrhages

Retinal and vitreous hemorrhages are rare disorders that may precede the appearance of preeclampsia. They are presented as a sudden vision loss in a normotensive pregnant women, who usually develop preeclampsia within 2 weeks after labor [54, 55].

Advertisement

6. Conclusion

Preeclampsia and eclampsia are the most common conditions associated with PRES. Due to the high predilection of pathological lesions in white matter of the occipital lobes, PRES could be manifested with different types of ocular disorders. Some of these complications can be serious including cortical blindness, SRD, CRVO, CRAO, AION, and vitreal and retinal hemorrhages. Clinicians should be aware of these ocular manifestations, and careful ophthalmological, neurological, and neuroradiological evaluation should be carried out to ascertain the various causes of vision loss in pregnancy. In most cases, visual prognosis is usually good with permanent vision recovery. Effective treatment of preeclampsia/eclampsia along with termination of pregnancy is the mainstay of treatment.

Advertisement

Conflict of interest

The authors declare they do not have any conflict of interest.

References

  1. 1.Lamy C, Oppenheim C, Méder JF, Mas JL. Neuroimaging in posterior reversible encephalopathy syndrome. Journal of Neuroimaging. 2004;14:89-96
  2. 2.Sudulagunta SR, Sodalagunta MB, Kumbhat M, Settikere NA. Posterior reversible encephalopathy syndrome (PRES). Oxford Medical Case Reports. 2017;2017:omx011. DOI: 10.1093/omcr/omx011
  3. 3.Bartynski WS. Posterior reversible encephalopathy syndrome, part 1: Fundamental imaging and clinical features. AJNR. American Journal of Neuroradiology. 2008;29:1036-1042. DOI: 10.3174/ajnr.A0928
  4. 4.Hinchey J, Chaves C, Appignani B, Breen J, Pao L, Wang A, et al. A reversible posterior leukoencephalopathy syndrome. The New England Journal of Medicine. 1996;334:494-500. DOI: 10.1056/NEJM199602223340803
  5. 5.Staykov D, Schwab S. Posterior reversible encephalopathy syndrome. Der Nervenarzt. 2012;83:1013-1020. DOI: 10.1007/s00115-012-3480-2
  6. 6.Zeeman GG. Neurologic complications of pre-eclampsia. Seminars in Perinatology. 2009;33:166-172. DOI: 10.1053/j.semperi.2009.02.003
  7. 7.Postma IR, Slager S, Kremer HP, de Groot JC, Zeeman GG. Long-term consequences of the posterior reversible encephalopathy syndrome in eclampsia and preeclampsia: A review of the obstetric and nonobstetric literature. Obstetrical & Gynecological Survey. 2014;69:287-300. DOI: 10.1097/OGX.0000000000000069
  8. 8.Nielsen LH, Grén BS, Ovesen PG. Posterior reversible encephalopathy syndrome postpartum. Clinical Case Reports. 2015;3:266-270. DOI: 10.1002/ccr3.218
  9. 9.Richards CR, McMurray RC, Criman ET, Clark ME, Gillern S. An unusual presentation of a rare disease: Posterior reversible encephalopathy syndrome following abdominal sepsis. Journal of Surgical Case Reports. 2016;2016:rjw184. DOI: 10.1093/jscr/rjw184
  10. 10.Wagner SJ, Acquah LA, Lindell EP, Craici IM, Wingo MT, Rose CH, et al. Posterior reversible encephalopathy syndrome and eclampsia: Pressing the case for more aggressive blood pressure control. Mayo Clinic Proceedings. 2011;86:851-856. DOI: 10.4065/mcp.2011.0090
  11. 11.Neligan PJ, Laffey JG. Clinical review: Special populations—Critical illness and pregnancy. Critical Care. 2011;15:227. DOI: 10.1186/cc10256
  12. 12.Bo QY, Zhao XH, Yang X, Wang SJ. Reversible posterior encephalopathy syndrome associated with late onset postpartum eclampsia: A case report. Experimental and Therapeutic Medicine. 2016;12:1885-1888. DOI: 10.3892/etm.2016.3533
  13. 13.Fujiwara Y, Higaki H, Yamada T, Nakata Y, Kato S, Yamamoto H, et al. Two cases of reversible posterior leukoencephalopathy syndrome, one with and the other without pre-eclampsia. The Journal of Obstetrics and Gynaecology Research. 2005;31:520-526. DOI: 10.1111/j.1447-0756.2005.00345.x
  14. 14.Gewirtz AN, Gao V, Parauda SC, Robins MS. Posterior reversible encephalopathy yyndrome. Current Pain and Headache Reports. 2021;25:19. DOI: 10.1007/s11916-020-00932-1
  15. 15.Schwartz RB, Feske SK, Polak JF, et al. Preeclampsia-eclampsia: Clinical and neuroradiographic correlates and insight into the pathogenesis of hypertensive encephalopathy. Radiology. 2000;217:371-376. DOI: 10.1148/radiology.217.2.r00nv44371
  16. 16.Henderson RD, Rajah T, Nicol AJ, Read SJ. Posterior leukoencephalopathy following intrathecal chemotherapy with MRA-documented vasospam. Neurology. 2003;60:326-328. DOI: 10.1212/01.wnl.0000042095.49520.1e
  17. 17.Schwartz RB, Mulkern RV, Gudbjartsson H, Jolesz F. Diffusion-weighted MR imaging in hypertensive encephalopathy: Clues to pathogenesis. AJNR. American Journal of Neuroradiology. 1998;19:859-862
  18. 18.Trommer BL, Homer D, Mikhael MA. Cerebral vasospasm and eclampsia. Stroke. 1988;19:326-329. DOI: 10.1161/01.str.19.3.326
  19. 19.Parasher A, Jhamb R. Posterior reversible encephalopathy syndrome (PRES): Presentation, diagnosis and treatment. Postgraduate Medical Journal. 2020;96:623-628. DOI: 10.1136/postgradmedj-2020-137706
  20. 20.Sesar A, Cavar I, Sesar AP, Sesar I. Transient cortical blindness in posterior reversible encephalopathy syndrome after postpartum eclampsia. Taiwan Journal of Ophthalmology. 2018;8:111-114. DOI: 10.4103/tjo.tjo_5_18
  21. 21.Hugonneta E, Inesa DD, Boby H, Claise B, Petitcolin V, Lannareix V, et al. Posterior reversible encephalopathy syndrome (PRES): Features on CT and MR imaging. Diagnostic and Interventional Imaging. 2013;94:45-52. DOI: 10.1016/j.diii.2012.02.005
  22. 22.Roth C, Ferbert A. Posterior reversible encephalopathy syndrome: Long-term follow-up. Journal of Neurology, Neurosurgery, and Psychiatry. 2010;81:773-777. DOI: 10.1136/jnnp.2009.189647
  23. 23.Garg RK, Kumar N, Malhotra HS. Posterior reversible encephalopathy syndrome in eclampsia. Neurology India. 2018;66:1316-1323. DOI: 10.4103/0028-3886.241364
  24. 24.Singh K, Jain D, Wallang B. Purtscher’s retinopathy in pre-eclampsia: A blinding combination. International Ophthalmology. 2014;34:103-106. DOI: 10.1007/s10792-013-9739-1
  25. 25.Tung CF, Peng YC, Chen GH, Chow WK, Yang DY, Hu WH. Hemolysis, elevated liver enzymes, and low platelet count (HELLP) syndrome with acute cortical blindness. Zhonghua Yi Xue Za Zhi (Taipei). 2001;64:482-485
  26. 26.Mourelo M, Alvarez M, Díaz JL, García T, Galeiras R, Freire D. Postpartum amaurosis in a woman with severe preeclampsia. Indian Journal of Critical Care Medicine. 2011;15:227-229. DOI: 10.4103/0972-5229.92077
  27. 27.Abu SK. The eye and visual system in the preeclampsia/eclampsia syndrome: What to expect? Saudi Journal of Ophthalmology. 2013;27:51-53. DOI: 10.1016/j.sjopt.2012.04.003
  28. 28.Servillo G, Striano P, Striano S, Tortora F, Boccella P, De Robertis E, et al. Posterior reversible encephalopathy syndrome (PRES) in critically ill obstetric patients. Intensive Care Medicine. 2003;29:2323-2326. DOI: 10.1007/s00134-003-1901-1
  29. 29.Hauswald M. Cortical blindness and late postpartum eclampsia. The American Journal of Emergency Medicine. 1987;5:130-132. DOI: 10.1016/0735-6757(87)90091-x
  30. 30.Cunningham FG, Fernandez CO, Hernandez C. Blindness associated with preeclampsia and eclampsia. American Journal of Obstetrics and Gynecology. 1995;172:1291-1298. DOI: 10.1016/0002-9378(95)91495-1
  31. 31.Roos NM, Wiegman MJ, Jansonius NM, Zeeman GG. Visual disturbances in (pre)eclampsia. Obstetrical & Gynecological Survey. 2012;67:242-250. DOI: 10.1097/OGX.0b013e318250a457
  32. 32.Delefosse D, Samain E, Helias A, Regimbeau JM, Deval B, Farah E, et al. Late onset of cortical blindness in a patient with severe preeclampsia related to retained placental fragments. Anesthesiology. 2003;98:261-263. DOI: 10.1097/00000542-200301000-00038
  33. 33.Wilson SJ, Best RM, Love M, Kamel H. Cortical blindness following pre-eclampsia. Eye (London, England). 2000;14:254-256. DOI: 10.1038/eye.2000.70
  34. 34.Torres PJ, Antolin E, Gratacós E, Chamorro A, Cararach V. Cortical blindness in preeclampsia: Diagnostic evaluation by transcranial Doppler and magnetic resonance imaging techniques. Acta Obstetricia et Gynecologica Scandinavica. 1995;74:642-644. DOI: 10.3109/00016349509013479
  35. 35.Llovera I, Roit Z, Johnson A, Sherman L. Cortical blindness, a rare complication of pre-eclampsia. The Journal of Emergency Medicine. 2005;29:295-297. DOI: 10.1016/j.jemermed.2005.03.008
  36. 36.Borromeo CJ, Blike GT, Wiley CW, Hirsch JA. Cortical blindness in a preeclamptic patient after a cesarean delivery complicated by hypotension. Anesthesia and Analgesia. 2000;91:609-611. DOI: 10.1097/00000539-200009000-00021
  37. 37.Rasdi AR, Nik-Ahmad-Zuky NL, Bakiah S, Shatriah I. Hypertensive retinopathy and visual outcome in hypertensive disorders in pregnancy. The Medical Journal of Malaysia. 2011;66:42-47
  38. 38.Reddy SC, Nalliah S, George SRA, Who TS. Fundus changes in pregnancy induced hypertension. International Journal of Ophthalmology. 2012;5:694-697. DOI: 10.3980/j.issn.2222-3959.2012.06.08
  39. 39.Rodríguez NA, Zurutuza A. Manifestaciones oftalmológicas de la hipertensión arterial [ophthalmological manifestations of arterial hypertension]. Anales del Sistema Sanitario de Navarra. 2008;31:13-22
  40. 40.Prado RS, Figueiredo EL, Magalhães TVB. Retinal detachment in preeclampsia. Arquivos Brasileiros de Cardiologia. 2002;79:183-186. DOI: 10.1590/s0066-782x2002001100011
  41. 41.Sunness JS. The pregnant women’s eye. Surv Ophthalmol. Vol. 32; 1988. p. 219-238
  42. 42.Katsimpris JM, Theoulakis PE, Manolopoulou P, Brinkmann CK, Gatzogias MI, Petropoulos IK. Bilateral serous retinal detachment in a case of preeclampsia. Klinische Monatsblätter für Augenheilkunde. 2009;226:352-354. DOI: 10.1055/s-0028-1109252
  43. 43.Younis MT, McKibbin M, Wright A. Bilateral exudative retinal detachment causing blindness in severe pre-eclampsia. Journal of Obstetrics and Gynaecology. 2007;27:847-848. DOI: 10.1080/01443610701803891
  44. 44.Blodi BA, Johnson MW, Gass JD, Fine SL, Joffe LM. Purtscher's-like retinopathy after childbirth. Ophthalmology. 1990;97:1654-1659. DOI: 10.1016/s0161-6420(90)32365-5
  45. 45.Lara-Torre E, Lee MS, Wolf MA, Dinesh MS. Bilateral retinal occlusion progressing to long-lasting blindness in severe preeclampsia. Obstetrics and Gynecology. 2002;100:940-942. DOI: 10.1016/S0029-7844(02)02181-6
  46. 46.Stewart MW, Brazis PW, Guier CP, Thota SH, Wilson SD. Purtscher-like retinopathy in a patient with HELLP syndrome. American Journal of Ophthalmology. 2007;143:886-887. DOI: 10.1016/j.ajo.2006.12.005
  47. 47.Agrawal A, McKibbin MA. Purtscher's and Purtscher-like retinopathies: A review. Survey of Ophthalmology. 2006;51:129-136. DOI: 10.1016/j.survophthal.2005.12.003
  48. 48.Giridhar P, Freedman K. Nonarteritic anterior ischemic optic neuropathy in a 35-year-old postpartum woman with recent preeclampsia. JAMA Ophthalmology. 2013;131:542-544. DOI: 10.1001/jamaophthalmol.2013.2884
  49. 49.Beck RW, Gamel JW, Willcourt RJ, Berman G. Acute ischemic optic neuropathy in severe preeclampsia. American Journal of Ophthalmology. 1980;90:342-346. DOI: 10.1016/s0002-9394(14)74914-1
  50. 50.Ehlers JP, Fekret S. Retinal vein occlusion: Beyond the acute event. Survey of Ophthalmology. 2011;56:281-299. DOI: 0.1016/j.survophthal.2010.11.006
  51. 51.Rahman I, Saleemi G, Semple D, Stanga P. Pre-eclampsia resulting in central retinal vein occlusion. Eye (London, England). 2006;20:955-957. DOI: 10.1038/sj.eye.6702065
  52. 52.Kirfan G, Arunachalam M. Bilateral central retinal artery occlusion in pregnant women with severe preeclampsia post caesarian section delivery. American Journal of Respiratory and Critical Care Medicine. 2016;193:A6931
  53. 53.Shilpa YD, Kalpana BN, Sheetal. Bilateral central retinal artery occlusion in a case of eclampsia. Egypt Retina Journal. 2018;2:50-52. DOI: 10.4103/erj.erj_8_18
  54. 54.Capoor S, Goble RR, Wheatley T, Casswell AG. White-centered retinal hemorrhages as an early sign of preeclampsia. American Journal of Ophthalmology. 1995;119:804-806. DOI: 10.1016/s0002-9394(14)72793-x
  55. 55.Leff SR, Yarian DL, Masciulli L, Green SN, Baldomero RE. Vitreous haemorrhage as a complication of HELLP syndrome. The British Journal of Ophthalmology. 1990;74:498. DOI: 10.1136/bjo.74.8.498

Written By

Katarina Cvitkovic, Anita Pusic Sesar, Antonio Sesar and Ivan Cavar

Submitted: September 10th, 2021Reviewed: October 18th, 2021Published: November 14th, 2021