Reversible Blindness in Severe Preeclampsia and Eclampsia

JK SCIENCE
CASE REPORT
Reversible Blindness in Severe
Preeclampsia and Eclampsia
Jyotsana, Ashok K Sharma*, Sunil Bhatt**
Abstract
Visual disturbances are common with severe preeclampsia, however, blindness either alone or
accompanying convulsions is uncommon. Most women with varying degree of amaurosis are found
to have radiographic evidence of extensive occipital lobe hypodensities.In this case report, we present
the clinical course of two women in whom preeclampsia was further complicated by blindness.
These were managed by standard pre eclampsia- eclampsia regimen used at our hospital which
includes Diazepam /Phenytoin therapy to control seizures, nifedipine to lower elevated blood pressure,
intravenous fluid restriction and termination of pregnancy. Abnormal findings in these women were
seen by computed tomography and magnetic resonance imaging technique. CT demonstrated low
density areas localized predominantly in occipital area. Blindness persisted from 24 hrs to 72 hrs, it
subsequently resolved completely in both.
Key words
Eclampsia, Preeclampsia, Blindness, Computed tomography, Magnetic resonance imaging.
Introduction
Severe preeclampsia and eclampsia remains one
emphasized cortical blindness which is characterized by
of the leading causes of maternal and perinatal mortality
intact pupillary light reflexes and normal ophthalmoscopic
and morbidity in many parts of the world. Patients may
findings.
present with symptoms of headache and visual
Here we report the clinical course in two women
disturbances in the form of scotoma, sudden inability to
in whom preeclampsia-eclampsia was further
focus, blurred vision and in severe cases to complete
complicated by blindness. Abnormal findings in these
blindness. Although visual disturbances develop in perhaps
women were seen by computed tomography and
25% of women with severe pre eclampsia, blindness is
magnetic resonance imaging techniques. None of the
rare and an incidence of 1-3% is reported with eclampsia
patients had the diagnosis of seizure disorder, migraine
(1). In past most cases of blindness were attributed to
headaches or collagen vascular disease.
retinal abnormalities that include edema, vascular changes
Case Reports
and detachment. Retinal detachment may cause altered
Case 1— 20 yr old primigravida presented with
vision although it is usually one sided and seldom causes
headache, hypertension (160/100 mm of Hg) and
total visual loss (2). More recently case reports have
generalized edema in the 38th week of pregnancy. Urine
From the Deptt. of Gynaecology, GB Pant Hospital and Ophthalmology* and Radiology** Govt. Madical College, Jammu.
Correspondence to : Dr. Jyotsana, Gynaecologist, 161/4, Trikuta Nagar, Jammu.
Vol. 6 No. 1, January-March 2004
4 3

---

JK SCIENCE
examination showed proteinuria 3+. Her serum creatinine
acuity returned to normal showed complete resolution.
was 1.2 mg/dl. Serum aspartate aminotransferase was
Patient was normotensive 2 months postpartum. None
96u /lt. She was treated with nifedipine to control her BP
of the patients had thrombocytopenia.
and intravenous fluid administration was restricted to 60
ml /hr. Since she had good bishops score so labour was
induced and augmented with oxytocin infusion. Soon after
vaginal delivery she noted severe impairment of vision in
both eyes. She was examined by an ophthalmologist and
neurologist. Computed tomography scan was advised
which showed low density area localized predominantly
in the occipital lobe. Cortical blindness lasted for 24 hrs
and was followed by complete recovery of vision by 7
days. Patient was normotensive postpartum.
Case 2— 23 yr old, para1 presented with post
partum eclampsia. Her BP at the time of admission was
170/90 mm of Hg. Urine examination showed proteinuria
4+. Her serum creatinine was 0.8 mg/dl. Serum aspartate
aminotransferase was 93u /lt. Computed tomography
showed low density lesions in occipitoparietal area.
Fig. 1. CT Scan head shows resolution of the ischemic changes
(Fig.1). Repeat CT scans after one week showed partial
after two weeks.
resolution at one week. (Fig. 2) Follow up neurological
Discussion
studies 2 weeks later by which time the patient’s visual
The neuropathologic mechanism for eclampsia is
unclear except when overt hemorrhage is identified, Some
factors that have been implicated including cerebral
vasospasm, hemorrhage, ischemia, edema as well as
hypertensive and metabolic encephalopathy .Recently
Schwart et al proposed that the findings of preeclampsia-
eclampsia can be explained by the loss of autoregulation
of the posterior cerebral circulation (3). Aside from
convulsions other dramatic neurologic effects, albeit
uncommon, include blindness, an altered state of
consciousness and coma. In the past most cases of
blindness were attributed to retinal abnormalities that
include edema, vascular changes and detachment. More
recently case reports have emphasized cortical blindness,
which is characterized by intact pupillary response and
normal ophthalmoscopic findings.
In 1980, Grimes et al reported the first case in which
Fig. 1. CT Scan head shows hypodense lesion in rt. occipital
lobe suggestive of ischemic changes.
computed tomographic scanning was used to demonstrate
4 4
Vol. 6 No. 1, January-March 2004

---

JK SCIENCE
reversible cortical lesion in a women with preeclampsia
hypertension, and fluid restriction to avoid worsening of
and temporary blindness (4, 5). Others have reported
cerebral edema. Ophthalmologic and neurologic
low density areas predominantly in the occipital lobes of
consultation along with neuroimaging is undertaken;
women with blindness associated with severe
however, delivery should not be delayed unnecessarily.
preeclampsia or eclampsia. Radiologic findings have
On the basis of previously published experiences with
ranged from normal to documentation of wide spread
computed tomography in women with eclampsia, as well
low density areas. The latter are nonenhancing and have
as the experience described here, we conclude that
been attributed to localized areas of decreased perfusion
reversible cortical blindness associated with preeclampsia-
associated with arterial spasm, infarction or cerebral
eclampsia may result from petechial hemorrhages and
edema (6). Computed Tomography in both of our cases
focal edema in the cerebral cortex.
with cortical blindness, showed similar occipital lobe
References
hypodensities. Various authors have reported partial
1.
Dieckman WJ. The toxemias of pregnancy. 2nd ed St Louis:
resolution of these radiologic hypodensities by 3 to 5 days
CV Mosby, 1952:240-49.
with complete resolution within 14 days (7, 8). We
2.
Ohio et al. Hypertensive disorders in pregnancy. In:
observed a similar time course for their resolution and
Cunnighm FG (ed). Williams Obstetrics. 21st ed. McGraw
Hill, New York 2001; 581-82.
observed that clinical recovery precedes normalization
3.
Schwartz RB, James KM, Kalina P, et al. Hypertensive
of CT findings.
encephalopathy: Findings on CT, MR imaging and SPECT
There is other evidence that these lesions are
Imaging in 14 cases. Am J Roentgenol 1992; 159:379-83.
induced by vascular changes. Using doppler velocimetry,
4.
Grimes DA, Ekbladh LE, McCartney WH. Cortical blindness
Williams and Mclean showed that cerebral blood flow
in preeclampsia. Int J Gynaecol Obstet 1980; 17: 601-03
velocity is increased in pregnancy-induced hypertension,
5.
Liebowitz HA, Hall PE. Cortical blindness as a complication
of eclampsia. Ann Emey Med 1984; 13: 365-67
suggesting an increased resistance to flow. Velocity
6.
Apollan KM, Robinson JN, Scwartz RB, Norwitz EP.
increased even more in the immediate puerperium (9).
Cortical blindness in severe preeclampsia: Computed
Thus the nature and duration of these reversible focal
tomography, Magnetic Resonance imaging, single-photon-
neurological lesions and transient cortical blindness are in
emission Computed Tomography findings. Obstet Gynaecol
concert with the characteristic reversible
2000; 95 : 1017-19.
pathophysiologic changes of preeclampsia-
7.
Cunningham FG, Twickler D. Cerebral edema complicating
eclampsia. Am J Obstet Gynaecol 2000; 182 : 94-100.
eclampsia (10).
8.
Cunningham FG, Carlos Fernendez CO, Hernandez C.
The management guidelines are straightforward for
Blindness associated with preeclampsia and eclampsia. Am
women with severe preeclampsia or eclampsia in whom
J Obstet Gynaecol 1995; 172: 1291-98.
cortical blindness develops. Generally they are the same
9.
Williams KP, Mc Lean C. Peripartum changes in maternal
cerebral blood flow velocity in normotensive and
as for women without this sequeale and include
preeclamptic patients. Obstet Gynecol. 1993; 82:334-37.
anticonvulsants, (Magnesium Sulfate, Phenytoin and
10.
Moodley J, Pillay M, Pillay R. Temporary blindness &
Diazepam) for seizure prophylaxis, control of severe
eclampsia : a report of 2 cases S.Afr Med J 1985; 68: 677-8.
Vol. 6 No. 1, January-March 2004
4 5

---