Abstract

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Sudden and complete loss of vision in patients with severe pre eclampsia and eclampsia is a rare occurrence. It is usually due to involvement of the occipital cortex or the retina. Though distressing and alarming it is generally reversible with complete recovery of blindness in one week. We report a rare case of patient with severe preeclampsia who underwent caesarean section, had complete loss of vision in the post-operative period. Vision started improving within 24 hours and completely recovered in one week.

Introduction

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In developing countries like India where routine antenatal check-up is beyond the reach of the majority , severe pre-eclampsia and eclampsia still remains one of the leading cause of maternal and perinatal morbidity and mortality.Patient may present with headache, epigastric pain, pedal oedema and visual disturbances. The common visual disturbances include scotoma, sudden inability to focus, blurred vision and in severe cases blindness. It has been estimated that around 25% of women with severe pre eclampsia complain of visual disturbances however the development of complete blindness is rare and seen in only 1%-3% of cases (1). Earlier the cause of blindness was attributed to retinal pathology like vascular abnormalities, oedema or detachment but these days more emphasis is being laid on cortical blindness due to the numerous case reports of cortical blindness in patients with severe pre eclampsia and eclampsia (2). We report a rare case of a patient with severe preeclampsia who underwent caesarean section and developed reversible cortical blindness in the post-operative period.

Case Report(s)

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A 22 years old primigravida presented to us at the gestational age of 38 weeks with the complaints of severe headache. She was an unbooked case with no antenatal check-up. On examination pedal oedema was present and BP was 180/120 mm of Hg. Per abdomen uterus was term size, cephalic presentation with good foetal heart rate. Urine examination revealed proteinuria 3+. Haemoglobin, liver function tests, renal function tests, platelet count, PTI were within normal limits. On per vaginum examination os was closed, uneffaced, posterior and bilateral ischial spines were prominent. BP was controlled with nifedepine and in view of poor Bishops score, severe pre eclampsia and borderline pelvis she was taken up for caesarean section and gave birth to a healthy baby weighing 3 kg with APGAR score of 8 and 9 at 1 and 5 minutes respectively. Post-operative her BP was 130/86 mm of Hg. Apart from fluid restriction no antihypertensives were administered. Eight hours after caesarean section she complained of sudden, painless loss of vision both eyes with perception of light present and projection of rays inaccurate. Anterior segment showed no abnormal finding. Fundus showed evidence of hypertensive retinopathy with decreased arteriolar:venous ratio and areas of focal arteriolar spasm. Both pupils were reactive to light. Computed tomography scan was advised, which showed hypodense lesions predominantly in the occipital lobe. Diagnosis of cortical blindness was made that lasted for 24 hours and slowly improved with complete recovery of vision in 7 days. She was discharged on the 10 th post-operative day with BP of 124/82 mm of Hg and 6/6 vision.

Discussion

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Development of sudden and complete loss of vision in patients with severe pre eclampsia and eclampsia is a rare occurrence. It is usually due to involvement of the occipital cortex or the retina. The common retinal pathologies attributed to the development of blindness include retinal detachment, retinal oedema and vascular abnormalities .Cortical blindness is a clinical syndrome characterized by intact pupillary reflexes and normal fundoscopic findings (3). The loss of vision is usually regained within 1 week (4). Jyotsna et al reported 2 similar cases of cortical blindness associated with severe pre eclampsia and eclampsia with complete recovery of vision and resolution of hypodensities on CT within 2 weeks (5). The management of patients with severe pre eclampsia or eclampsia is same whether it is complicated by blindness or not and includes effective control of BP and delivery. Complete recovery of vision occurs in almost all cases.

References

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1. Dieckman WJ. The toxemias of pregnancy. 2 nd ed. St Louis: CV Mosby; 1952. p. 240-9.
2. Swende TZ, Abwa T. Reversible blindness in fulminating preeclampsia. Ann Afr Med. 2009 Jul-Sep;8(3):189-91.
3. 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. Chin Med J (Taipei) 2001;64:482-5.
4. Cunningham FG, Fernandez CO, Hernandez C. Blindness associated with preeclampsia and eclampsia. Am J Obstet Gynecol 1995;172:1291-8.
5. Jyotsana, Sharma AK, Bhatt S. Reversible blindness in severe preeclampsia and eclampsia. JK Science 2004;6:43-5.

Source(s) of Funding

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Nil

Competing Interests

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Nil

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