Little is known of the effect of ophthalmic medications on pregnancy, fetal well-being, and breast milk contamination.[8, 9, 10, 11] However, the National Registry of Drug-Induced Ocular Side Effects published a comprehensive review of their findings. Their findings and recommendations are summarized below.

Glaucoma medications

Beta-blockers (eg, timolol, levobunolol, betaxolol, carteolol) should be avoided or used in the lowest possible dose in the first trimester of pregnancy and be discontinued 2-3 days prior to delivery to avoid beta-blockade in the infant. Due to case reports of beta-blockers being concentrated in breast milk, they should be avoided in mothers who are breastfeeding.[12] However, timolol has been reported to be compatible with lactation according to the American Academy of Pediatrics.

Topical and systemic carbonic anhydrase inhibitors (eg, acetazolamide, dorzolamide, brinzolamide) are contraindicated during pregnancy because of potential teratogenic effects. They should be avoided in mothers who are breastfeeding because of the potential hepatic and renal effects to the infant. However, acetazolamide has been reported to be compatible with lactation according to the American Academy of Pediatrics.

Miotics (eg, pilocarpine, echothiophate, carbachol) appear to be safe during pregnancy. The toxicity during lactation is unknown. One exception is demecarium, which is toxic and is contraindicated in pregnancy and mothers who are breastfeeding.

Prostaglandin analogs (eg, latanoprost) are not well studied, and the reports that do exist are conflicting. Prostaglandins are used systemically for labor induction and termination, and as such, the topical use for glaucoma during pregnancy raises natural concern. Therefore, caution should be exercised when latanoprost is administered in women who are pregnant or breastfeeding.

In animal studies, adrenergic agonists (eg, brimonidine) have not demonstrated any fetal risk. Although no studies were conducted in pregnant patients, it may be used if necessary. Whether brimonidine is excreted in human milk is not known. Therefore, caution should be exercised since topical brimonidine given to human infants aged younger than 2 months has been reported to cause bradycardia, hypertension, hypothermia, and apnea.

Mydriatics

Use of occasional dilating drops during pregnancy for the purposes of ocular examination is safe. However, repeated use is contraindicated because of potential teratogenic effects of both parasympatholytics (eg, atropine) and sympathomimetics (eg, epinephrine). Due to either the anticholinergic or hypertensive effects on the fetus, use of mydriatics is contraindicated in mothers who are breastfeeding.

Corticosteroids

Although systemic corticosteroids are contraindicated in pregnancy, there are no known teratogenic effects of topical steroids. Because little is known about the risk of topical corticosteroids during lactation, it should be avoided in mothers who are breastfeeding.

Antibiotics

Antibiotics that are known to be safe during pregnancy include erythromycin, ophthalmic tobramycin, ophthalmic gentamicin, polymyxin B, and the quinolones. During lactation, polymyxin B and sulfonamides have been shown to be safe. Known antibiotics that should be avoided during pregnancy include the following:

•           Chloramphenicol         
•           Systemic gentamicin         
•           Neomycin         
•           Rifampin         
•           Tetracycline         
•           Systemic tobramycin         

Antivirals

All antivirals should be avoided during pregnancy because of teratogenic effects. Moreover, they should be avoided in mothers who are breastfeeding because of tumorigenicity. However, acyclovir has been reported to be compatible with lactation according to the American Academy of Pediatrics.

Fluorescein

No known teratogenic effects of fluorescein during pregnancy exist. However, the effect of fluorescein in mothers who are breastfeeding is unknown.

Topical anesthetic

No known contraindications exist to the use of topical anesthetic drops in pregnancy or in mothers who are breastfeeding.

Medication use

As described above, patients who are pregnant may require the use of medication to supplement their treatment. However, to ensure a decreased incidence of systemic absorption and toxicity two simple measures have been used. First, prescribing the patient the lowest recommended dose reduces the total amount of available drug. Secondly, patients are instructed when using topical medications to provide nasolacrimal duct and punctual occlusion thus reducing the amount of medication absorbed by the nasal mucosa.