Puberty to Postmenopause: Managing the Ocular Needs
of Your Female Patients
A. Gender Differences
1. Rarely evaluated
2. Clinical research often “sex neutral”
3. Studies often have small samples
4. Is it a real issue?
B. The Female Eye
1. 0.4 – 0.8 mm shorter
 mostly due to vitreous chamber depth
 also anterior chamber differences
2. Cornea is slightly narrower and steeper
3. Women have poorer visual acuity
4. Female lens is slightly thicker
 male lens is heavier
5. Women are more prone to develop cataracts
 excess risk is 10-20%
 higher frequency of cortical cataracts
 2:1 ratio for cataract surgery
 poorer outcomes
6. Posterior ciliary artery
 decreased end-diastolic velocity
7. More age-related maculopathy
 If >75 YO, women 2X as likely to be legally blind (Framingham Eye
Study)
8. Demonstrate stereopsis sooner
9. Motor skill differences
 Finger Tap vs Grooved Peg Board
10. Eye movements - longer gaze, shorter excursion
11. More likely to be undercorrected post-LASIK
12. Goblet cell density is lower in females
 impression cytology
 changes are a sensitive marker for ocular surface disease
13. Also More Common in Females...
• Macular Holes
Graves Disease
• Myasthenia Gravis
Rheumatoid Arthritis
• Systemic Lupus Erythematosus
• Sjogren Syndrome
Rosacea
C. Mental Health Issues
D. Eating Disorders
1. all socioeconomic classes
2. higher risk in certain sports
3. 3rd most common chronic illness in teenage girls
4. “the relentless pursuit of thinness”
5. less than 85% of expected weight
6. amenorrhea of at least 3 cycles
7. intense fear of gaining weight
8. distorted body self-image
9. absence of other physical disorders
10. Eating Disorders
• Anorexia Nervosa
 Bulimia Nervosa (4% college females)
– diet-binge-purge
– 30% of anorexia nervosa
• Anorexia Athletica
• Body Dysmorphic Disorder
11. Ocular Complications
• Episcleral capillary aneurysms
• Subconjunctival hemorrhages
• Night photosensitivity
• SPK
• Decreased tear production
– 11.3 mm vs 22.4 mm
• Decrease in goblet cell density
• Conjunctival squamous metaplasia
• Dry skin
• Subcapsular cataracts
• Nonischemic CRVO
– may be secondary to anemia
• IOP effect?
– one study showed 3 mm difference
E. The Menstrual Cycle
1. Need to understand the normal hormonal fluctuations and associated physical
changes
2. Hormones involved…
3. Ocular Symptoms
• Contact lens discomfort/intolerance
• Dry eye
• Blurred vision
• Intermittent complaints
• Increased corneal thickness
• Decreased corneal sensitivity
• Refractive Error Change?
2
•
•
•
•
Lid edema and chemosis
Increase lipid production
Blood may appear in tears
Herpes simplex
•
Cyclic macular edema
• Premenstrual Tension Syndrome
• Conjunctiva
– cyclic cytologic maturational changes
– at its best when hyperestrogen
– Goblet cell count is depressed most during ovulation
4. Oral Birth Control – Side Effects
• Expect ocular effects similar to those when estrogen and/or
progesterone are high
• Blink rate has been studied
– Females
• OC 19.6 blinks/min
• No OC 14.9 blinks/min
– Males 14.5 blinks/min
– OC may reset blink clock rate??
• Dry Eye
– decreased lacrimal output
• Decreased CL tolerance
• Change in color perception (B/Y)
• Occlusive disease
– CRAO
– CRVO
• Papilledema
– Idiopathic Intracranial Hypertension
F. Pregnancy
1. Ocular Effects
• Decreased corneal sensitivity
– 50-86%
– recovers 6-8 wks postpartum
• Increased corneal thickness
• Increased corneal curvature
• Refractive Changes
• Transient loss of accommodation
• Increase lysozyme secretion
– CLs become “greasy”
• Ptosis
3
•
•
•
•
Bell’s Palsy
Melasma / Chloasma
– “The mask of pregnancy”
Spider Angioma
– at least 2/3
Papillomas
• Skin malignant melanomas
– few cases of Choroidal MM
• Krukenberg spindles
• Decreased IOP
– late in pregnancy
– mediated by progesterone
2. Pregnancy and Diabetes
3. Potential Ocular Complications
• Central Serous Chorioretinopathy
• Stroke
• Papilledema
• Papillophlebitis
• Visual Field changes
4. Pregnancy Induced Hypertension
• PIH – hypertension in a previously normotensive female
• Up to 5%
•
•
Toxemia
– preeclampsia
– eclampsia
May originate in placenta (underperfusion)
G. Menopause
1. occurs around age 50
2. estrogen and progesterone decrease
3. Ocular symptoms
– at least 35%
– dryness, tearing
– decreased vision
– red / swollen lids
– FB sensation
– visual coordination complaints
4. HRT = Hormone Replacement Therapy
• Protective to crystalline lens
• May relieve dry eye symptoms
4