For glaucoma specialists, pregnancy introduces a distinct set of constraints that can complicate even routine treatment decisions. When intraocular pressure (IOP) cannot be controlled with medications or laser therapy, the question of surgery becomes unavoidable. However, there are no established guidelines for these cases; most evidence guiding care for a pregnant woman with glaucoma is derived from animal studies, case reports, or small case series. Sunita Radhakrishnan, MD, a surgeon at the Glaucoma Center of San Francisco, addressed the issue in a presentation at the American Glaucoma Society’s 2026 annual meeting in Palm Springs, California.

Across all indications, nonobstetric surgery has been reported in up to 2% of pregnancies, most often for urgent conditions such as appendicitis or cholecystitis. Maternal outcomes are generally comparable to those in nonpregnant patients, and commonly used anesthetic agents have no reported teratogenic effects at clinical doses. However, risks to the fetus remain a concern (Table 1). “It is unclear whether these risks are due to the surgery, the underlying condition necessitating surgery, or both,” Dr. Radhakrishnan said. As a result, the American College of Obstetricians and Gynecologists and the American Society of Anesthesiologists advise postponing elective procedures until after delivery, while acknowledging that medically necessary surgery should not be delayed.

Compared with other nonobstetric procedures, ophthalmic surgery does offer some advantages: shorter operative times, the ability to perform surgery with local anesthesia, and limited postoperative pain. Even so, given the potential risks, Dr. Radhakrishnan cautioned against surgical intervention, if possible.

Planning prior to pregnancy plays a central role, with counseling on the risk of IOP elevation and disease progression, and consideration of selective laser trabeculoplasty (SLT) before conception as a medication-sparing strategy. During pregnancy, if IOP increases, medical therapy can be escalated in consultation with the obstetrician and SLT may be used as adjunct therapy.

When incisional surgery becomes unavoidable, several factors guide decision-making. Timing is a primary consideration. When possible, the second trimester is generally preferred because the risks of spontaneous abortion and preterm labor are lower. Procedure selection is less clearly defined. There is no single preferred operation and the traditional glaucoma surgeries such as trabeculectomy, aqueous drainage devices, and cyclophotocoagulation have all been reported during pregnancy. With regard to trabeculectomy, there is a higher risk of postoperative fibrosis given the relatively young age of these patients and the fact that antimetabolites are contraindicated. In general, said Dr. Radhakrishnan, MIGS procedures may be preferable to tubes or trabs, given the shorter surgical time, faster recovery, and favorable safety profile. However, there is no published data on MIGS during pregnancy.

Perioperative management requires additional modifications. Local anesthesia is feasible and preferred during pregnancy and can be achieved with a combination of topical, subconjunctival, or sub-Tenon approaches. Lidocaine, a pregnancy category B agent, is most commonly used, while bupivacaine is avoided because of its association with fetal bradycardia. Sedation is usually minimized; general anesthesia is not contraindicated but is generally avoided when possible, said Dr. Radhakrishnan. For a patient who is later in pregnancy, positioning must also be adjusted to avoid aortocaval compression, typically by tilting the patient’s abdomen to the left. Obstetric teams guide decisions regarding intraoperative fetal monitoring and delivery planning, particularly when surgery occurs later in pregnancy.

Postoperative care generally mirrors standard practice, with some additional considerations. Topical steroids and antibiotics are commonly used despite category C classifications, based on clinical experience suggesting minimal systemic risk.

A case presented at AGS by Dr. Radhakrishnan illustrates these principles. A young patient with progressive glaucoma and uncontrolled IOP underwent trabeculectomy without an antimetabolite during early pregnancy, using local anesthesia and no intravenous sedation. Her postoperative course was uneventful, and IOP remained controlled throughout pregnancy. She delivered a healthy infant at term.

For most patients, however, surgery remains a last resort. “Surgery is not considered the safest first option during pregnancy and should be avoided when possible,” Dr. Radhakrishnan concluded. “However, when necessary, it can be performed with appropriate modifications and multidisciplinary coordination involving obstetrics, anesthesia, and, when needed, neonatology.” GP