Retinal imaging in pre-eclamptic pregnancy: systematic review.

objectiveTo explore potential changes in retinal structures in pregnant women with pre-eclampsia (PE).

methodsThis was a systematic review of the literature on retinal assessment in pregnancies complicated by PE. PubMed, EMBASE via Ovid, The Cochrane Library and Scopus databases were searched in July 2025 using an a-priori-designed protocol for studies examining the retina of pregnant women with an established diagnosis of PE or those who developed PE following retinal assessment. Randomized controlled trials and prospective and retrospective cohort, case-control and population-based studies were eligible. Risk of bias was assessed using the Risk Of Bias In Non-randomized Studies of Interventions version 2 (ROBINS-I V2) tool. Due to substantial heterogeneity observed between studies in the methods of retinal assessment, retinal parameters studied and gestational age at retinal examination, a meta-analysis was not performed.

resultsThe electronic database search yielded 1544 results, of which 75 were eligible for full-text review and 24 studies were included in the systematic review. The methods of retinal assessment utilized in the included studies were optical coherence tomography (OCT), optical coherence tomography angiography (OCTA), retinal fundus photography and central retinal artery Doppler. Each method examined a variety of retinal parameters. Studies using OCT reported that the choroidal thickness was decreased, increased or not significantly different in women with PE vs non-PE controls. With regard to retinal thickness, retinal nerve fiber layer thickness, macular thickness, ganglion cell layer thickness, choroidal vessel density and total retinal volume, most studies reported similar values in PE and non-PE groups. For OCTA parameters, including foveal avascular zone area, vessel density in the deep and superficial capillary plexuses and choriocapillaris blood flow, some studies reported reduced values in the PE group, while others reported no significant differences between groups. Retinal fundus photography was performed in two studies; one reported reduced arteriolar and venular equivalents in women with PE, and the other reported reduced arteriole-to-vein ratio in women with severe PE vs without PE. One study used Doppler to assess the central retinal artery and reported a higher resistance index in those with PE compared to non-PE controls. According to the ROBINS-I V2 tool, the risk of bias was moderate in eight studies and serious in 16 studies.

conclusionsFindings on the changes in retinal structure and function in pregnancies complicated by PE are inconclusive. The degree of change, and whether the changes precede the clinical onset of PE or are a result of hypertension and associated cardiovascular sequalae, is uncertain. There is an unmet need for large-scale prospective studies to address this uncertainty. © 2026 The Author(s). Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.