Ocular Surface, Tear Film, and Corneal Biomechanics in Pregnancy: A Systematic Review of Hormonal–immunological Modulation with a Translational Case Perspective
Aloysius Suryawan, Wiku Andonotopo, Ridwan Abdullah Putra, Theresia Monica Rahardjo, Rizna Tyrani Rumanti, Roland Frederik Lengkey, Julia Windi Gunadi, Arief Setiawan, Muhammad Adrianes Bachnas, Mochammad Besari Adi Pramono, Julian Dewantiningrum, I. Nyoman Hariyasa Sanjaya, Dudy Aldiansyah, Waskita Ekamaheswara Kasumba AndanaputraAbstract
Pregnancy introduces a complex physiological state in which endocrine, immunological, and metabolic shifts occur simultaneously, yet their implications for the anterior segment of the eye remain only partially understood. While retinal and neuro-ophthalmic changes have been more extensively discussed in prior literature, the ocular surface and corneal microenvironment often receive less focused attention, despite their clear clinical relevance. This systematic review was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-analyses 2020 guidelines to synthesize available evidence on how pregnancy-related biological changes influence tear film stability, ocular surface homeostasis, and corneal structure and biomechanics. A comprehensive search across major databases identified 675 records, of which 32 studies met predefined eligibility criteria after systematic screening. The included literature suggests that pregnancy is associated with a consistent pattern of tear film instability, altered meibomian gland function, and increased ocular surface vulnerability, often manifesting clinically as dry eye symptoms or visual fluctuation. At the corneal level, increases in central corneal thickness and subtle changes in curvature appear relatively common, whereas biomechanical alterations – although less frequently measured – raise important questions regarding transient corneal weakening and susceptibility to ectatic progression, particularly in predisposed individuals. What becomes evident, though perhaps not immediately intuitive, is that these changes are unlikely to be isolated phenomena. Instead, they reflect a converging axis of hormonal signaling, immune modulation, and extracellular matrix remodeling. The clinical implications are therefore not trivial. Recognizing these dynamics may improve diagnostic interpretation, reduce unnecessary interventions, and guide safer longitudinal care. Further prospective, mechanistically oriented studies are needed to clarify reversibility and long-term impact.