Hydroxychloroquine Retinopathy

Junyeop Lee; Joo Yong Lee

doi:10.4078/jrd.2015.22.3.140

Journal List > J Rheum Dis > v.22(3) > 1064182

Go to TopGo to Top Go to BottomGo to Bottom

TOOLS

Lee and Lee: Hydroxychloroquine Retinopathy

Review Article

J Rheum Dis 2015;22(3):140-145.

Published online: 31 October 2015

DOI: https://doi.org/10.4078/jrd.2015.22.3.140

Hydroxychloroquine Retinopathy

Junyeop Lee, Joo Yong Lee

Department of Ophthalmology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea

Corresponding to: Joo Yong Lee, Department of Ophthalmology, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul 138-736, Korea. E-mail: ophthalmo@amc.seoul.kr

Received 8 May 2015 Revised 20 May 2015 Accepted 20 May 2015

This is a Free Access article, which permits unrestricted non-commerical use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Hydroxychloroquine (HCQ) has been widely used for treatment of various rheumatic and dermatologic diseases. However, under a high cumulative dose, HCQ may cause retinal toxicity. In this review, we summarize the underlying mechanisms, prevalence, risk factors, clinical characteristics, screening tests, treatments, and prognosis of HCQ retinopathy. Because HCQ retinopathy is rarely reversible, screening tests to determine the retinal toxicity prior to its development are important. The American Academy of Ophthalmology screening protocols for early detection were updated in 2013. However, as a different clinical type is found in Asian patients, predominantly the pericentral type of photoreceptor damage, rather than the traditional parafoveal type, we propose a modified screening protocol for detection of HCQ retinopathy in Korean and other Asian patients.

Keywords: Hydroxychloroquine, Retina, Toxicity

REFERENCES

1. Tehrani R, Ostrowski RA, Hariman R, Jay WM. Ocular toxicity of hydroxychloroquine. Semin Ophthalmol. 2008; 23:201–9.

2. Fox RI. Mechanism of action of hydroxychloroquine as an antirheumatic drug. Semin Arthritis Rheum. 1993; 23(2 Suppl 1):82–91.

3. Shearer RV, Dubois EL. Ocular changes induced by long-term hydroxychloroquine (plaquenil) therapy. Am J Ophthalmol. 1967; 64:245–52.

4. Levy GD, Munz SJ, Paschal J, Cohen HB, Pince KJ, Peterson T. Incidence of hydroxychloroquine retinopathy in 1,207 patients in a large multicenter outpatient practice. Arthritis Rheum. 1997; 40:1482–6.

5. Mäntyjärvi M. Hydroxychloroquine treatment and the eye. Scand J Rheumatol. 1985; 14:171–4.

6. Lee DH, Melles RB, Joe SG, Lee JY, Kim JG, Lee CK, et al. Pericentral hydroxychloroquine retinopathy in Korean patients. Ophthalmology. 2015; 122:1252–6.

7. Melles RB, Marmor MF. Pericentral retinopathy and racial differences in hydroxychloroquine toxicity. Ophthalmology. 2015; 122:110–6.

8. Yam JC, Kwok AK. Ocular toxicity of hydroxychloroquine. Hong Kong Med J. 2006; 12:294–304.

9. Marmor MF, Carr RE, Easterbrook M, Farjo AA, Mieler WF. American Academy of Ophthalmology. Recommendations on screening for chloroquine and hydroxychloroquine retinopathy: a report by the American Academy of Ophthalmology. Ophthalmology. 2002; 109:1377–82.

10. Michaelides M, Stover NB, Francis PJ, Weleber RG. Retinal toxicity associated with hydroxychloroquine and chloroquine: risk factors, screening, and progression despite cessation of therapy. Arch Ophthalmol. 2011; 129:30–9.

11. Melles RB, Marmor MF. The risk of toxic retinopathy in patients on long-term hydroxychloroquine therapy. JAMA Ophthalmol. 2014; 132:1453–60.

12. Johnson MW, Vine AK. Hydroxychloroquine therapy in massive total doses without retinal toxicity. Am J Ophthalmol. 1987; 104:139–44.

13. Mavrikakis M, Papazoglou S, Sfikakis PP, Vaiopoulos G, Rougas K. Retinal toxicity in long term hydroxychloroquine treatment. Ann Rheum Dis. 1996; 55:187–9.

14. Falcone PM, Paolini L, Lou PL. Hydroxychloroquine toxicity despite normal dose therapy. Ann Ophthalmol. 1993; 25:385–8.

15. Shroyer NF, Lewis RA, Lupski JR. Analysis of the ABCR (ABCA4) gene in 4-aminoquinoline retinopathy: is retinal toxicity by chloroquine and hydroxychloroquine related to Stargardt disease? Am J Ophthalmol. 2001; 131:761–6.

16. Marmor MF. Efficient and effective screening for hydroxychloroquine toxicity. Am J Ophthalmol. 2013; 155:413–4.

17. Wei LC, Chen SN, Ho CL, Kuo YH, Ho JD. Progression of hydroxychloroquine retinopathy after discontinuation of therapy: case report. Chang Gung Med J. 2001; 24:329–34.

18. Brinkley JR Jr, Dubois EL, Ryan SJ. Long-term course of chloroquine retinopathy after cessation of medication. Am J Ophthalmol. 1979; 88:1–11.

19. Easterbrook M. The ocular safety of hydroxychloroquine. Semin Arthritis Rheum. 1993; 23(2 Suppl 1):62–7.

20. Bienfang D, Coblyn JS, Liang MH, Corzillius M. Hydroxychloroquine retinopathy despite regular ophthalmologic evaluation: a consecutive series. J Rheumatol. 2000; 27:2703–6.

Figure 1.

Comparisons of parafoveal type and pericentral type of hydroxychloroquine retinopathy. (A) Fundus autofluorescence images of normal (left), parafoveal type (middle), and pericentral type (right) hydroxychloroquine retinopathy. Hyperfluorescent area indicating the damage of retinal pigment epithelium was highlighted as dot line. (B) Spectral-domain optical coherence tomography images of normal (left), parafoveal type (middle), and pericentral type (right) hydroxychloroquine retinopathy. (C) 30-2 visual field tests of normal (left), parafoveal type (middle), and pericentral type (right) hydroxychloroquine retinopathy.

Figure 2.

Parafoveal type hydroxychloroquine retinopathy. (A) Fundus photography of typical bull's eye maculopathy. (B) Fundus autofluorescence image showing parafoveal hypera-utofluorescence. (C) Spectral-domain optical coherence tomography images presenting parafoveal damages of photo-receptors and retinal pigment epithelium (arrows). (D) Central scotoma at 30-2 visual field test and ring scotoma in 10-2 visual field tests.

Figure 3.

Pericentral type hydroxychloroquine retinopathy. (A) Fundus photography of in-visible typical bull's eye mac-ulopathy. (B) Fundus autofluorescence image showing large hyperautofluorescent area involving optic disc at pericentral retina. (C) Pericentral scotoma at 30-2 visual field test, but normal 10-2 visual field test. (D) Spectral-domain optical coherence tomography images presenting pericentral damages of photoreceptors and retinal pigment epithelium (arrows).

TOOLS

Similar articles