Journal List > J Rheum Dis > v.25(3) > 1099058

Ahn and Lee: Hydroxychloroquine Retinopathy Update

Abstract

Hydroxychloroquine (HCQ) has been used widely for the treatment of several rheumatologic and dermatologic conditions, including systemic lupus erythematosus and rheumatoid arthritis. Its toxic effects on the retina, HCQ retinopathy, is not uncommon among long-term users, and produces characteristic irreversible and progressive outer retinal damage. Recent studies of Asian populations showed different patterns of retinopathy according to ethnicity; for example, a pericentral pattern is more common in Asian populations, whereas the parafoveal type is more prevalent in Caucasian patients. The pericentral pattern, which is common in Asian patients, is likely to lead to a late diagnosis with conventional imaging modalities, thereby necessitating increased attention to the screening of Asian patients. The most recent American Academy of Ophthalmology guidelines suggest optical coherence tomography and a visual field examination as the primary screening tests, and multifocal electroretinogram and fundus autofluorescence as other recommended objective screening tests. The optimal timing and frequency of annual screening depend on the systemic and ocular risk factors. Annual screening should begin from 5 years of drug use in cases without any known risk factors, but patients with major risk factors require earlier regular screening. After a diagnosis of HCQ retinopathy, a decision regarding whether to stop the drug should be made in consultation with the prescribing physician, and the progression of retinopathy should be monitored carefully because the retinopathy can progress even after drug cessation.

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Figure 1.
Fundus photograph (Fd), optical coherence tomography (OCT), fundus autofluorescence (FAF), and visual field (VF) examination of the right eye in a 54-year-old female systemic lupus erythematosus patient with hydroxychloroquine retinopathy. Retinal pig-mentary changes observable in the fundus photograph corre-spond to outer retinal damage visible on the OCT image, hy-po-autofluorescence on FAF, and complete visual field loss in visual field examination. The visual acuities in both eyes were “hand motion.”
jrd-25-153f1.tif
Table 1.
Screening for hydroxychloroquine retinopathy recommended for Asian patients with hydroxychloroquine use
Recommended tests Protocols
Automated visual field examination 30-2 (for pericentral pattern) and/or 10-2 (parafoveal pattern)
Spectral-domain OCT Wide-field (at least 9-mm [30 o] scan length) OCT Macular volume scan may be useful to obtain eccentric scan images of the posterior pole
Multifocal electroretinogram No protocols specified for Asian patients
FAF Wide-field FAF (30 o or greater)

OCT: optical coherence tomography, FAF: fundus autofluorescence.

Table 2.
Diagnostic ability, sensitivity, and specificity of the recommended screening tests for hydroxychloroquine retinopathy [18]
Examinations Sensitivity Specificity
10-2 VF examination 85.7 92.5
Spectral-domain OCT 78.6 98.1
Multifocal electroretinogram 92.9 86.9
Spectral-domain OCT and 10-2 VF examination 85.7 92.5

Values are presented as percentage. VF: visual field, OCT: optical coherence tomography. Data from the article of Browning DJ (Hydroxychloroquine and chloroquine retinopathy.

New York, Springer, 2014, p. 219) [18].

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