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Mark Hughes, Francesca Aquilina, Mark Sigona, Spencer Ellis, SJÖGREN’S SYNDROME AND OTHER CONNECTIVE TISSUE DISORDERS
308. HYDROXYCHLOROQUINE-INDUCED RETINOPATHY: TIME TO OPEN OUR EYES TO SCREENING?, Rheumatology, Volume 56, Issue suppl_2, April 2017, kex062.310, https://doi.org/10.1093/rheumatology/kex062.310 - Share Icon Share
Background: A 43 year old woman with a background of systemic lupus erythematosus (SLE) and secondary Sjögren’s syndrome, developed an acute hydroxychloroquine (HCQ) retinopathy following treatment with HCQ 200mg BD for 9 years. This resulted in significant impairment of visual acuity. She had regular optician review while taking HCQ.
Methods: This case has led us to scrutinize the variability of routine referral for ophthalmology assessment in HCQ patients in our Trust, beyond baseline optician tests and recommendation for annual optician review. Hydroxychloroquine is known to cause retinopathy; initial changes are reversible, but not once visual impairment has occurred.
Results: The Royal College of Ophthalmologists (RCO) published guidance in 2009 that did not recommend routine ophthalmology screening, due to the rarity of retinopathy and lack of a reliable test, at the time, to detect it at a reversible stage. The incidence of HCQ-related retinal toxicity may be more common than previously thought, possibly exceeding 1% after 5–7 years of use. This rises towards 2% between 10 and 15 years of continuous usage. In addition, the emergence of more sensitive diagnostic techniques such as Fundus Auto Fluorescence (FAF) have suggested that retinal changes may be detected at an earlier stage, potentially avoiding late progression of retinal toxicity and visual loss. In light of these developments, the American Academy of Ophthalmology updated recommendations to include baseline examination before treatment and annual testing by an ophthalmologist after 5 years of therapy. Current evidence suggests that retinopathy is very unlikely to occur until the total cumulative dose is beyond 1000g (7 years of 400mg per day). Therefore dose reduction to 200mg daily, where possible, may reduce risk of retinopathy development.
Conclusion: We propose that in order to detect retinopathy at an early stage, prior to visual impairment, all patients treated with HCQ are referred to ophthalmology specialists for screening no later than 5 years after starting therapy. We suggest that the current RCO recommendations remain unchanged for the first 5 years of treatment, as baseline retinopathy testing, prior to initiation of HCQ, is unlikely to be logistically feasible. This might otherwise cause unacceptable treatment delay for patients with autoimmune rheumatic diseases, therefore a pragmatic balance must be struck. Furthermore, in order to reduce the chance of HCQ retinopathy, clinicians should aim to reduce dose in patients with well controlled rheumatic disease.
Disclosure statement: The authors have declared no conflicts of interest.
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