The hallmark of hydroxychloroquine toxicity is bilateral pigmentary retinopathy . The finding of corneal verticillata bares no correlation with retinal toxicity and is not an indication to stop the medication . This condition does not cause symptoms and is reversible with cessation of the medication. Verticillata are cornea deposits of salts within the corneal epithelium. Ocular manifestations of hydroxychloroquine include corneal verticillata and retinal toxicity. Unfortunately, the retinal damage from these medications is largely irreversible, so it is critical to detect early retinal toxicity in the hopes of limiting the extent of visual loss. Hydroxychloroquine has significantly less retinal toxicity and has largely replaced chloroquine as a treatment of inflammatory disease. Chloroquine-induced retinal toxicity was first described in 1959 and the retinal toxic effects of hydroxychloroquine were later described in 1967 . It is now considered for new disease applications in diabetes, heart disease and adjunct cancer therapies .Ĭhloroquine and hydroxychloroquine both belong to the quinolone family and share similar clinical indications and side effects, including retinal toxicity. Color schematic of the data demonstrates blunted peak in the right (C) and left (D) eyes.ĭiagnosis: Hydroxychloroquine-induced retinal toxicity DiscussionĬhloroquine (CQ) and hydroxychloroquine (Plaquenil) (HCQ) have been used for many years, initially for the treatment of malaria but now more commonly for the treatment of inflammatory diseases such as rheumatoid arthritis and lupus . The raw data from both the right (A) and left (B) eyes demonstrate decreased signal centrally and paracentrally. Near-infrared autofluorescence imaging shows increased signal at the fovea OU (C and D).įigure 5: Multifocal electroretinogram. Fluorescein angiography shows parafoveal hyperfluorescence OU (C and D).įigure 2: 10-2 Humphrey visual fields demonstrate dense paracentral scotomas with decreased foveal sensitivity in both the left (A) and right (B) eyes.įigure 3: Spectral domain optical coherence tomography demonstrates loss of the IS/OS junction and thinning of the outer retina in the parafoveal region (arrows), with preservation of these structures in the fovea of both the right (A) and left (B) eyes.įigure 4: Autofluorescence imaging shows an increase in signal in the parafoveal region of both the right (A) and left (B) eyes. Figure 1: Fundus photos demonstrate mild paracentral depigmentation of the RPE that spare the central fovea in both the right (A) and left (B) eyes. Fluorescein angiography shows parafoveal hyperfluorescence OU (C and D). Ancillary Testsįigure 1: Fundus photos demonstrate mild paracentral depigmentation of the RPE that spare the central fovea in both the right (A) and left (B) eyes. There was no posterior vitreous detachment, retinal tears, or retinal detachments. The vessels and peripheral exam were normal OU (Figure 1). There was mild paracentral depigmentation of the RPE in the macula that spared the central fovea OU. The optic nerves appeared healthy with a 0.3 cup-to-disc ratio. No relative afferent pupillary defect (RAPD).Įxtraocular movements: Full, both eyes (OU) Pupils: Reactive to light in each eye from 5 mm in the dark to 2 mm in the light. Social History: occasional alcohol but no tobacco or intravenous drug use.īlurred vision, halos, dry eye, dry mouth, gastroesophageal reflux, joint pain OCULAR EXAMINATION Visual Acuity Medications: prednisone, methotrexate, amitriptyline, ranitidine, estradiol, tizanidine, diltiazem, Restasisįamily History: heart disease, arthritis, cancer Medical History: Sjogren syndrome and inflammatory arthritis, supraventricular tachycardia, anxiety, depression, peptic ulcer disease She was previously treated with hydroxychloroquine (Plaquenil) 200mg bid (6.5mg/kg) for 10 years, which was stopped one year prior to presentation. She suffered from Sjogren syndrome and inflammatory arthritis and was currently treated with prednisone and methotrexate.
Mahajan, MD, PhDĬhief complaint: Whirling and flashing lights History of Present IllnessĪ 57-year-old female presented to the Ophthalmology clinic at UIHC complaining bilateral central photopsias for the past two years. Hydroxychloroquine (Plaquenil) Toxicity and Recommendations for Screening
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