Hydroxychloroquine and chloroquine retinopathy: screening for drug toxicity1

https://doi.org/10.1016/S0002-9394(02)01392-2Get rights and content

Abstract

PURPOSE: To report hydroxychloroquine and chloroquine retinopathy and consider screening for drug toxicity.

DESIGN: Retrospective observational case series.

METHODS: Review of clinical records, visual fields, fundus photographs, and fluorescein angiography of six patients from a retina referral practice.

RESULTS: All cases arose because of failure by physicians to avoid dosing above published safe levels. Five cases developed despite accepted ophthalmologic patterns of screening for toxicity. All cases developed parafoveal retinal pigment epithelial atrophic changes and paracentral scotomas to threshold visual field testing.

CONCLUSIONS: New cases of hydroxychloroquine and chloroquine toxicity continue to develop in a screening environment. Increased ophthalmologic attention to dosing, awareness of location and nature of early visual field defects, and traditional attention to presence or absence of maculopathy can reduce the incidence of this avoidable condition.

Section snippets

Design

This study is a retrospective observational case series.

Methods

The patients come from a single retina practice. There is no medical school within a 100-mile radius tending to exclude the possibility of overlap in experience with university-based reports. The six comprise all patients with this disorder seen by the author between July 1, 1986 and December 5, 2001. The diagnosis of advanced hydroxychloroquine or chloroquine retinopathy was made based on the combined presence of parafoveal retinal pigment epithelial atrophy as seen on fundus biomicroscopy and

Results

Six cases of advanced hydroxychloroquine and chloroquine retinopathy were diagnosed during a 15-year interval; one in a patient taking chloroquine and five in patients on hydroxychloroquine. The daily dose divided by body mass, the duration of therapy, and the cumulative dose are listed in Table 1. Fundus photographic documentation of toxic retinopathy for five cases is shown in Figure 1, Figure 2, Figure 3, Figure 4, Figure 5 and progression of visual field changes while under monitoring in

Case 3

:A 48-year-old 130-pound Caucasian female was prescribed higher than recommended doses of hydroxychloroquine (Table 1) for her rheumatoid arthritis from 1980 until June 26, 1993, when it was stopped, because of lack of rheumatologic efficacy. She had visual acuity checks, funduscopy, and visual field testing by her ophthalmologist every 6 months. The appropriateness of the patient’s dosage was not questioned throughout this interval. Her visual field was normal in 1989 and 1990 Figure 6, Figure

Discussion

Hydroxychloroquine and chloroquine retinal toxicity begins as paracentral scotomata, which are detectable by threshold visual field testing before any fundus changes are seen. If the toxic drug is stopped before fundus changes occur, the scotomata can resolve though they may not. If the drug is not stopped, parafoveal retinal pigment epithelial atrophic lesions usually develop next and, later, peripheral retinal pigment epithelial mottling occurs. Very advanced changes include arteriolar

References (32)

  • M Easterbrook

    Detection and prevention of maculopathy associated with antimalarial agents

    Int Ophthalmol Clin

    (1999)
  • L Vu et al.

    Detection of color vision defects in chloroquine retinopathy

    Ophthalmology

    (1999)
  • P Gouras et al.

    The EOG in chloroquine and other retinopathies

    Arch Ophthalmol

    (1963)
  • P Henkind et al.

    Early chloroquine retinopathyclinical and functional findings

    Arch Ophthalmol

    (1964)
  • E Okun et al.

    Chloroquine retinopathya report of eight cases with ERG and dark-adaptation findings

    Arch Ophthalmol

    (1963)
  • P Falcone et al.

    Hydroxychloroquine toxicity despite normal dose therapy

    Ann Ophthalmol

    (1993)
  • Cited by (84)

    • Acute chloroquine and hydroxychloroquine toxicity: A review for emergency clinicians

      2020, American Journal of Emergency Medicine
      Citation Excerpt :

      Loss of balance, sensorineural hearing loss, and ataxia are believed to be related to vestibular dysfunction [79,80]. Ophthalmologic sequelae of acute aminoquinoline intoxication include diplopia, loss of visual acuity, tunnel vision, mydriasis, and scotomata [81]. Onset of ocular symptoms often follows other clinical presentations, such as arrhythmia or hypotension by several hours.

    • The Impact of Systemic Medications on Retinal Function

      2023, Asia-Pacific Journal of Ophthalmology
    View all citing articles on Scopus
    1

    InternetAdvance publication at ajo.com April 24, 2002.

    View full text