Retinal toxicity secondary to Plaquenil therapy

doi:10.1016/j.optm.2007.08.017

Optometry - Journal of the American Optometric Association

Volume 79, Issue 2, February 2008, Pages 90-94

https://doi.org/10.1016/j.optm.2007.08.017 Get rights and content

Abstract

Background

Hydroxychloroquine sulfate (Plaquenil; Sanofi-Aventis, Bridgewater, New Jersey) is an antimalarial agent, which is sometimes used for the treatment of certain autoimmune disorders. Its use has been associated with ocular side effects; the most concerning is toxic maculopathy.

Case report

A 71-year-old arthritic white woman requested a second opinion regarding retinal Plaquenil toxicity. The patient℉s history was significant for seronegative rheumatoid arthritis diagnosed 6 years prior. She had taken Plaquenil 400 mg a day for about 5 years but had discontinued the drug 6 months before when bilateral central scotomas were first noted. At the consultation visit, her visual acuities were 20/20 in both eyes. SITA-Standard 10-2 disclosed a dense scotoma with 4° of central sparing in each eye. Fundus examination found retinal pigment epithelium changes bilaterally; no “bull℉s eye” retinopathy was observed.

Conclusion

Withdrawal of the medication is the only effective treatment for Plaquenil toxicity and, even then, the toxic effects may progress because of the slow clearance of the drug. Though controversy exists regarding screening recommendations, a baseline ophthalmic examination should be performed on all patients before initiating Plaquenil. If a patient is considered low risk, examinations can be scheduled annually. For high-risk patients, 6-month progress visits are strongly recommended.

Section snippets

Case report

A 71-year-old arthritic white woman, weighing 110 pounds, presented with a feared complaint of retinal hydroxychloroquine sulfate (Plaquenil) toxicity. She reported a light fog, just right of her central vision, worse in the right eye than the left. She first noticed this visual distortion approximately 1 year before and stated that it had progressed slightly since onset. The patient℉s history was significant for seronegative rheumatoid arthritis diagnosed 6 years earlier. She was initially

Discussion

Hydroxychloroquine sulfate is an antimalarial agent sometimes used in the treatment of systemic lupus erythematosus and rheumatoid arthritis. Because the potential adverse effects include irreversible retinopathy, it is vital for eye care providers to know the incidence, the risk factors, and the presentation of toxicity.

There is lack of consensus regarding what constitutes hydroxychloroquine toxic retinopathy, but it often is defined by 2 methods. One is the development of persistent

References (15)

I. Mavrikakis et al.
The incidence of irreversible retinal toxicity in patients treated with hydroxychloroquine
Ophthalmology
(2003)
M. Marmor et al.
Recommendations on screening for chloroquine and hydroxychloroquine retinopathy
Ophthalmology
(2002)
D. Browning
Hydroxychloroquine and chloroquine retinopathy: screening for drug toxicity
Am J Ophthalmol
(2002)
F. Rigaudiere et al.
Updated ophthalmological screening and follow-up management for long-term antimalarial treatment
J Fr Ophthalmol
(2004)
I. Ingster-Moati et al.
Analysis of 925 patients on long-term hydroxychloroquine or chloroquine treatment: results of ophthalmological screening
J Fr Ophthalmol
(2004)
E. Bui Quoc et al.
Ophthalmologic prevention of chloroquine and hydroxychloroquine induced retinopathy
Ann Dermatol Venereol
(2005)
I. Ingster-Moati et al.
Severe chloroquine and hydroxychloroquine-induced retinopathy
J Fr Ophthalmol
(2006)

There are more references available in the full text version of this article.

Cited by (7)

Regional morphology and pathophysiology of retinal vascular disease
2013, Progress in Retinal and Eye Research
Citation Excerpt :
Dystrophic conditions in the retina involve atrophy of the photoreceptors and the underlying pigment epithelium (Zobor and Zrenner, 2012). When the primary photoreceptor degeneration includes the central cones, either in congenital cone dystrophy (Zervas and Smith, 1987) or in acquired conditions such as toxic retinopathy (Hanna et al., 2008), the retina may display a pericentral ring-shaped atrophic area contrasting with the normal fovea, much resembling a shooting target. This ring-shaped area coincides with the area where the retinal ganglion cell layer is thickest, but it is unknown whether this is related to the pathogenesis of the toxic reaction.
Disturbances in the retinal vascular supply are involved in the pathophysiology of the most frequent diseases causing visual impairment and blindness in the Western World. These diseases are diagnosed by noting how morphological lesions in the retina vary in shape, size, location and dynamics, and subsequently concluding the presence of a specific disease entity. This diagnostic approach can be used to identify the site of a retinal vascular occlusion, to assess whether retinal diseases are primarily due to changes in the larger retinal vessels or the microcirculation, and to differentiate the relative involvement of the choroidal and the retinal vascular systems. However, a number of morphological manifestations of retinal vascular disease cannot presently be related to the underlying pathophysiology.
The review concludes that there is a need for developing new methods for assessing vascular structure and function in the ciliary vascular system supplying the choroid and the optic nerve head. Presently, the study of these structures relies on imaging techniques with limited penetration and resolution into the tissue. Secondly, there is a need for studying oscillations in retinal vascular function occurring within days to weeks, and for studying regional manifestations of retinal vascular disease. This may constitute the basis for future research in retinal vascular pathophysiology and for the development of new treatment modalities to reduce blindness secondary to retinal vascular disease.
Therapy and pharmacological properties of hydroxychloroquine and chloroquine in treatment of systemic lupus erythematosus, rheumatoid arthritis and related diseases
2015, Inflammopharmacology
Hydroxychloroquine and chloroquine retinopathy
2014, Hydroxychloroquine and Chloroquine Retinopathy
Assessing chloroquine toxicity in RA patients using retinal nerve fibre layer thickness, multifocal electroretinography and visual field test
2010, British Journal of Ophthalmology
Retinal damage by (Hydroxy)chloroquine intake: Published evidence for an efficient ophthalmological follow-up
2009, Klinische Monatsblatter fur Augenheilkunde
Ocular toxicity of hydroxychloroquine
2008, Clinical and Surgical Ophthalmology

View all citing articles on Scopus

View full text

Clinical careRetinal toxicity secondary to Plaquenil therapy

Abstract

Background

Case report

Conclusion

Section snippets

Case report

Discussion

Ophthalmology

Ophthalmology

Am J Ophthalmol

J Fr Ophthalmol

J Fr Ophthalmol

Ann Dermatol Venereol

J Fr Ophthalmol

Clinical care
Retinal toxicity secondary to Plaquenil therapy