American Academy of Ophthalmology StatementRecommendations on Screening for Chloroquine and Hydroxychloroquine Retinopathy (2016 Revision)
Section snippets
Hydroxychloroquine and Chloroquine Toxicity
The mechanism of CQ and HCQ toxicity is not well understood. High experimental doses have acute effects on the metabolism of retinal cells, but it is not clear how these short-term metabolic effects relate to the slow and chronic damage that characterizes the clinical state of toxicity. Binding to melanin in the RPE may serve to concentrate the agents and contribute to, or prolong, their toxic effects. However, melanin binding also could serve as a mechanism for removing toxic agents from
Statistical Risk of Toxicity
Earlier literature on the prevalence of CQ or HCQ retinopathy included few patients on long-term therapy and only recognized severe toxicity (bull's-eye changes). These reports have been superseded now by a large study of 2361 patients who used HCQ for more than 5 years and were evaluated with 10-2 visual fields or spectral-domain optical coherence tomography (SD OCT) so that toxicity could be recognized before there were any visible signs on fundus examination.2 The overall prevalence of
Dosage Recommendations
On the basis of the risk data described, we recommend that all patients using HCQ keep daily dosage <5.0 mg/kg real weight.2 There may be rare instances when higher doses are needed to manage life-threatening disease or a lower limit is advisable because of major risk factors (described later). Following this guideline will minimize the risk of retinopathy and allow long-term use of HCQ for most patients. Previous recommendations to use ideal body weight for the calculation of dose were based
Major Factors
The most important risk factors are listed in Table 1.
Rationale for Screening
Hydroxychloroquine and CQ retinopathy are not reversible, and cellular damage may progress even after the drugs are stopped. When retinopathy is not recognized until a bull's-eye appears, the disease can progress for years, often with foveal thinning and an eventual loss of visual acuity. However, when retinopathy is recognized early, before RPE damage, there is only mild and limited progression after discontinuing the medication, and the fovea is not threatened.5 Thus, screening may not
Clinical Examination Techniques
Screening techniques that are recommended or that should be avoided are listed in Table 3.
Management of Eyes at Risk or with Retinopathy
No diet or medical therapy has proven effective as yet to prevent, treat, or reduce risk from HCQ or CQ retinopathy other than cessation of the drug. Even stoppage of the drug does not prevent progression of retinopathy, although this is typically mild if the toxicity is recognized before there is RPE damage. Patients with age-related maculopathy or macular dystrophies sometimes are advised to avoid excessive sun exposure and maintain intake of lutein and zeaxanthin (which are foveal
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Correspondence: Flora Lum, MD, Department of Quality of Care and Knowledge Base Development, American Academy of Ophthalmology, 655 Beach Street, San Francisco, CA 94109-1336. E-mail: [email protected].
Financial Disclosure(s): The author(s) have made the following disclosure(s): T.Y.Y.L.: Consultant − Allergan, Bayer Healthcare, Novartis Pharmaceuticals, Genentech; Grants/grants pending − Bayer Healthcare, Novartis Pharmaceuticals; Lecture fees − Allergan, Bausch & Lomb, Bayer Healthcare, Novartis Pharmaceuticals; Payment − manuscript preparation from Novartis Pharmaceuticals.