Skip to main content

Main menu

  • Home
  • Content
    • First Release
    • Current
    • Archives
    • Collections
    • Audiovisual Rheum
    • COVID-19 and Rheumatology
  • Resources
    • Guide for Authors
    • Submit Manuscript
    • Author Payment
    • Reviewers
    • Advertisers
    • Classified Ads
    • Reprints and Translations
    • Permissions
    • Meetings
    • FAQ
    • Policies
  • Subscribers
    • Subscription Information
    • Purchase Subscription
    • Your Account
    • Terms and Conditions
  • About Us
    • About Us
    • Editorial Board
    • Letter from the Editor
    • Duncan A. Gordon Award
    • GDPR Policy
    • Accessibility
  • Contact Us
  • JRheum Supplements
  • Services

User menu

  • My Cart
  • Log In

Search

  • Advanced search
The Journal of Rheumatology
  • JRheum Supplements
  • Services
  • My Cart
  • Log In
The Journal of Rheumatology

Advanced Search

  • Home
  • Content
    • First Release
    • Current
    • Archives
    • Collections
    • Audiovisual Rheum
    • COVID-19 and Rheumatology
  • Resources
    • Guide for Authors
    • Submit Manuscript
    • Author Payment
    • Reviewers
    • Advertisers
    • Classified Ads
    • Reprints and Translations
    • Permissions
    • Meetings
    • FAQ
    • Policies
  • Subscribers
    • Subscription Information
    • Purchase Subscription
    • Your Account
    • Terms and Conditions
  • About Us
    • About Us
    • Editorial Board
    • Letter from the Editor
    • Duncan A. Gordon Award
    • GDPR Policy
    • Accessibility
  • Contact Us
  • Follow jrheum on Twitter
  • Visit jrheum on Facebook
  • Follow jrheum on LinkedIn
  • Follow jrheum on RSS
Case ReportImages in Rheumatology

Hydroxychloroquine-induced Retinal Toxicity

KAYLENE L. CARTER and DIANA V. DO
The Journal of Rheumatology April 2020, 47 (4) 632; DOI: https://doi.org/10.3899/jrheum.190538
KAYLENE L. CARTER
MSEE;
Roles: Medical student
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
  • ORCID record for KAYLENE L. CARTER
DIANA V. DO
Byers Eye Institute, Department of Ophthalmology, Stanford University School of Medicine, Stanford, California, USA.
Roles: Professor
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
  • For correspondence: dianado@stanford.edu
  • Article
  • Figures & Data
  • References
  • Info & Metrics
  • PDF
  • eLetters
PreviousNext
Loading

Hydroxychloroquine (HCQ) retinopathy is rare, with an estimated 0.33% incidence before 5–7 years of therapy, increasing to 2.1% by 15 years1.

A 62-year-old 59-kg woman with fibromyalgia and systemic lupus erythematosus presented to the ophthalmology clinic with blurry central vision in both eyes for several years. She had been taking 800 mg of HCQ daily for the past 8 years. Optical coherence tomography imaging revealed bilateral disruption of the outer retinal structures and retinal pigment epithelium (RPE; Figure 1), and fundus autofluorescence imaging showed characteristic ring-shaped damage around the macula (Figure 2) known as bull’s eye maculopathy, a late finding of HCQ-induced retinal toxicity. Additional manifestations may include perifoveal inner retinal thinning and displacement of inner retinal structures toward the RPE2,3. A maximum dose of ≤ 5 mg/kg/day is recommended by the American Academy of Ophthalmology, because greater doses can increase the risk of retinal toxicity, as in this case4. Other risk factors for retinal toxicity include advanced age, low body weight, tamoxifen use, and concomitant retinal, renal, or liver disease, which may necessitate more frequent screening4,5. In the early stages patients are typically asymptomatic, but as toxicity progresses patients can experience diminished visual acuity, peripheral vision, and night vision. Irreversible retinal changes may continue despite drug discontinuation, and therefore multi-modal imaging measures are important to screen and identify signs of early toxicity. This patient was advised to immediately discontinue HCQ. Despite stopping the drug, progression of her central vision loss and the corresponding retinal and RPE abnormalities continued.

Figure 1.
  • Download figure
  • Open in new tab
  • Download powerpoint
Figure 1.

Optical coherence tomography of the patient’s right eye. Bilateral disruption of the outer retinal structures and retinal pigment epithelium was detected in the parafoveal region (white arrowheads). Preservation of the central fovea outer retinal structures created an ovoid appearance of the central fovea (white arrow) known as the “flying saucer” sign of hydroxychloroquine retinopathy.

Figure 2.
  • Download figure
  • Open in new tab
  • Download powerpoint
Figure 2.

Fundus autofluorescence of the patient’s right eye. An increased ring-shaped signal surrounding the macula (white arrow) displays retinal pigment epithelium degeneration and is a characteristic late finding in hydroxychloroquine retinopathy.

Footnotes

  • Ethics board approval is not required because this is a single case report and no intervention had been made for research. The patient gave written informed consent to publish the material.

REFERENCES

  1. 1.↵
    1. Wolfe F,
    2. Marmor M
    . Rates and predictors of hydroxychloroquine retinal toxicity in patients with rheumatoid arthritis and systemic lupus erythematosus. Arthritis Care Res 2010;62:775–84.
    OpenUrlCrossRef
  2. 2.↵
    1. Pasadhika S,
    2. Fishman G,
    3. Choi D,
    4. Shahidi M
    . Selective thinning of the perifoveal inner retina as an early sign of hydroxychloroquine retinal toxicity. Eye 2010;24:756–62.
    OpenUrlCrossRefPubMed
  3. 3.↵
    1. Chen E,
    2. Brown D,
    3. Benz M,
    4. Fish R,
    5. Wong T,
    6. Kim R,
    7. et al.
    Spectral domain optical coherence tomography as an effective screening test for hydroxychloroquine retinopathy (the “flying saucer” sign). Clin Ophthalmol 2010;4:1151–8.
    OpenUrlPubMed
  4. 4.↵
    1. Marmor M,
    2. Kellner U,
    3. Lai Y,
    4. Melles R,
    5. Mieler W;
    6. American Academy of Ophthalmology
    . Recommendations on screening for chloroquine and hydroxychloroquine retinopathy (2016 Revision). Ophthalmology 2016;123:1386–94.
    OpenUrlCrossRefPubMed
  5. 5.↵
    1. Peponis V,
    2. Kyttaris V,
    3. Chalkiadakis S,
    4. Bonovas S,
    5. Sitaras N
    . Ocular side effects of anti-rheumatic medications: what a rheumatologist should know. Lupus 2010;19:675–82.
    OpenUrlCrossRefPubMed
View Abstract
PreviousNext
Back to top

In this issue

The Journal of Rheumatology
Vol. 47, Issue 4
1 Apr 2020
  • Table of Contents
  • Table of Contents (PDF)
  • Index by Author
  • Editorial Board (PDF)
Print
Download PDF
Article Alerts
Sign In to Email Alerts with your Email Address
Email Article

Thank you for your interest in spreading the word about The Journal of Rheumatology.

NOTE: We only request your email address so that the person you are recommending the page to knows that you wanted them to see it, and that it is not junk mail. We do not capture any email address.

Enter multiple addresses on separate lines or separate them with commas.
Hydroxychloroquine-induced Retinal Toxicity
(Your Name) has forwarded a page to you from The Journal of Rheumatology
(Your Name) thought you would like to see this page from the The Journal of Rheumatology web site.
CAPTCHA
This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.
Citation Tools
Hydroxychloroquine-induced Retinal Toxicity
KAYLENE L. CARTER, DIANA V. DO
The Journal of Rheumatology Apr 2020, 47 (4) 632; DOI: 10.3899/jrheum.190538

Citation Manager Formats

  • BibTeX
  • Bookends
  • EasyBib
  • EndNote (tagged)
  • EndNote 8 (xml)
  • Medlars
  • Mendeley
  • Papers
  • RefWorks Tagged
  • Ref Manager
  • RIS
  • Zotero

 Request Permissions

Share
Hydroxychloroquine-induced Retinal Toxicity
KAYLENE L. CARTER, DIANA V. DO
The Journal of Rheumatology Apr 2020, 47 (4) 632; DOI: 10.3899/jrheum.190538
del.icio.us logo Digg logo Reddit logo Twitter logo CiteULike logo Facebook logo Google logo Mendeley logo
  • Tweet Widget
  • Facebook Like
  • Google Plus One
Save to my folders

Jump to section

  • Article
    • Footnotes
    • REFERENCES
  • Figures & Data
  • References
  • Info & Metrics
  • PDF
  • eLetters

Related Articles

Cited By...

More in this TOC Section

  • Porphyria Cutanea Tarda Masquerading as Systemic Sclerosis: Two Cases Demonstrating an Important Clinical Observation
  • Severe Hypopyon Uveitis in the Right Eye of Ankylosing Spondylitis
  • Cytomegalovirus Enteritis in a Patient with Rheumatoid Arthritis Receiving Baricitinib
Show more Images in Rheumatology

Similar Articles

Content

  • First Release
  • Current
  • Archives
  • Collections
  • Audiovisual Rheum
  • COVID-19 and Rheumatology

Resources

  • Guide for Authors
  • Submit Manuscript
  • Author Payment
  • Reviewers
  • Advertisers
  • Classified Ads
  • Reprints and Translations
  • Permissions
  • Meetings
  • FAQ
  • Policies

Subscribers

  • Subscription Information
  • Purchase Subscription
  • Your Account
  • Terms and Conditions

More

  • About Us
  • Contact Us
  • My Alerts
  • My Folders
  • RSS Feeds
The Journal of Rheumatology
The content of this site is intended for health care professionals.
Copyright © 2016 by The Journal of Rheumatology Publishing Co. Ltd.
Print ISSN: 0315-162X; Online ISSN: 1499-2752
Powered by HighWire