Hydroxychloroquine retinopathy

The prevalence of retinopathy following long-term use of hydroxychloroquine is around 7.5%, and this can increase to 20-50% after 20 years of therapy, depending on dose and duration of the medication. Retinopathy is manifest as damage to the photoreceptors and subsequent degeneration of the retinal pigment epithelium (RPE). This may lead to “Bull’s eye maculopathy” and central visual loss, requiring a change or cessation of the medication.

Community monitoring

Monitoring for hydroxychloroquine and chloroquine retinopathy is not part of a routine private or GOS sight test, but in the past community optometrists have sometimes been asked to monitor patients on hydroxychloroquine using simple checks, such as reading charts, retinal photography, visual fields and colour vision testing. This is no longer considered adequate, and if patients on these medications are not being monitored in accordance with the criteria below (and there is no local community service available in your area) you should contact the patient’s GP and ask them to arrange monitoring. There is no specific recommendation for patients to arrange annual community optometry assessments, or any specific form of self-assessment, before monitoring commences.

Current guidance

In December 2020, the Royal College of Ophthalmologists issued guidance on monitoring for hydroxychloroquine and chloroquine retinopathy. Current guidance is that patients should be offered an annual fundus examination with widefield fundus autofluorescence (FAF) after they’ve been taking the medication for a certain period of time.

Current clinical guidelines include the following recommendations:

1. Annual monitoring should be offered as follows:

Medication	Patient should be referred for annual monitoring after
Chloroquine (NB: chloroquine appears to be more retino-toxic than hydroxychloroquine)	1 year
Hydroxychloroquine and patient has increased risk factors (eg taking more than 5mg/kg/day, also taking Tamoxifen, renal impairment etc)	1 year
Hydroxychloroquine	5 years

2. At each monitoring, patients should undergo SD-OCT (TD-OCT resolution is too poor to detect photoreceptor damage) and widefield fundus autofluorescence imaging (FAF), with dilation if needed. If there is an abnormality suggestive of toxicity on these tests, patients should receive 20-2 or 30-2 Humphrey Visual Field testing
3. Patients with persistent and significant visual field defects consistent with hydroxychloroquine retinopathy, but without evidence of structural defects on SD-OCT or FAF may be considered for multifocal electroretinography

LOCSU have developed a pathway and clinical management guidelines which offer an integrated service delivery model with data collection in primary care by optometrists and virtual review by a consultant ophthalmologist. The pathway is aligned with the RCOphth guidelines and allows patients to be seen within the community in a consultant-led service. LOCSU provides a range of downloadable support for members of Local Optical Committees who want to introduce these pathways in their area.