50-year-old woman with lupus and slowly decreasing vision | Figure 1
50-year-old woman with lupus and slowly decreasing vision
What is the role of the primary care or emergency medicine physician?
Patients who develop symptoms of hydroxychloroquine retinopathy should be referred urgently to follow-up with their ophthalmologist.
What is the role of the ophthalmologist?
The ophthalmologist should offer counseling to patients about the risk of toxicity and the importance of regular screening. Patients who are on hydroxychloroquine should be screened by an ophthalmologist as follows:
- Screening should occur within 1 year of starting hydroxychloroquine, and it should be performed annually after 5 years of use.
- Patients with certain risk factors (eg, excessive dosing, kidney or liver disease, macular disease, older age) should be screened more often.
Screening, at minimum, includes the following:
- a dilated fundus exam to detect a bull's-eye maculopathy appearance
- an extended visual field test to assess for central scotomas (blind spots)
- optical coherence tomography to assess for structural changes to the photoreceptor layers
What is the treatment?
If hydroxychloroquine retinopathy is detected, the medication should be discontinued immediately, and the patient's rheumatologist should be involved to determine alternative treatments for systemic disease.
No treatments are currently available to reverse the retinopathy. Retinopathy progression may continue following cessation of the drug, so the ophthalmologist should consider monitoring the patient closely.
Review the full case on the Academy website for more details, including links to educational resources on key topics related to the case.
Diagnosis added by author
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Image is consistent with bull's-eye maculopathy, & the differential includes hydroxychloroquine retinopathy: * Long duration of use of hydroxychloroquine (>5 years) & high dosage (>5 mg/kg of body weight daily) can damage macular rods & cones & lead to classic appearance of bull's eye in the macula * Retinopathy tends to be bilateral, symmetric, & irreversible. Early, frequent screening & early detection important to prevent sequelae * Differentials: AMD, cone or cone-rod dystrophy, & Stargardt
and/or retinal tear that could progress to a retinal detachment. What is the role of the ophthalmologist? The role of the ophthalmologist includes the following: * examining the eye with a slit-lamp biomicroscope * assessing for location, size, and cause of vitreous hemorrhage * B-scan ultrasonography can help detect vitreous hemorrhage, posterior vitreous detachment, retinal tears, and retinal detachment if a complete view of the retina is obscured. What is the treatment? Vitreous hemorrhage may resolve spontaneously in some cases. Treatment is based on the underlying cause. Anti-vascular endothelial growth factor (anti-VEGF) injections and/or panretinal photocoagulation may be used to treat proliferative diabetic retinopathy. Scleral buckling, pneumatic retinopexy, and/or pars plana vitrectomy may be used to treat retinal detachments. Review the full case on the Academy website for more details, including links to educational resources on key topics related to the case.](https://app.figure1.com/cdn-cgi/image/format=auto,quality=85,width=168,height=168,fit=cover,gravity=auto/https://figure1-pro-prod.imgix.net/cases/images/e0a65338ff7b5b05c7e3279ccf8dba55639141d66c27bdc236013a38dd854d2f.png)
What is the role of the primary care or emergency medicine physician?
- The patient should be referred to an ophthalmologist urgently (within 24 hours) due to concern for a retinal detachment and/or retinal tear that could progress to a retinal detachment.
What is the role of the ophthalmologist?
The role of the ophthalmologist includes the following:
- examining the eye with a slit-lamp biomicroscope
- assessing for location, size, and cause of vitreous hemorrhage
- B-scan ultrasonography can help detect vitreous hemorrhage, posterior vitreous detachment, retinal tears, and retinal detachment if a complete view of the retina is obscured.
What is the treatment?
Vitreous hemorrhage may resolve spontaneously in some cases. Treatment is based on the underlying cause. Anti-vascular endothelial growth factor (anti-VEGF) injections and/or panretinal photocoagulation may be used to treat proliferative diabetic retinopathy. Scleral buckling, pneumatic retinopexy, and/or pars plana vitrectomy may be used to treat retinal detachments.
Review the full case on the Academy website for more details, including links to educational resources on key topics related to the case.
If cataracts are suspected, nonurgent referral to an ophthalmologist for cataract evaluation is warranted.
What is the role of the ophthalmologist?
- Perform cataract evaluation with a complete dilated eye examination, including a slit-lamp examination to determine the cataract type and extent.
- Assess for best-corrected visual acuity and perform glare testing.
- Order testing to help determine the intraocular lens needed.
- Perform cataract extraction and placement of an intraocular lens.
Review the full case on the Academy website for more details, including links to educational resources on key topics related to the case.