What is your treatment process when a lifesaving therapy results in worsening ocular symptoms?
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Monitor hydroxychloroquine intake
As a retina specialist, my busy private practice sees a wide spectrum of the patient population. We have a significant number of patients on therapies for systemic conditions. These conditions can have multiple side effects on the eye; therefore, we are required to continually monitor these patients for toxicities.
The most common systemic medication for which patients are monitored for toxicity is hydroxychloroquine (HCQ). HCQ continues to be one of the fundamental treatments for patients with lupus, rheumatoid arthritis and other connective tissue diseases. The risk for toxicity is factored on daily dosage amounts and the overall duration a patient is on the medication. The recommended dose is less than 5 mg/kg using real body weight. Other major risks are renal failure or concomitant use of tamoxifen. Patients who are on tamoxifen for breast cancer and take HCQ simultaneously have approximately a fivefold increased risk for toxicity. Without the high-risk factors, the rate of toxicity is under 1% at 5 years and 2% up to 10 years. The risk for toxicity, however, significantly increases to 20% after 20 years.
Based on the latest American Academy of Ophthalmology guidelines, all patients placed on HCQ should have a baseline screening exam within the first year. After that, the exam can be deferred for 5 years unless the patient is in the high-risk group. Patients who are not in the high-risk group are monitored annually after 5 years on treatment. We perform annual dilated fundus exams, visual field testing, spectral domain OCT and fundus autofluorescence at those visits.
The goal of HCQ screening is to diagnose retinopathy at an early stage to avoid central vision loss as the retinopathy is not reversible. If we see signs of toxicity based on the exam and multimodal imaging, we recommend the patients to discontinue HCQ.
Arshad M. Khanani, MD, MA, is a Healio/OSN Board Member. Disclosure: Khanani reports no relevant financial disclosures.
Empower physicians to treat systemic diseases
Ophthalmologists need to chase after those ocular symptoms and leave the lifesaving therapy in place. As a glaucoma specialist, one of the things I am keenly aware of is that patients who are going blind from macular disease may develop glaucoma as a side effect if they are getting steroids or Avastin (bevacizumab, Genentech) injections. One of the things I strive to do every day is to make the patient’s treating doctor aware that I want to preserve their central vision and let me worry about their pressure. I can always start drops; I can add laser; I can treat the glaucoma. As a result, I want to keep them seeing. Keeping the central vision good is more important than high pressure as long as I am doing my job correctly.
In my career, I have seen a variety of systemic problems that have intervened with the eye. A basic one is systemic steroid therapy. These are patients who have autoimmune disease, or, often as I see in the Bronx, patients with horrible asthma. They will come in with high pressures, and the last thing I want to do is discourage their doctor from treating them. It is upon me to make sure their doctor has considered a steroid-sparing agent and for them to understand that the steroid is causing side effects, but I also have to do a good job to make the doctor unafraid to treat their asthma or autoimmune disorder. Some doctors can let patients suffer unnecessarily because they overworry about the glaucoma aspect.
An interesting case I saw involved a young man who had serious dry eye disease. I reviewed his medical history, and I realized he had a more serious problem with bipolar disorder. He was on many anticholinergics and antipsychotic drugs. Knowing the patient population and how difficult it can be for some to adhere to therapy, I did not want the patient to worry about the medications he was on that were stabilizing a serious psychiatric disorder. We focused on treating the dry eye with standard dry eye pharmacotherapies, prescription medications and punctal plugs, and the patient did well.
We want to live to fight another day, and we want to protect our patient’s systemic health, but oftentimes, particularly with diseases such as glaucoma, the pressure may be high but the patient is not going blind immediately. We have great glaucoma therapies, and it is better to empower the physician treating their overall systemic health to treat aggressively. We should reassure the physician that we are competent enough to manage the glaucoma, even if it is a side effect, and that the physician should not feel bad for treating the patient’s systemic disease aggressively. At the end of the day, we can handle glaucoma one way or the other.
Nathan M. Radcliffe, MD, is a Healio/OSN Board Member. Disclosure: Radcliffe reports no relevant financial disclosures.
Communication is key
There are many illnesses, as well as treatments associated with those conditions, that can directly affect the eye. As specialists, we are often called to educate and manage the side effects of systemic lifesaving treatments.
The key is to communicate with the primary care/treating physician as well as the patient and family. Understanding the severity of the systemic medical condition will allow the us to help our patients determine the willingness to tolerate the ophthalmic adverse events and undergo possible ophthalmic treatments. The benefit-risk decision is sometimes difficult to make. The best choice depends on the particular situation. Patients must decide what risks they will accept in order to save their life. For example, if facing a life-threatening illness, they might choose to accept more risk in the hope of getting the benefits of a cure or living a longer life. On the other hand, if one is facing a minor illness, you and the patient might decide the risk of treatment is not worth the effect on the eye, for example.
Our job is to help minimize the negative ophthalmic impact as much as possible, if at all possible. Understanding the patient’s care goals in the context of a serious illness allows the eye care provider to align the care provided with what is most important to the patient. Treatment choices, particularly those that are made in the context of a serious, life-threatening illness, are also influenced by an individual’s values and preferences, and this is reflected in the patient’s goals for care. Understanding an individual’s goals allows us to align the care with what is most important to the patient and his or her family. In some cases, the patient’s primary goals are not medical but more personal in nature, focused on how they want to live their lives in whatever time they have remaining. For instance, if a lifesaving treatment may only prolong life for a few weeks to months but at a risk for losing vision, a patient may decide the extra time is not worth the disabling consequence on the eye. Or, if the subsequent ocular treatment carries a high morbidity, observing the ocular adverse event may be a better option for the patient.
If one’s goal is to live as long as possible and the patient is willing to take significant risks to do so, then therapy, even with the effect on the eye, may be the best choice. If, on the other hand, one is focused mostly on comfort and quality of life, then that therapy may not best meet the goal. An honest and open discussion about the patient’s goals, as well as the risks and benefits of these therapies, is crucial to helping assist the patient in making treatment decisions. Without this goals-based discussion, it is hard to facilitate shared decision-making between the doctor and the patient.
I. Paul Singh, MD, is a Healio/OSN Board Member. Disclosure: Singh reports no relevant financial disclosures.