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RPE damage continues in patients with severe HCQ retinopathy after drug cessation
Severe retinal pigment epithelial damage after long-term drug cessation in patients with hydroxychloroquine retinopathy may lead to injury that chronically destabilizes cellular function, according to findings published in Retina.
Brandon H. Pham, BS, and Michael F. Marmor, MD, sought to characterize the stability or progression of different stages of hydroxychloroquine (HCQ) retinopathy up to 20 years after patients stopped taking the drug.
“Patients with retinopathy detected at early stages seemed to stabilize with little risk of central vision loss, whereas those with preexisting damage to the retinal pigment epithelium [RPE] showed progressive photoreceptor damage,” Pham, of the Stanford University School of Medicine, and Marmor, of the Byers Eye Institute at Stanford University, wrote. “However, it remains unclear whether the apparent stability of milder cases would last over longer periods and whether more severe cases would eventually stabilize.”
The researchers examined the findings of 13 patients with initial HCQ retinopathy with early, moderate and or severe classifications. Patients who were off of HCQ for as long as 14 years at initial examination had a 5- to 8-year follow-up with repeated fundus autofluorescence and spectral domain OCT imaging.
Pham and colleagues found that patients with early and moderate classifications stabilized in fundus appearance, foveal thickness, ellipsoid zone line length and visual acuity for 9 years after HCQ use. In patients with severe HCQ retinopathy, a continual loss of the parameters was found for up to 20 years after use.
RPE damage found in initial examination predicted progressive retinopathy over many years, the researchers wrote.
Pham and colleagues said their findings stress the importance of early detection to minimize progression and visual loss. – by Earl Holland Jr.
Disclosures: The authors report no relevant financial disclosures.
Perspective
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Once again, we have confirmation that there is a “point of no return” in losing vision when toxic levels of HCQ have been achieved. This study confirms that the patient is at risk of progressive loss once RPE changes associated with HCQ toxicity have been detected, even when the medication is discontinued.
Noteworthy is the 20-year time frame of the study as a major strength, while acknowledging the low number of enrolled patients. Even with the study’s limitations, the clinical implication is clear and consistent with what was suspected before.
The American Academy of Ophthalmology originally published a screening guideline in 2002, and it has been revised twice over the past 8 years (2011 and 2016). Most of the modifications are due to advancing retinal imaging technology that has allowed clinicians to detect the onset of toxicity at the earliest stage.
While each revision aimed to provide a compass for early detection, the guideline overall maintained the stance of yearly surveillance beginning 5 years after initiation of therapy. This conservative stance has sparked some academic discussions but has not had much of an impact on the more commonly performed annual toxicity surveillance.
Still, this study highlights something we are very aware of: Early detection of HCQ retinal toxicity can only benefit our patient’s vision.
Reference:
Marmor MF, et al. Ophthalmology. 2016;doi.org/10.1016/j.ophtha.2016.01.058.
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