Skip to main content

Advertisement

SpringerLink
Log in

Accelerated hydroxychloroquine toxic retinopathy

  • Clinical Case Report
  • Published:
Documenta Ophthalmologica Aims and scope Submit manuscript

Abstract

Purpose

To report a case series of patients with retinal toxicity due to hydroxychloroquine (HCQ) within a short span of treatment.

Methods

A retrospective review of case records of patients with accelerated HCQ toxicity within 1 year of starting the treatment was done. Systemic co-morbidities, details of HCQ treatment, details of ocular examination, and results of multimodal investigations were noted.

Results

Nine patients (1 male, 8 females) with age ranging from 40 to 73 years (mean 54.2 ± 13.4 years) who showed accelerated HCQ toxicity were included. None had systemic conditions or drug history predisposing to early HCQ toxicity. The treatment duration ranged from 2 to 11 months and the cumulative HCQ dose ranged from 18 to 120 g (mean 45.0 ± 33.0 g). The visual acuity was normal in 8 (88.9%) patients and retinal evaluation was normal in 4 (44.4%). Optical coherence tomography was abnormal in 4 (44.4%). Six (66.6%) cases had reduced sensitivity in the parafoveal point on visual field testing. All 9 cases had multifocal electroretinographic changes diagnostic of HCQ toxicity. The HCQ treatment was stopped in 8 and continued with reduced dose in 1 patient. The mean duration of follow-up was 11.2 ± 9.6 months during which 5 patients showed improved mfERG and 1 patient had a stable mfERG. Visual fields improvement was noted in 2 cases.

Conclusions

Patients on HCQ need to be kept on regular monitoring with more frequent follow-ups to detect signs of early onset toxicity and prevent permanent visual impairment. mfERG is an important diagnostic tool for HCQ toxicity.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1

Similar content being viewed by others

References

  1. Rainsford KD, Parke AL, Clifford-Rashotte M, Kean WF (2015) Therapy and pharmacological properties of hydroxychloroquine and chloroquine in the treatment of systemic lupus erythematosus, rheumatoid arthritis, and related diseases. Inflammopharmacology 23(5):231–269

    Article  CAS  PubMed  Google Scholar 

  2. Stokkermans TJ, Goyal A, Trichonas G (2022) Chloroquine And Hydroxychloroquine Toxicity. StatPearls. StatPearls Publishing, Treasure Island

    Google Scholar 

  3. Marmor MF, Kellner U, Lai TY, Melles RB, Mieler WF (2016) American academy of ophthalmology. Recommendations on screening for chloroquine and hydroxychloroquine retinopathy. Ophthalmology 123(6):1386–1394

    Article  PubMed  Google Scholar 

  4. Melles RB, Marmor MF (2014) The risk of toxic retinopathy in patients on long-term hydroxychloroquine therapy. JAMA Ophthalmol 132(12):1453–1460

    Article  PubMed  Google Scholar 

  5. Manic G, Obrist F, Kroemer G, Vitale I, Galluzzi L (2014) Chloroquine and hydroxychloroquine for cancer therapy. Mol Cell Oncol 1(1):e29911

    Article  PubMed  PubMed Central  Google Scholar 

  6. Rosenfeld MR, Ye X, Supko JG et al (2014) A phase I/II trial of hydroxychloroquine in conjunction with radiation therapy and concurrent and adjuvant temozolomide in patients with newly diagnosed glioblastoma multiforme. Autophagy 10(8):1359–1368

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  7. Yam JC, Kwok AK (2006) Ocular toxicity of hydroxychloroquine. Hong Kong Med J 12(4):294–304

    CAS  PubMed  Google Scholar 

  8. Marmor MF, Kellner U, Lai TY, Lyons JS, Mieler WF (2011) American Academy of Ophthalmology. Revised recommendations on screening for chloroquine and hydroxychloroquine retinopathy. Ophthalmology 118(2):415–422

    Article  PubMed  Google Scholar 

  9. Pasaoglu I, Onmez FE (2019) Macular toxicity after short-term hydroxychloroquine therapy. Indian J Ophthalmol 67(2):289–292

    Article  PubMed  PubMed Central  Google Scholar 

  10. Hernández Bel L, Monferrer Adsuara C, Hernández Garfella M, Cervera TE (2018) Early macular toxicity following 2 months of hydroxychloroquine therapy. Arch Soc Esp Oftalmol 93(3):e20–e21

    Article  PubMed  Google Scholar 

  11. Lian YY, Ma YC, Cheng CK (2022) Unusual presentation of acute hydroxychloroquine retinopathy. Ocul Immunol Inflamm 2022:1–4

    Google Scholar 

  12. Leung LS, Neal JW, Wakelee HA, Sequist LV, Marmor MF (2015) Rapid onset of retinal toxicity from high-dose hydroxychloroquine given for cancer therapy. Am J Ophthalmol 160(4):799-805.e1

    Article  CAS  PubMed  Google Scholar 

  13. Sharma A, Maiz AM, Tucker WR, Cukras C (2019) Accelerated onset of retinal toxicity from hydroxychloroquine use with concomitant breast cancer therapy. Retin Cases Brief Rep 13(2):98–102

    Article  PubMed  PubMed Central  Google Scholar 

  14. Stern EM, Johnson JS, Mazzulla DA (2017) Highly accelerated onset of hydroxychloroquine macular retinopathy. Ochsner J 17(3):280–283

    PubMed  PubMed Central  Google Scholar 

  15. Hood DC, Bach M, Brigell M, Keating D, Kondo M, Lyons JS, Marmor MF, McCulloch DL, Palmowski-Wolfe AM (2012) International society for clinical electrophysiology of vision. ISCEV standard for clinical multifocal electroretinography (mfERG) (2011 edition). Doc Ophthalmol 124(1):1–13. https://doi.org/10.1007/s10633-011-9296-8

    Article  PubMed  Google Scholar 

  16. Hoffmann MB, Bach M, Kondo M, Li S, Walker S, Holopigian K, Viswanathan S, Robson AG (2021) ISCEV standard for clinical multifocal electroretinography (mfERG) (2021 update). Doc Ophthalmol 142(1):5–16. https://doi.org/10.1007/s10633-020-09812-w

    Article  PubMed  PubMed Central  Google Scholar 

  17. Tsang AC, Ahmadi Pirshahid S, Virgili G, Gottlieb CC, Hamilton J, Coupland SG (2015) Hydroxychloroquine and chloroquine retinopathy: a systematic review evaluating the multifocal electroretinogram as a screening test. Ophthalmology 122(6):1239-1251.e4

    Article  PubMed  Google Scholar 

  18. Geamănu Pancă A, Popa-Cherecheanu A, Marinescu B, Geamănu CD, Voinea LM (2014) Retinal toxicity associated with chronic exposure to hydroxychloroquine and its ocular screening review. J Med Life 7(3):322–326

    PubMed  PubMed Central  Google Scholar 

  19. Phillips BN, Chun DW (2014) Hydroxychloroquine retinopathy after short-term therapy. Retin Cases Brief Rep 8(1):67–69

    Article  PubMed  Google Scholar 

  20. Lee JY, Vinayagamoorthy N, Han K et al (2016) Association of polymorphisms of cytochrome P450 2D6 with blood hydroxychloroquine levels in patients with systemic lupus erythematosus. Arthritis Rheumatol 68(1):184–190

    Article  CAS  PubMed  Google Scholar 

  21. Rodríguez-Hurtado FJ, Sáez-Moreno JA, Rodríguez-Ferrer JM (2015) Ocular toxicity and functional vision recovery in a patient treated with hydroxychloroquine. Rheumatol Clin 11(3):170–173

    Google Scholar 

  22. Maturi RK, Yu M, Weleber RG (2004) Multifocal electroretinographic evaluation of long-term hydroxychloroquine users. Arch Ophthalmol 122(7):973–981

    Article  CAS  PubMed  Google Scholar 

  23. Lai TY, Chan WM, Li H, Lai RY, Lam DS (2005) Multifocal electroretinographic changes in patients receiving hydroxychloroquine therapy. Am J Ophthalmol 140(5):794–807

    Article  PubMed  Google Scholar 

  24. Lyons JS, Severns ML (2007) Detection of early hydroxychloroquine retinal toxicity enhanced by ring ratio analysis of multifocal electroretinography. Am J Ophthalmol 143(5):801–809

    Article  CAS  PubMed  Google Scholar 

  25. Tsang A, Kanda P, Gottlieb C, Virgili G, Kantungane L, Coupland S (2022) A novel 5-ring multifocal electroretinography stimulus for detecting hydroxychloroquine retinal toxicity. Doc Ophthalmol 144(2):117–124

    Article  PubMed  Google Scholar 

Download references

Funding

None.

Author information

Authors and Affiliations

  1. Department of Vitreoretinal Diseases, Sankara Nethralaya, 41/18, College Road, Chennai, Tamil Nadu, 600006, India

    Ayushi Mohapatra, Prasad Gupta & Dhanashree Ratra

Authors
  1. Ayushi Mohapatra
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Prasad Gupta
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Dhanashree Ratra
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Dhanashree Ratra.

Ethics declarations

Conflict of interest

The authors declare that there is no conflict of interest regarding the publication of this manuscript.

Consent to publish

Written informed consent was taken from the patients.

Statement of human rights

The article was written in agreement with the declaration of Helsinki.

Statement on the welfare of animals

Not applicable.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Mohapatra, A., Gupta, P. & Ratra, D. Accelerated hydroxychloroquine toxic retinopathy. Doc Ophthalmol 148, 37–45 (2024). https://doi.org/10.1007/s10633-023-09950-x

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s10633-023-09950-x

Keywords

Search

Navigation