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Toxic Retinopathy


Presentation

  • We present two cases of HCQ toxic retinopathy, as well as a discussion on how to diagnose and manage early toxicity findings; Two cases are presented of patients who experienced toxic effects of HCQ therapy.[ncbi.nlm.nih.gov]
  • Presents a more streamlined format to the printed text to help you focus on the clinically actionable information you need everyday.[books.google.com]
  • Toxic and nutritional optic neuropathies resemble each other in terms of their clinical presentation in that their presentation is simultaneously bilateral but may vary in congruence.[emedicine.medscape.com]
  • Presentation - these patients present at puberty with a progressive, painless visual impairment. The optic disc pit itself may be asymptomatic and so this may be the first time this diagnosis is made.[patient.info]
Pallor
  • Retinal abnormalities do not usually occur, but temporal disk pallor may develop late.[merckmanuals.com]
  • Fundus - pigmentry changes, vascular attenuation & optic disc pallor Toxicity is more dependent on total daily dose than on cumulative dose.[ejournalofophthalmology.com]
  • .  In late-stage disease, optic disc pallor.  Retinal toxicity has been shown in patients taking greater than 3 mg/kg/day of chloroquine or 6.5 mg/kg/day of hydroxychloroquine.  Patients should be monitored annually, as toxicity can be irreversible[slideshare.net]
  • Continued damage to the optic nerve results in the development of optic atrophy, classically seen as temporal pallor of the optic disc.[en.wikipedia.org]
Surgical Procedure
  • View videos of surgical procedures and access the complete contents of Retina, 5th Edition online at www.expertconsult.com, fully searchable, with regular updates and a downloadable image gallery.[books.google.com]
  • Retinal Perforations, Breaks Surgical Procedures and Postoperative Cases Toxic Retinopathies; see also Light Toxicitiy Canthaxanthin Retinopathy, Gold Dust Retinopathy Carbon Monoxide Retinopathy Chloroquine Retinopathy Chlorthalidone Retinopathy Contraceptive[atlasophthalmology.net]
  • This may be idiopathic or secondary to retinal surgical procedures, retinal vascular disease, intraocular inflammation or trauma. The membrane may be thin (cellophane maculopathy) or thickened and contracted (macular pucker).[patient.info]
  • Rare reports exist of crystalline retinopathy as a result of calcium oxylate deposition following methoxyflurane inhalation after prolonged surgical procedures with methoxyflurane anesthesia or after illicit methoxyflurane abuse.[27] [28] DEFEROXAMINE[medtextfree.wordpress.com]
Epilepsy
  • Long term changes in the visual fields of patients with temporal lobe epilepsy using vigabatrin. Br J Ophthalmol 2000; 84: 788-790. 28. Hardus P, Verduin WM, Engelsman M, Edelbroek PM, Segers JP, Berendschot TT, et al.[geneesmiddelenbulletin.com]
  • Vigabatrin Anti epilepsy drug associated with visual field defects. GABA transaminase inhibitor. Chlorpropamide Anti diabetes tablet. Digitalis Heart antiarhythmic acting as a Na ,K -ATPase (sodium pump) inhibitor. Amiodarone Heart antiarhythmic.[ifond.org]
Goiter
  • […] article: PDF Only Abstract Background:Potassium iodate (KIO3) is an iodized salt used for iodine supplementation in areas endemic for goiter. KIO3 overdose in humans is rare.[journals.lww.com]
  • […] a acetone bodyアセトン体 acid-base balance酸塩基平衡 acidosisアシドーシス acromegaly先端巨大症 acute adrenocorticalinsufficiency (adrenal crisis)急性副腎不全、副腎クリーゼ Addison (Addison's) disease アジソン病 adenohypophyseal hormone下垂体前葉ホルモン adenoma腺腫、アデノーマ adenomatous goiter腺腫様甲状腺腫 adrenal[tokyo-med.ac.jp]
Arthritis
  • Arthritis Rheumatol. 2017; 69 (suppl 10). . Accessed May 13, 2019. « Back to 2017 ACR/ARHP Annual Meeting ACR Meeting Abstracts -[acrabstracts.org]
  • Arthritis Rheum 1997;40:1482–1486. 5. Mäntyjärvi M. Hydroxychloroquine treatment and the eye. Scand J Rheumatol 1985;14:171–174. 6. Lee DH, Melles RB, Joe SG, Lee JY, Kim JG, Lee CK, et al.[synapse.koreamed.org]
  • Party): JooYong Lee, Asan Medical Center Brief Summary: The purpose of this study is to evaluate the incidence and risk factor of toxic maculopathy who treated with hydroxychloroquine or chloroquine due to their autoimmune disease such as rheumatoid arthritis[clinicaltrials.gov]
  • "Women with breast cancer and lupus or rheumatoid arthritis who need to take tamoxifen chemotherapy should probably avoid concurrent hydroxychloroquine therapy," Dr. Melles said. Dr.[healthylivingmagazine.us]
Blurred Vision
  • Risk factors for retinopathy normal daily doses range 150 – 600mg. toxic dose 800mg/day Symptoms – blurred vision, dyschromatopsia (reddish or brownish discoloration of vision) & nyctalopia.[ejournalofophthalmology.com]
  • .  With progression, symptoms can include blurred vision, scotomas and photopsias.  Bilateral bulls-eye maculopathy. 6.  In late-stage disease, optic disc pallor.  Retinal toxicity has been shown in patients taking greater than 3 mg/kg/day of chloroquine[slideshare.net]
  • If they do have symptoms they complain of visual color deficits, specifically red objects, missing central vision, difficulty reading, reduced or blurred vision, glare, flashing lights, and metamorphopsia [1] [2] [3] .[eyewiki.aao.org]
  • Patients usually complain of difficulty with reading, decreased vision, missing central vision, glare, blurred vision, light flashes, and metamorphopsia. They can also be asymptomatic.[karger.com]
  • Patients on these medications may be asymptomatic or present with blurred vision, browning of the vision or difficulty in seeing at night. Current prescribing practice should not lead to retinopathy.[patient.info]
Central Scotoma
  • (failure to see the dot suggests a central scotoma). (If there is no central scotoma): 'I want you to focus on the central dot and tell me whether you can see all four corners of the big box out of the corner of your eye.'[patient.info]
  • scotomas, or bitemporal see if using examine every month if dose 15mg/kg/day (physicians desk reference).Average male dose is 1gm/day, which is 15mg/kg, and this is the therapeutic dose. 1% toxicity lower than this dose, at 100mg/kg/day 50% toxic. baseline[goodhopeeyeclinic.org.uk]
  • Discussion and report of three cases of central scotomas. Arch Ophthalmol 1966; 76: 640-645. 20. Closson RG. Visual hallucinations as the earliest symptom of digoxin intoxication. Arch Neurol 1983; 40: 386. 21.[geneesmiddelenbulletin.com]
  • Humphrey 10-2 visual fields can demonstrate (para)central scotomas [1] . Multifocal electroretinogram may show “moat around a small hill” appearance [4] .[eyewiki.aao.org]
  • If the drug is not discontinued at this early phase, the characteristic bulls-eye shaped alterations of the macula develop, leading to irreversibly reduced visual acuity and absolute (peri-)central scotoma.[bmcophthalmol.biomedcentral.com]
Photophobia
  • In keratopathy, patients complain of halos around light and photophobia. In ciliary body dysfunction, patients will not be able to read or do other activities requiring accommodation.[eyewiki.aao.org]
  • […] asymptomatic.Earliest symptoms - difficulty in reading/ fine tasks due to central / paracentral scotomas.Gradually these enlarge & involve fixation, reducing visual acuity later.Other symptoms- metamorphopsia, red-green haloes, cycloplegia, amblyopia, photophobia[ejournalofophthalmology.com]
  • .  Patients may present with visual disturbances, complaining of cyanopsia, photophobia and blurred vision.  Typically, visual acuity is unchanged and there are no fundus changes.  Case reports have also described NAAION, CSR, cilioretinal arterial[slideshare.net]
Diplopia
  • This may in turn give rise to diplopia, as there is a discrepancy between the image perceived in the healthy eye and in the diseased eye. Assessment of macular function Visual acuity The most important test is the assessment of visual acuity.[patient.info]
Background Retinopathy
  • Diagnosis Code H35.00 ICD-10: H35.00 Short Description: Unspecified background retinopathy Long Description: Unspecified background retinopathy This is the 2019 version of the ICD-10-CM diagnosis code H35.00 Valid for Submission The code H35.00 is valid[icdlist.com]

Workup

Central Scotoma
  • (failure to see the dot suggests a central scotoma). (If there is no central scotoma): 'I want you to focus on the central dot and tell me whether you can see all four corners of the big box out of the corner of your eye.'[patient.info]
  • scotomas, or bitemporal see if using examine every month if dose 15mg/kg/day (physicians desk reference).Average male dose is 1gm/day, which is 15mg/kg, and this is the therapeutic dose. 1% toxicity lower than this dose, at 100mg/kg/day 50% toxic. baseline[goodhopeeyeclinic.org.uk]
  • Discussion and report of three cases of central scotomas. Arch Ophthalmol 1966; 76: 640-645. 20. Closson RG. Visual hallucinations as the earliest symptom of digoxin intoxication. Arch Neurol 1983; 40: 386. 21.[geneesmiddelenbulletin.com]
  • Humphrey 10-2 visual fields can demonstrate (para)central scotomas [1] . Multifocal electroretinogram may show “moat around a small hill” appearance [4] .[eyewiki.aao.org]
  • If the drug is not discontinued at this early phase, the characteristic bulls-eye shaped alterations of the macula develop, leading to irreversibly reduced visual acuity and absolute (peri-)central scotoma.[bmcophthalmol.biomedcentral.com]

Treatment

  • Put the very latest scientific and genetic discoveries, diagnostic imaging methods, drug therapies, treatment recommendations, and surgical techniques to work in your practice.[books.google.com]
  • Helps you make optimal use of the newest drug therapies, including Anti-VEGF treatment for wet ARMD and bevacizumab treatment for complications of diabetes.[books.google.com]
  • Toxic retinopathy is an uncommon sequella in the treatment of certain autoimmune diseases with hydroxychloroquine (HCQ).[ncbi.nlm.nih.gov]
  • The Risk of Hydroxychloroquine Toxic Retinopathy and Its Risk Factors in the Treatment of Rheumatic Diseases: A Systematic Review [abstract]. Arthritis Rheumatol. 2017; 69 (suppl 10). .[acrabstracts.org]

Prognosis

  • Again, prognosis is variable and dependent upon the affected individual, treatment compliance, and degree of vision loss at diagnosis.[en.wikipedia.org]
  • Prognosis Patients with decreased vision may improve if the cause is treated or removed quickly. Once the optic nerve has atrophied, vision usually does not recover.[msdmanuals.com]
  • The prognosis tends to be highly dependent on presenting visual acuity, with initial visual acuities of [ 2 ].[patient.info]
  • Prognosis Premaculopathy is fully reversible [1] . True bull’s eye maculopathy is irreversible. Most patient’s vision remains stable after cessation of treatment. Occasionally, patient’s vision will continue to worsen [1] .[eyewiki.aao.org]
  • In contrast, the prognosis of those with early retinopathy, that is, without RPE changes, was better: the changes stabilized and the risk of progression to visual loss was minimal.[academic.oup.com]

Etiology

  • Etiology Toxic amblyopia is usually bilateral and symmetric. Undernutrition and vitamin deficiencies (eg, vitamins B 1 or B 1 2 or folate) may be the cause, particularly in alcoholics. True tobacco-induced amblyopia is rare.[msdmanuals.com]
  • Tamoxifen Tamoxifen (Nolvadex), used for both prevention and treatment of breast cancer, has been implicated in the etiology of toxic optic neuropathy, even at low dosage.[emedicine.medscape.com]
  • However, our analysis can not exclude that other as yet unknown AMD-associated variants may play a role in the etiology of toxic maculopathy or that our patient cohort may lack statistical power to detect significant differences with minor effects.[bmcophthalmol.biomedcentral.com]

Epidemiology

  • Goodman, Division of Epidemiology and Ophthalmology, Stellenbosch University, South Africa Ari Ziskind, Division of Ophthalmology, Stellenbosch University, South Africa Full Text: HTML EPUB XML PDF (1MB) Share this article Abstract Purpose: To determine[avehjournal.org]
  • Epidemiology [ edit ] In industrialized nations, toxic and nutritional optic neuropathy is relatively uncommon and is primarily associated with specific medications, occupational exposures, or tobacco and alcohol abuse.[en.wikipedia.org]
Sex distribution
Age distribution

Pathophysiology

  • Comprehensively updated to reflect everything you need to know regarding retinal diagnosis, treatment, development, structure, function, and pathophysiology, this monumental ophthalmology reference work equips you with expert answers to virtually any[books.google.com]
  • Pathophysiology [ edit ] All of the above risk factors impact mitochondrial oxidative phosphorylation. Thus, the toxic and nutritional optic neuropathies are actually acquired mitochondrial optic neuropathies.[en.wikipedia.org]
  • Pathophysiology Hydroxychloroquine binds to melanin, accumulates in the RPE, and remains there for long periods of time. It is directly toxic to the RPE, causing cellular damage and atrophy [2] .[eyewiki.aao.org]

Prevention

  • Overexpression of GLO1, UCP-1, or MnSOD prevented this glucose-stimulated switch. Sp3 coimmunoprecipitated with the corepressor mSin3A.[stke.sciencemag.org]
  • “Retinal toxicity from hydroxychloroquine use cannot be completely prevented, but effective screening should recognize retinal toxicity before symptoms or significant risk of central vision loss appear (ie, before the appearance of bull’s eye maculopathy[eyedock.com]
  • Primary prevention A complete ophthalmologic examination is recommended before starting hydroxychloroquine therapy.[eyewiki.aao.org]
  • An ophthalmic evaluation is primarily for early detection and minimization of toxicity, not for prevention.[reviewofoptometry.com]
  • Rubsamen PE, Davis P, Hernandez E, O’Grady G, Cousins SW (1994) Prevention of experimental proliferative vitreoretinopathy with a biodegradable intravitreal implant for the sustained release of fluorouracil.[link.springer.com]

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