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]

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]

• Congestive Heart Failure

  Digoxin (Lanoxin) is a cardiac glycoside used in the treatment of atrial fibrillation, atrial flutter and congestive heart failure. [reviewofophthalmology.com]

  Digoxin       Digoxin (Lanoxin) is a cardiac glycoside: used in atrial fibrillation, atrial flutter and congestive heart failure. Systemic toxicity is rare when plasma digoxin concentration is less than 0.8 µg/L. [slideshare.net]

• Vascular Disease

  Includes a new chapter on vascular disease, especially important since optometrists are sometimes the first to notice these types of changes. [books.google.com]

  Congenital Abnormalities and Syndromes Diseases of Hematopoesis (see under Systemic Diseases) Hereditary Degenerations and Dystrophies Infections (see Systemic Diseases) Light Toxicity Retinal Detachment, Rhegmatogenous. [atlasophthalmology.net]

  About Contact Retinal Anatomy Retinal Diseases Home Hydroxychloroquine is an immunomodulating drug that is commonly used in treating collagen vascular diseases such as rheumatoid arthritis and systemic lupus erythematosus. [retinareference.com]

  disease, cause a cumulative dose-related pigmentary retinopathy. [ejournalofophthalmology.com]

  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]

• Blurred Vision

  Non-specific blurred vision and kerato-conjunctivitis sicca may also occur after busulphan infusion [ 20 ]. [hoajonline.com]

  With progression, symptoms can include blurred vision, decreased vision, scotomas and photopsias. [reviewofophthalmology.com]

  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]

• 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]

  […] loss (n=10) generalized constriction including central loss (n=3) superior peripheral VF constriction and central loss (n=1) paracentral loss (n=1) Visual acuity ranged from 20/20 OU to hand motion. [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]

  The ocular toxicities caused include diplopia, photophobia and, decreased visual acuity secondary to optic neuritis with or without disc edema or cortical blindness [ 44 ]. [hoajonline.com]

  […] 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]

  While it is selective for PDE5, sildenafil also acts on the retina to alter cGMP levels by inhibiting retina-specific PDE6. 21 Patients may present with visual disturbances, complaining of cyanopsia, photophobia and blurred vision. [reviewofophthalmology.com]

• Diplopia

  A single case treated for nephrotic syndrome has been reported to develop diplopia, bilateral papilledema and retinal hemorrhages [ 20 ]. [hoajonline.com]

  There was history of occasional diplopia. Patient was also a known case of Type II diabetes mellitus and hypertension on treatment for the last 4 years. [cancerjournal.net]

  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]

• Visual Acuity Decreased

  Visual acuity decreases are usually secondary to foveal cyst development. [cancerjournal.net]

• 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]

  […] loss (n=10) generalized constriction including central loss (n=3) superior peripheral VF constriction and central loss (n=1) paracentral loss (n=1) Visual acuity ranged from 20/20 OU to hand motion. [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]

The Risk of Hydroxychloroquine Toxic Retinopathy and Its Risk Factors in the Treatment of Rheumatic Diseases: A Systematic Review [abstract]. [acrabstracts.org]

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]

Uses case presentations to demonstrate clinical test interpretation, differential diagnosis, treatment, and the development of a prognosis. Reflects the most current technologies in examination and testing. [books.google.com]

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]

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]

Patients should be advised that toxicity may progress despite discontinuation of medication, and the etiology of this progression is poorly understood. [kjophthal.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]

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]

It incorporates a multidisciplinary approach, from the underlying pathophysiological mechanisms, to testing and diagnosis methods, to medical and surgical management. [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]

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]