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Yusuf IH, Han RC, Downes SM, Sharma SM. The incidence, monitoring coverage and clinical characteristics of hydroxychloroquine retinopathy in the United Kingdom. Eye (Lond) 2024; 38:2796-2804. [PMID: 39085597 PMCID: PMC11427468 DOI: 10.1038/s41433-024-03168-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Revised: 05/03/2024] [Accepted: 06/06/2024] [Indexed: 08/02/2024] Open
Abstract
BACKGROUND Retinal monitoring is recommended for hydroxychloroquine users to detect pre-symptomatic retinopathy and preserve visual function. However, the incidence of hydroxychloroquine retinopathy and monitoring coverage in the U.K. are incompletely characterised. Moreover, the visual benefits of monitoring for retinopathy - recommended for over 70,000 long-term hydroxychloroquine users in the U.K. - remain unproven. METHODS A national, prospective observational study was undertaken with the British Ophthalmological Surveillance Unit (BOSU). Newly diagnosed cases of hydroxychloroquine retinopathy in the U.K. were reported and data captured using a standardised questionnaire over 3.5 years (July 2018-Dec 2021). The frequency of retinopathy and coverage of monitoring amongst long-term users was estimated. Visual function was compared between asymptomatic individuals detected on monitoring and those presenting with visual symptoms. The clinical characteristics, dosing and management of reported cases were captured. RESULTS The annualised number of incident cases of hydroxychloroquine retinopathy was 29-57, with an annualised frequency of 0.04-0.08% amongst long-term users (~1 in 1247-2625). The coverage of monitoring was approximately 2.6-5.5%. Visual acuity (0.1 vs. 0.22 logMAR; p = 0.007) and visual field mean deviation (-3.73 dB vs. -8.69 dB; p = 0.017) were better preserved in asymptomatic individuals compared to those presenting with visual symptoms. CONCLUSION These data support the efficacy of monitoring in the preservation of visual function in patients with hydroxychloroquine retinopathy at diagnosis. The overall population coverage of monitoring was low, consistent with the high proportion of symptomatic patients at diagnosis. This study presents a method for evaluating the yield of monitoring for hydroxychloroquine retinopathy in the U.K.
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Affiliation(s)
- Imran H Yusuf
- Nuffield Laboratory of Ophthalmology, Department of Clinical Neurosciences, Oxford University, West Wing, John Radcliffe Hospital, Headley Way, Oxford, OX3 9DU, UK.
- Oxford Eye Hospital, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Headley Way, Oxford, OX3 9DU, UK.
| | - Ruofan C Han
- Nuffield Laboratory of Ophthalmology, Department of Clinical Neurosciences, Oxford University, West Wing, John Radcliffe Hospital, Headley Way, Oxford, OX3 9DU, UK
- Oxford Eye Hospital, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Headley Way, Oxford, OX3 9DU, UK
| | - Susan M Downes
- Nuffield Laboratory of Ophthalmology, Department of Clinical Neurosciences, Oxford University, West Wing, John Radcliffe Hospital, Headley Way, Oxford, OX3 9DU, UK
- Oxford Eye Hospital, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Headley Way, Oxford, OX3 9DU, UK
| | - Srilakshmi M Sharma
- Oxford Eye Hospital, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Headley Way, Oxford, OX3 9DU, UK.
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Yusuf IH, Han RC, Downes SM, Sharma SM. A nationwide survey of hydroxychloroquine retinopathy presenting to the hospital eye service in the United Kingdom. Eye (Lond) 2023; 37:2082-2088. [PMID: 36380090 PMCID: PMC10333228 DOI: 10.1038/s41433-022-02291-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Revised: 09/20/2022] [Accepted: 10/11/2022] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND The risk of developing hydroxychloroquine retinopathy is considered sufficient to justify national monitoring programmes. There are an estimated 71,144-77,170 long-term hydroxychloroquine users in the UK. However, the number of patients diagnosed with retinopathy is unknown. This study aimed to identify the number of cases and clinical characteristics of hydroxychloroquine retinopathy diagnosed annually in hospital eye services across the UK. METHODS A nationwide, prospective case ascertainment study was undertaken using the British Ophthalmological Surveillance Unit, which sends approximately 1420 reporting cards to UK Ophthalmologists monthly. The case definition was two abnormal tests suggestive of hydroxychloroquine retinopathy. Demographic and clinical data relating to hydroxychloroquine use and retinopathy were collected from identified cases using a standardised questionnaire over a 1-year period (2018-2019). RESULTS Sixty-six cases of hydroxychloroquine retinopathy were reported, and 46 questionnaires were received (73% response rate). Twenty-four incident cases of hydroxychloroquine retinopathy were identified (24-43 cases following adjustment). The median duration of drug therapy was 19 years (range: 4-50 years, IQR: 14.5-23 years). Fourteen patients were asymptomatic, and 9 symptomatic at diagnosis. A trend towards a lower mean deviation on visual field testing was observed in the symptomatic group (-11.55 dB versus -6.9 dB; P = 0.15). CONCLUSION Between 1 in 1655 and 3215 (0.03-0.06%) long-term hydroxychloroquine users were diagnosed with retinopathy over the study period. We estimate that monitoring was available for 1.9-3.8% of long-term users, accounting for a lower than expected incidence. The high proportion of symptomatic retinopathy at diagnosis underlines the importance of monitoring to detect pre-symptomatic disease.
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Affiliation(s)
- Imran H Yusuf
- Nuffield Laboratory of Ophthalmology, Nuffield Department of Clinical Neurosciences, University of Oxford, West Wing, John Radcliffe Hospital, Headley Way, Oxford, OX3 9DU, UK
- Oxford Eye Hospital, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Headley Way, Oxford, OX3 9DU, UK
| | - Ruofan C Han
- Nuffield Laboratory of Ophthalmology, Nuffield Department of Clinical Neurosciences, University of Oxford, West Wing, John Radcliffe Hospital, Headley Way, Oxford, OX3 9DU, UK
- Oxford Eye Hospital, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Headley Way, Oxford, OX3 9DU, UK
| | - Susan M Downes
- Nuffield Laboratory of Ophthalmology, Nuffield Department of Clinical Neurosciences, University of Oxford, West Wing, John Radcliffe Hospital, Headley Way, Oxford, OX3 9DU, UK
- Oxford Eye Hospital, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Headley Way, Oxford, OX3 9DU, UK
| | - Srilakshmi M Sharma
- Oxford Eye Hospital, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Headley Way, Oxford, OX3 9DU, UK.
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Yusuf IH, Charbel Issa P, Ahn SJ. Hydroxychloroquine-induced Retinal Toxicity. Front Pharmacol 2023; 14:1196783. [PMID: 37324471 PMCID: PMC10267834 DOI: 10.3389/fphar.2023.1196783] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Accepted: 05/17/2023] [Indexed: 06/17/2023] Open
Abstract
Long-term use of hydroxychloroquine can cause retinopathy, which may result in severe and progressive visual loss. In the past decade, hydroxychloroquine use has markedly increased and modern retinal imaging techniques have enabled the detection of early, pre-symptomatic disease. As a consequence, the prevalence of retinal toxicity in long-term hydroxychloroquine users is known to be higher than was previously estimated. The pathophysiology of the retinopathy is incompletely characterised, although significant advances have been made in understanding the disease from clinical imaging studies. Hydroxychloroquine retinopathy elicits sufficient public health concern to justify the implementation of retinopathy screening programs for patients at risk. Here, we describe the historical background of hydroxychloroquine retinopathy and summarize its current understanding. We review the utility and limitations of each of the mainstream diagnostic tests used to detect hydroxychloroquine retinopathy. The key considerations towards a consensus on the definition of hydroxychloroquine retinopathy are outlined in the context of what is known of the natural history of the disease. We compare the current screening recommendations for hydroxychloroquine retinopathy, identifying where additional evidence is required, and the management of proven cases of toxicity. Finally, we highlight the areas for further investigation, which may further reduce the risk of visual loss in hydroxychloroquine users.
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Affiliation(s)
- Imran H. Yusuf
- Oxford Eye Hospital and Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, University of Oxford, Oxford, United Kingdom
| | - Peter Charbel Issa
- Oxford Eye Hospital and Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, University of Oxford, Oxford, United Kingdom
| | - Seong Joon Ahn
- Department of Ophthalmology, Hanyang University Hospital, Hanyang University College of Medicine, Seoul, South Korea
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Yusuf IH, Charbel Issa P, Ahn SJ. Novel imaging techniques for hydroxychloroquine retinopathy. Front Med (Lausanne) 2022; 9:1026934. [PMID: 36314000 PMCID: PMC9606779 DOI: 10.3389/fmed.2022.1026934] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Accepted: 09/26/2022] [Indexed: 11/13/2022] Open
Abstract
Hydroxychloroquine retinopathy is an increasingly recognized cause of iatrogenic, irreversible visual impairment due to the expanding use of hydroxychloroquine in combination with improvements in disease detection following advances in retinal imaging techniques. The prevalence of disease is estimated to be greater than 5% amongst individuals who have used the drug for 5 years or more. In addition to conventional imaging modalities, such as spectral-domain optical coherence tomography (OCT) and fundus autofluorescence (FAF), novel retinal imaging techniques such as en face OCT, OCT angiography, fluorescence lifetime imaging ophthalmoscopy, quantitative autofluorescence, and retromode imaging are capable of detecting structural changes in the retina. These novel retinal imaging techniques have shown promise in detecting earlier disease than is possible with current mainstream imaging modalities. Moreover, these techniques may identify disease progression as well as enabling functional correlation. In the future, these novel imaging techniques may further reduce the risk of visual loss from hydroxychloroquine retinopathy through the earlier detection of pre-clinical disease.
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Affiliation(s)
- Imran H Yusuf
- Oxford Eye Hospital and Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, University of Oxford, Oxford, United Kingdom
| | - Peter Charbel Issa
- Oxford Eye Hospital and Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, University of Oxford, Oxford, United Kingdom
| | - Seong Joon Ahn
- Department of Ophthalmology, Hanyang University Hospital, Hanyang University College of Medicine, Seoul, South Korea
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Marshall E, Robertson M, Kam S, Penwarden A, Riga P, Davies N. Prevalence of hydroxychloroquine retinopathy using 2018 Royal College of Ophthalmologists diagnostic criteria. Eye (Lond) 2021; 35:343-348. [PMID: 32587388 PMCID: PMC7316164 DOI: 10.1038/s41433-020-1038-2] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2020] [Revised: 06/01/2020] [Accepted: 06/09/2020] [Indexed: 12/14/2022] Open
Abstract
INTRODUCTION To measure the prevalence of hydroxychloroquine retinopathy in patients attending a hydroxychloroquine monitoring service using 2018 Royal College of Ophthalmologists diagnostic criteria. METHODS A service evaluation audit of a hydroxychloroquine retinopathy monitoring service was undertaken. Results of Humphrey 10-2 field tests, spectral-domain optical coherence tomography and fundus autofluorescence were collected with data on dose, weight, duration of treatment, estimated glomerular filtration rate, and concurrent tamoxifen therapy. Visual field tests were assessed as reliable or unreliable, and classified as normal, hydroxychloroquine-like, poor test or related to other pathology. Cases of definite and possible retinopathy were identified using the 2018 RCOphth criteria. RESULTS There were 1976 attendances over two years of 1597 patients. Seven hundred and twenty-eight patients had taken hydroxychloroquine for less than 5 years and 869 had taken hydroxychloroquine for 5 years or more. Fourteen patients were identified with definite hydroxychloroquine retinopathy (1.6%), and 41 patients with possible retinopathy (4.7%). Sixty-seven per cent of 861 visual fields were performed reliably, with 66.9% classified as normal, 24.9% as poor test, 5.2% hydroxychloroquine-like and 3.0% abnormal due to other pathology. CONCLUSIONS The 1.6% prevalence of hydroxychloroquine retinopathy is lower than the previously reported prevalence of 7.5% as reported by Melles and Marmor JAMA Ophthalmol 132: 1453-60 (2014). This is because of a difference in the diagnostic criteria. Both definite and possible retinopathy would meet the diagnostic criteria of the Melles and Marmor study; 6.3% in our data, compared with 7.5%, a much smaller difference and likely to be explained by differences in the risk characteristics of the two groups.
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Affiliation(s)
- Elena Marshall
- Department of Ophthalmology, Guy's and St Thomas' NHS Foundation Trust, Westminster Bridge Road, London, SE1 7EH, UK
| | - Matt Robertson
- Department of Ophthalmology, Guy's and St Thomas' NHS Foundation Trust, Westminster Bridge Road, London, SE1 7EH, UK
| | - Satu Kam
- Department of Ophthalmology, Guy's and St Thomas' NHS Foundation Trust, Westminster Bridge Road, London, SE1 7EH, UK
| | - Alison Penwarden
- Department of Ophthalmology, Guy's and St Thomas' NHS Foundation Trust, Westminster Bridge Road, London, SE1 7EH, UK
| | - Paraskevi Riga
- Department of Ophthalmology, Guy's and St Thomas' NHS Foundation Trust, Westminster Bridge Road, London, SE1 7EH, UK
| | - Nigel Davies
- Department of Ophthalmology, Guy's and St Thomas' NHS Foundation Trust, Westminster Bridge Road, London, SE1 7EH, UK.
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Yusuf IH, Foot B, Galloway J, Ardern-Jones MR, Watson SL, Yelf C, Burdon MA, Bishop PN, Lotery AJ. The Royal College of Ophthalmologists recommendations on screening for hydroxychloroquine and chloroquine users in the United Kingdom: executive summary. Eye (Lond) 2018; 32:1168-1173. [PMID: 29887605 PMCID: PMC6043500 DOI: 10.1038/s41433-018-0136-x] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2018] [Accepted: 03/22/2018] [Indexed: 11/08/2022] Open
Affiliation(s)
- Imran H Yusuf
- Oxford Eye Hospital, West Wing, John Radcliffe Hospital, Headington, Oxford, OX3 9DU, UK
| | - Barny Foot
- The Royal College of Ophthalmologists, 18 Stephenson Way, Kings Cross, London, NW1 2HD, UK
| | - James Galloway
- Department of Rheumatology, King's College Hospital NHS Foundation Trust, Denmark Hill, London, SE5 9RS, UK
| | - Michael R Ardern-Jones
- Department of Dermatology, University Hospital Southampton NHS Foundation Trust, Tremona Road, Southampton, Hampshire, SO16 6YD, UK
| | | | - Cathy Yelf
- The Macular Society, Crown Chambers, South St, Andover, Hampshire, SP10 2BN, UK
| | - Michael A Burdon
- Queen Elizabeth Hospital, Mindelsohn Way, Edgbaston, Birmingham, B15 2GW, UK
| | - Paul N Bishop
- Manchester Royal Eye Hospital, Manchester University Hospitals NHS Foundation Trust, Manchester, M13 9WL & School of Biological Sciences, University of Manchester, Manchester, M13 9PL, UK
| | - Andrew J Lotery
- Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, SO16 6YD, UK.
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Yusuf IH, Lotery AJ, Ardern-Jones MR. Joint recommendations for retinal screening in long-term users of hydroxychloroquine and chloroquine in the United Kingdom, 2018. Br J Dermatol 2018; 179:995-996. [PMID: 29770429 DOI: 10.1111/bjd.16782] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- I H Yusuf
- The Oxford Eye Hospital, West Wing, John Radcliffe Hospital, Headley Way, Headington, Oxford, OX3 9DU, U.K
| | - A J Lotery
- Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, SO16 6YD, U.K
| | - M R Ardern-Jones
- Department of Dermatology, University Hospital Southampton NHS Foundation Trust, Tremona Road, Southampton, SO16 6YD, U.K
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