This 77YO female had a long prior history of Plaquenil (hydroxychloroquine) use for lupus. Although it was discontinued 10 years ago, vision was 20/200 OU with classic findings for Plaquenil toxicity.
Optos color imaging shows a hyperpigmented bull’s-eye pattern of pigmentary changes surrounding each macular center. Fundus autofluorescence (FAF) shows pericentral hypo-FAF from RPE damage, with a surrounding narrow ring of hyper-FAF.
Triton swept-source OCT shows outer retinal thinning with more severe near-total central neurosensory retinal thinning with pseudo-macular holes. To further confuse the OCT findings, she also gave a history of macular hole surgery in one of her eyes!
Learning Points:
Current screening guidelines should make Plaquenil toxicity a thing of the past. Last revised in 2016, the American Academy of Ophthalmology (AAO) recommends that a baseline exam be performed before starting the medication, with annual screenings beginning at least 5 years after initiating treatment, unless major risk factors are present.
However, in practice, patients are usually screened yearly once they are placed on this medication. Optical coherence tomography (OCT) is performed annually to assess outer retinal findings, including ellipsoid zone loss.
Humphrey 10-2 visual field testing (24-2 for Asians, since their macular involvement is usually more peripheral) is also needed annually, as about 10% of patients will have field loss despite normal examinations and OCT testing.
Plaquenil dosing should also be based on real, not ideal, weight to better predict the optimal dose. See Marmor et al Ophthalmology 2016;123;1386-1394 for the full screening guidelines.
