LAS VEGAS– With the help of newer equipment, ophthalmologists are catching hydroxychloroquine-associated retina changes earlier than ever before, but it’s not clear if early changes signal trouble and a need to discontinue the drug, a linchpin of lupus therapy, according to Dr. Susan Manzi.
Hydroxychloroquine (Plaquenil) causes eye damage in an estimated 1% of users after about 5-7 years of use. Bilateral “bull’s-eye” retinal pigment-change lesions are the traditional telltale signs; by the time they appear, patients already have some permanent vision loss.
Dr. Susan Manzi
The hope is to catch problems earlier. Newer ophthalmologic techniques – optical coherence tomography, fundus autofluorescence screening, and others – detect far more subtle retina changes earlier in the course of treatment, but the importance of those early changes is not clear. This uncertainty makes it hard for patients and rheumatologists to know what to do when they hear about such findings, especially when hydroxychloroquine is working, Dr. Manzi said at the annual Perspectives in Rheumatic Diseases held by Global Academy for Medical Education.
“Before, they used to look in the eye for pigment changes. Now, [we are] getting calls from ophthalmologists with concerns about” retinal edema and other less obvious problems, which are sometimes described as “early maculopathy, so we have to stop the drug” even if there are no vision problems. “We really don’t know what to make of it when [maybe] there’s just a little edema. It reminds me of the era when we started doing MRIs. We weren’t sure if all the things we found were relevant; I think we are going to be hearing more from ophthalmologists about some of these changes” and how much to worry about them, said Dr. Manzi, chair of the Allegheny Health Network department of medicine and director of the Lupus Center of Excellence, both in Pittsburgh.
In the meantime, “I can count the times I’ve stopped” hydroxychloroquine for eye issues, “and mostly it was because of [concomitant] macular degeneration or diabetic retinopathy,” not hydroxychloroquine-induced damage, she said.
In 2011, the American Academy of Ophthalmology recommended baseline screening with the newer technologies, and follow-up screening after 5 years. When “possible” toxicity is found, the group recommends screening every 3-6 months.
“There is no firm definition of ‘early’ toxicity, so that subtle changes (especially if parafoveal) – in visual field sensitivity, macular pigmentation, or any of the objective screening tests … should be taken seriously. If such changes occur, the tests should be repeated for verification or verified with other procedures. However, mild and nonspecific changes can appear in all tests for reasons other than toxicity (including cataract, early macular degeneration, and testing variation of the visual field …), and a relationship to [hydroxychloroquine] is difficult to confirm without evidence of paracentral functional or structural loss,” the group said (Ophthalmology 2011;118:415-22).
Dr. Manzi follows this screening advice. She also requests repeat testing if ophthalmologists find a problem on somewhat subjective measures, such as peripheral vision. Repeat testing sometimes alleviates worries.
Her practice also mirrors the academy’s dosing guidelines, which aim to minimize eye and other toxicities. For most lupus patients, that means 200 mg twice a day, or 400 mg once daily. “Most people do fine with that,” although 200 mg a day is a better call in small women and adolescents, she said.
Dr. Manzi is an adviser or consultant for Genentech, Eli Lilly, Bristol-Myers Squibb, GlaxoSmithKline, and other companies. Global Academy for Medical Education and this news organization are owned by Frontline Medical Communications.