Background/Purpose: Hydroxychloroquine (HCQ) is a commonly used medication for SLE because of its highly favorable risk-benefit ratio. Drug-induced retinopathy is one of very few serious toxicities associated with long-term use. Studies have reported varied prevalence of HCQ retinopathy ranging from 0.5% to 7.5%. In 2016, the American Academy of Ophthalmology published revised guidelines for drug-induced retinopathy prevention. Despite the guidelines, there is some degree of expected variability in clinical practice. We reviewed a large, diverse cohort of SLE patients at an academic center in order to characterize physician practices and patient behaviors with regard to HCQ retinopathy screening and prevention.

Methods: A retrospective chart review was conducted of patients in our SLE cohort. There were 301 SLE patients reviewed, all of whom were seen at academic rheumatology practices between 2004 and 2018. Patients were categorized according to HCQ use at the time of most recent clinic visit. For patients who had been on HCQ, we determined timing of last retinopathy screening exam. We reviewed patients with documented eye-related concerns to determine specific findings and next steps taken.

Results: Of the 301 patients reviewed, 65% were taking HCQ as of the most recent visit and 91% had been on HCQ at some time. There were 205 patients with available rheumatology records for whom HCQ retinopathy screening was indicated. Based on the documentation, 46.8% were up to date on retinopathy screening, 10.2% were overdue, 7.8% had discussed screening with a rheumatologist but follow-up was unclear, and 35.1% had unknown screening status.

Among 274 active or former HCQ users, 11.7% had eye-related concerns while on HCQ. These included 1.8% with true drug-induced retinopathy, 5.1% with nonspecific retinal findings leading to HCQ discontinuation, and 4.7% with retinal pathology not attributed to HCQ who continued the drug.

Six patients with eye-related concerns had been tested for antiretinal antibodies and 100% were positive. HCQ was discontinued in four of these cases: one had confirmed drug-induced retinopathy and three had nonspecific retinal abnormalities. In the remaining two cases, HCQ was continued with close monitoring.

Conclusion: Our data suggest that there may be inconsistent compliance with ophthalmology guidelines for HCQ retinopathy screening. In addition, only a small subset of patients in our cohort with retinal abnormalities detected by screening was found to have confirmed HCQ retinopathy. Lastly, a select group of patients on HCQ with nonspecific retinal pathology had positive antiretinal antibodies. Further research is needed to determine the incidence of antiretinal antibodies in HCQ users without retinal pathology in order to understand the implications of this finding.

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ACR Meeting Abstracts - https://acrabstracts.org/abstract/the-risk-of-hydroxychloroquine-retinopathy-in-an-sle-cohort-screening-and-prevention-in-clinical-practice/