Classification of Hydroxychloroquine Retinopathy: A Literature Review and Proposal for Revision

Overview

Journal Diagnostics (Basel)

Specialty Radiology

Date 2024 Aug 29

PMID 39202291

Authors

Seong Joon Ahn

Affiliations

Soon will be listed here.

Abstract

Establishing universal standards for the nomenclature and classification of hydroxychloroquine retinopathy is essential. This review summarizes the classifications used for categorizing the patterns of hydroxychloroquine retinopathy and grading its severity in the literature, highlighting the limitations of these classifications based on recent findings. To overcome these limitations, I propose categorizing hydroxychloroquine retinopathy into four categories based on optical coherence tomography (OCT) findings: parafoveal (parafoveal damage only), pericentral (pericentral damage only), combined parafoveal and pericentral (both parafoveal and pericentral damage), and posterior polar (widespread damage over parafoveal, pericentral, and more peripheral areas), with or without foveal involvement. Alternatively, eyes can be categorized simply into parafoveal and pericentral retinopathy based on the most dominant area of damage, rather than the topographic distribution of overall retinal damage. Furthermore, I suggest a five-stage modified version of the current three-stage grading system of disease severity based on fundus autofluorescence (FAF) as follows: 0, no hyperautofluorescence (normal); 1, localized parafoveal or pericentral hyperautofluorescence on FAF; 2, hyperautofluorescence extending greater than 180° around the fovea; 3, combined retinal pigment epithelium (RPE) defects (hypoautofluorescence on FAF) without foveal involvement; and 4, fovea-involving hypoautofluorescence. These classification systems can better address the topographic characteristics of hydroxychloroquine retinopathy using disease patterns and assess the risk of vision-threatening retinopathy by stage, particularly with foveal involvement.

References

Rempenault C, Combe B, Barnetche T, Gaujoux-Viala C, Lukas C, Morel J . Clinical and Structural Efficacy of Hydroxychloroquine in Rheumatoid Arthritis: A Systematic Review. Arthritis Care Res (Hoboken). 2019; 72(1):36-40. DOI: 10.1002/acr.23826. View

De Sisternes L, Hu J, Rubin D, Marmor M . Localization of damage in progressive hydroxychloroquine retinopathy on and off the drug: inner versus outer retina, parafovea versus peripheral fovea. Invest Ophthalmol Vis Sci. 2015; 56(5):3415-26. PMC: 4455312. DOI: 10.1167/iovs.14-16345. View

Anderson C, Blaha G, Marx J . Humphrey visual field findings in hydroxychloroquine toxicity. Eye (Lond). 2011; 25(12):1535-45. PMC: 3234480. DOI: 10.1038/eye.2011.245. View

Marmor M, Durbin M, De Sisternes L, Pham B . SEQUENTIAL RETINAL THICKNESS ANALYSIS SHOWS HYDROXYCHLOROQUINE DAMAGE BEFORE OTHER SCREENING TECHNIQUES. Retin Cases Brief Rep. 2021; 15(3):185-196. DOI: 10.1097/ICB.0000000000001108. View

Ahn S, Seo E, Kim K, Kim Y, Lee B, Kim J . Long-Term Progression of Pericentral Hydroxychloroquine Retinopathy. Ophthalmology. 2020; 128(6):889-898. DOI: 10.1016/j.ophtha.2020.10.029. View

Fanouriakis A, Kostopoulou M, Alunno A, Aringer M, Bajema I, Boletis J . 2019 update of the EULAR recommendations for the management of systemic lupus erythematosus. Ann Rheum Dis. 2019; 78(6):736-745. DOI: 10.1136/annrheumdis-2019-215089. View

Chang A, Mieler W, Ohno-Matsui K, Lai C . Retina Update: Entering an Era of Personalized Medicine in Ophthalmology. Asia Pac J Ophthalmol (Phila). 2023; 12(2):111-112. DOI: 10.1097/APO.0000000000000603. View

Browning D, Lee C . Somatotype, the risk of hydroxychloroquine retinopathy, and safe daily dosing guidelines. Clin Ophthalmol. 2018; 12:811-818. PMC: 5939880. DOI: 10.2147/OPTH.S163451. View

Garrity S, Jung J, Zambrowski O, Pichi F, Su D, Arya M . Early hydroxychloroquine retinopathy: optical coherence tomography abnormalities preceding Humphrey visual field defects. Br J Ophthalmol. 2019; 103(11):1600-1604. DOI: 10.1136/bjophthalmol-2018-313350. View

10.

Ahn S, Ryu S, Lim H, Lee B . TOXIC EFFECTS OF HYDROXYCHLOROQUINE ON THE CHOROID: Evidence From Multimodal Imaging. Retina. 2018; 39(5):1016-1026. DOI: 10.1097/IAE.0000000000002047. View

11.

Maturi R, Yu M, Weleber R . Multifocal electroretinographic evaluation of long-term hydroxychloroquine users. Arch Ophthalmol. 2004; 122(7):973-81. DOI: 10.1001/archopht.122.7.973. View

12.

Marmor M, Melles R . Disparity between visual fields and optical coherence tomography in hydroxychloroquine retinopathy. Ophthalmology. 2014; 121(6):1257-62. DOI: 10.1016/j.ophtha.2013.12.002. View

13.

Varela M, Sen S, Cabral de Guimaraes T, Kabiri N, Pontikos N, Balaskas K . Artificial intelligence in retinal disease: clinical application, challenges, and future directions. Graefes Arch Clin Exp Ophthalmol. 2023; 261(11):3283-3297. PMC: 10169139. DOI: 10.1007/s00417-023-06052-x. View

14.

Ahn S, Joung J, Lee B . En Face Optical Coherence Tomography Imaging of the Photoreceptor Layers in Hydroxychloroquine Retinopathy. Am J Ophthalmol. 2018; 199:71-81. DOI: 10.1016/j.ajo.2018.11.003. View

15.

Melles R, Marmor M . Rapid Macular Thinning Is an Early Indicator of Hydroxychloroquine Retinal Toxicity. Ophthalmology. 2022; 129(9):1004-1013. DOI: 10.1016/j.ophtha.2022.05.002. View

16.

Kim K, Kim Y, Kim J, Ahn S . Macular Ganglion Cell Complex and Peripapillary Retinal Nerve Fiber Layer Thicknesses in Hydroxychloroquine Retinopathy. Am J Ophthalmol. 2022; 245:70-80. DOI: 10.1016/j.ajo.2022.07.028. View

17.

Lai T, Ngai J, Chan W, Lam D . Visual field and multifocal electroretinography and their correlations in patients on hydroxychloroquine therapy. Doc Ophthalmol. 2006; 112(3):177-87. DOI: 10.1007/s10633-006-9006-0. View

18.

Melles R, Marmor M . Pericentral retinopathy and racial differences in hydroxychloroquine toxicity. Ophthalmology. 2014; 122(1):110-6. DOI: 10.1016/j.ophtha.2014.07.018. View

19.

Marmor M . Fundus autofluorescence is not the best early screen for hydroxychloroquine toxicity. JAMA Ophthalmol. 2013; 131(11):1487-8. DOI: 10.1001/jamaophthalmol.2013.4835. View

20.

Rosenbaum J, Costenbader K, Desmarais J, Ginzler E, Fett N, Goodman S . American College of Rheumatology, American Academy of Dermatology, Rheumatologic Dermatology Society, and American Academy of Ophthalmology 2020 Joint Statement on Hydroxychloroquine Use With Respect to Retinal Toxicity. Arthritis Rheumatol. 2021; 73(6):908-911. DOI: 10.1002/art.41683. View