Plaquenil Retinopathy: The Risks and What Your Doctor is Looking For

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Have you ever been prescribed a medication where vision loss was a potential side effect?  For many people suffering from chronic inflammatory conditions, they are faced with a decision to take a medication that can help, but needs careful observation to prevent possible permanent vision loss. Plaquenil (hydroxychloroquine) is an anti-malaria oral medication that is more commonly prescribed in the US for inflammatory conditions like systemic lupus erythematosus, rheumatoid arthritis, and Sjogren's Syndrome.  This medication can help combat the crippling side effects of chronic inflammation, but it is not without its own potential risks.  If you have been prescribed Plaquenil, your rheumatologist likely referred you for a routine eye examination.  One of the uncommon side effects of this medication is vision loss, but since the damage can be permanent, this is a toxic effect that you and your doctor will be closely monitoring for.

Luckily Plaquenil maculopathy (damage to the central vision area or macula) is quite rare.  Much less than 1% of users develop this side effect, but there are several factors that can increase your chance of having vision damage due to the medication:

Increased Risks for Plaquenil Toxicity
> 5 years on medication
>1,000g total dosage  (the average recommended dosage is 400 mg daily)
Elderly age
Systemic Health issues: high BMI, liver or kidney function issues
Previous Ocular Disease

What does Plaquenil Toxicity Look Like?
During your yearly eye examination your eye doctor is looking for changes called "Bulls Eye Maculopathy". These are pigmentary changes typically in a target or ring pattern occurring right at the central vision area. Rarely enough, I have had a patient with confirmed plaquenil maculopathy.  She presented with 20/20 vision in both eyes, but her macula looked like this:


Unfortunately the pigmentary "bulls eye" changes that occur in plaquenil toxicity are a late stage finding, meaning that typically there has been structural damage and vision loss by the time these changes are observed on your eye exam.  As such, your doctor will be performing routine screenings with more advanced technology, separate from your comprehensive examination to ensure that there is no early damage developing.  These tests can include color vision screenings, central visual field tests, and periodically are required to include macular thickness scans (called OCT imaging), multifocal ERG, or fundus autofluorescence.  If you want to learn more about the required testing, and how often federal medical standards require that they be performed, follow the link to this post.
FUNDUS AUTOFLUORESCENCE showing photoreceptor damage in Plaquenil induced "Bulls Eye" Maculopathy via

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