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Background: The Royal College of Ophthalmologists (RCOPHTH) published in 2017 revised recommendations regarding screening for hydroxychloroquine (HCQ) toxicity. Recent data reported the prevalance of retinopathy to be around 7.5% and depending on dose and duration can rise to 20%–50% after 20 years of therapy. Much higher than the 0.5% reported previously in the 2009 guidelines. Risk is increased in patients taking more than 5 mg/kg/day, and those with renal dysfunction, pre-existing retinopathy or also taking tamoxifen. Retinopathy appears as damage to the photoreceptors, followed by degeneration of the retinal pigment epithelium (RPE). This can produce visual loss and a ”Bull’s eye maculopathy”.
Current guidelines state patients looking to take HCQ long term should have a baseline screening (10–2 Humphrey visual test) in a hospital eye department, and then be referred for annual screening after 5 years of therapy. Dosage should ideally be kept ≤5 mg/kg/day.
Previous guidelines recommend a maximum dose of ≤6.5 mg/kg/day, and baseline optometrist review. Referral to ophthalmologist only if a visual impairment or eye disease is detected at the baseline assessment or the patient notices reduced vision whilst on treatment. Long term HCQ patients, were advised to agree and individual screening arrangement with the local ophthalmologist.
Objectives: This single point of care audit was to assess real world practice at Central Middlesex Hospital against the new 2017 guidance as a gold standard.
Methods: HCQ questionnaires were collected from patients attending regular appointments over one month October-November and recorded:
1) date commenced HCQ, 2) est. total dose, 3) weight and 4)last retinal screen;
Hospital EPR database was used to confirm or assist documentation of therapy data.
Results: In one calendar month 152 of 414 patients were prescribed HCQ.
94/152 of the patients had been on HCQ for >5 years.
63/152 patients were high risk with doses of >5 mg/kg/day.
55/152 patients had either failed to attend a baseline screening, or had no record of having had a baseline screen.
Of the 21 patients that had started HCQ after the introduction of the new guidlines (2017); only 5 had failed to have a baseline hospital screen (3/5 instead had optometrist/high street screen instead). No cases of HCQ related retinopathy had been reported.
Conclusions: Real world OHC retinal screening was poor compared to new Guidance. These figures imply a huge medico-legal responsibility for the previously considered rare risk of retinal damage from OHQ. The logistics of the workload in Eye Clinics will necessitate local solutions including nurse screening clinics and closer monitoring and documentation of outcomes. This rare but serious complication of a very well tolerated and effective agent will not come at a cheap price today. A repeat audit following 12 months of an agreed screening policy is recommended.
References
Disclosure of Interest: None declared
DOI: 10.1136/annrheumdis-2018-eular.7522