Recommendations on screening for chloroquine and hydroxychloroquine retinopathy: a report by the American Academy of Ophthalmology.

Retinal toxicity from chloroquine and its analogue, hydroxychloroquine, has been recognized for many years. The first reports concerned long-term usage of chloroquine for malaria, and later reports showed retinopathy in the treatment of anti-inflammatory diseases. Chloroquine toxicity remains a problem in many parts of the world, but is seen infrequently in the United States where the drug has largely been replaced by hydroxychloroquine for the treatment of systemic lupus erythematosus, rheumatoid arthritis, and other inflammatory and dermatologic conditions. Retinal toxicity from hydroxychloroquine is quite rare relative to the many thousands of individuals who take this drug for medical indications, but it is of serious ophthalmologic concern because even after cessation of the drug there is little if any visual recovery, and sometimes a progression of visual loss. The potential permanence and severity of chloroquine and hydroxychloroquine toxicity make it imperative that ophthalmologists and other physicians be aware of this disorder and take measures to minimize its occurrence and effects. This document has been prepared because a diversity of screening regimens have been proposed, and these vary considerably in practicality, costs and cost/benefit ratio. There is need for a consensus recommendation. The Physicians’ Desk Reference, for example, recommends quarterly examinations that would potentially represent an enormous burden on health care resources. Most authors concur that some screening for early toxicity is reasonable. This statement examines the existing data on chloroquine and hydroxychloroquine toxicity, and suggests guidelines and techniques for screening that represent a balance of risks and benefits at the current state of knowledge. However, this is not intended to be a review article, and only selected references are cited. These suggestions may be varied according to the needs of individual patients, but provide a basic framework for the management of most patients. It cannot be emphasized too strongly that whatever screening regimen is followed, the keys to early recognition of toxicity, and to the avoidance of liability, are first informing the patient (and if possible the primary care physician) of the risks and of the need for examinations, and second documenting these admonitions carefully in the record. These drugs are typically prescribed by internists, rheumatologists or dermatologists who may not be fully aware of the ophthalmic implications. Patients and primary care physicians should understand that screening helps to recognize toxicity early, before damage is too severe, but cannot prevent toxicity or guarantee that there will be no visual loss.