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Vishal Parikh, Adrian Au, Yasha Modi, Rishi P Singh; Impact of the Revised American Academy of Ophthalmology Guidelines for Hydroxychloroquine Retinopathy Screening at an Tertiary Care Academic Institution. Invest. Ophthalmol. Vis. Sci. 2015;56(7 ):1789.
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© ARVO (1962-2015); The Authors (2016-present)
The purpose of this study was to determine the hydroxychloroquine (HCQ) retinopathy screening practice patterns following the revised HCQ retinopathy screening recommendations published by the American Academy of Ophthalmology (AAO) in 2011.
This was an observational, retrospective study and approval from the institutional review board was obtained. 756 patients presenting to the Cole Eye institute were identified as taking HCQ between 2011 and 2014 from their medication lists within the electronic medical record. Screening tests and follow-up intervals for all patients were analyzed and stratified by ophthalmic subspecialty. Per the 2011 guidelines, an appropriate screening visit was defined as having an objective (SD-OCT, mfERG, FAF) and a subjective test (HVF). Screenings were classified as “appropriate,” “over-screened,” “under-screened,” or “inappropriate.” The treating physician established diagnosis of toxicity, indeterminate findings, or a normal exam.
After classifying screening visits, 228 (31.0%) patients were appropriately screened, (7.6%) patients were “over-screened,” 163 (22.2%) patients were “under-screened,” and 288 (39.2%) patients were inappropriately screened. Differences between sub-specialties in screening include: 1) comprehensive ophthalmologists were more likely to order an Amsler test (p<0.0001); 2) glaucoma specialist were more likely to order the 24-2 HVF (p=0.002); 3) neuro-ophthalmologists were more likely to order the 30-2 HVF (p=0.008); 4) retina specialists were more likely to order the SD-OCT (p<0.0001), FAF (p<0.0001), FA (p=0.005), and fundus photos (p<0.0001). Twelve (1.6%) patients had definite toxicity. Eight (1.1%) patients had an abnormal or indeterminate exam concerning for HCQ toxicity. Of the patients with definite toxicity, eight (66.7%) had a cumulative dose >1 kg, seven (58.3%) exceeded 6.5 mg/kg/day based on ideal body weight, and two (16.7%) had comorbid renal or liver disease.
Screening for HCQ varied widely with 31% of patients undergoing appropriate screening, indicating a large percentage of screenings deviated from the recommended algorithm. Cumulative dosing is the most consistent risk factor for developing HCQ toxicity. SD-OCT was the primary screening tool coupled with the 10-2 HVF, with FAF and mf-ERG as additional tests if needed.
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