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HCQ Retinopathy OCT — SCE Rheumatology MCQ

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HardMusculoskeletal ImagingHCQ Retinopathy OCTSCE Rheumatology

A 62-year-old woman with rheumatoid arthritis has taken methotrexate and hydroxychloroquine for 8 years. She remains visually asymptomatic. Screening spectral-domain OCT shows bilateral parafoveal disruption of the photoreceptor inner segment/outer segment junction (ellipsoid zone), with preservation of the central foveal outer retina. Fundus autofluorescence is normal, and repeated 10-2 visual-field testing shows no anatomically corresponding defect. According to current UK monitoring recommendations, which is the best interpretation and management?

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Correct answer: A — Possible hydroxychloroquine retinopathy; continue hydroxychloroquine while obtaining multifocal electroretinography

The correct answer is A. Parafoveal ellipsoid-zone disruption with central foveal preservation produces the characteristic flying-saucer configuration of hydroxychloroquine-related outer-retinal injury. However, UK monitoring guidance classifies a typical abnormality on OCT alone as possible toxicity, not definite toxicity. Definite toxicity requires two anatomically corresponding abnormal tests, such as OCT plus FAF, visual-field testing or mfERG. With normal FAF and repeatedly normal visual fields, hydroxychloroquine should continue while mfERG is obtained to seek objective corroboration and avoid inappropriate withdrawal of an effective systemic treatment. B overcalls an isolated OCT result. D also stops treatment prematurely. C incorrectly treats characteristic photoreceptor disruption as normal, while E is unsafe because definite toxicity should prompt discussion between the prescriber and patient about stopping hydroxychloroquine rather than waiting for symptoms.

Reference: Royal College of Ophthalmologists, The Royal College of Ophthalmologists recommendations on monitoring for hydroxychloroquine and chloroquine users in the United Kingdom, sections 2.4-2.6 and SD-OCT imaging, 2020 revision. https://www.formularymk.nhs.uk/docs/Shared%20Care%20Guidelines/04-Clinical%20Guidelines%20RCOphth%20Hydroxychloroquine%20and%20Chloroquine%20Retinopathy%20Monitoring-December%202020.pdf