Hydroxychloroquine retinopathy — SCE Rheumatology MCQ

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EasyRheumatological pharmacologyHydroxychloroquine retinopathySCE Rheumatology

A 58-year-old woman with systemic lupus erythematosus has taken hydroxychloroquine for 12 years. She reports increasing difficulty reading. Visual-field testing demonstrates bilateral paracentral scotomas. Fundoscopy shows no obvious macular abnormality, but spectral-domain optical coherence tomography shows bilateral parafoveal outer retinal thinning with disruption of the ellipsoid zone. Which diagnosis best explains these findings?

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Correct answer: D — Hydroxychloroquine retinopathy

The diagnosis is hydroxychloroquine retinopathy. The discriminating features are prolonged hydroxychloroquine exposure, bilateral paracentral scotomas and parafoveal outer retinal thinning with ellipsoid-zone disruption on OCT. Fundoscopy may remain unremarkable or show only subtle changes in early toxicity. Optic neuritis more commonly causes acute, often painful monocular visual loss, impaired colour vision and a relative afferent pupillary defect rather than bilateral parafoveal photoreceptor injury. Scleritis causes marked ocular pain and scleral inflammation, while uveitis is associated with inflammatory cells, photophobia and often a red eye. Cataract causes gradual visual blurring with visible lens opacity but does not produce paracentral field defects or outer retinal disruption on OCT.

Reference: Royal College of Ophthalmologists, The Royal College of Ophthalmologists recommendations on monitoring for hydroxychloroquine and chloroquine users in the United Kingdom: 2020 revision, sections 4 and 15.2, 2020. https://www.formularymk.nhs.uk/docs/Shared%20Care%20Guidelines/04-Clinical%20Guidelines%20RCOphth%20Hydroxychloroquine%20and%20Chloroquine%20Retinopathy%20Monitoring-December%202020.pdf